Clinical OMICS

SEP-OCT 2017

Healthcare magazine for research scientists, labs, pathologists, hospitals, cancer centers, physicians and biopharma companies providing news articles, expert interviews and videos about molecular diagnostics in precision medicine

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12 Clinical OMICs September/October 2017 www.clinicalomics.com In the Clinic W ith some 70,000 unique genetic tests available on the U.S. market, according to genetic diag- nostics market tracker Concert Genet- ics, insurers continue to scramble to address which ones to cover and how. In recent weeks, two insurers have announced new programs designed to answer those questions by offering quick, direct prior authorizations for selected genetic tests to physicians. Anthem Blue Cross Blue Shield has introduced its Genetic Testing Solu- tion, a real-time automated electronic system designed to combine clinical review of testing requests and coor- dination with genetic testing labo- ratories. And effective November 1, UnitedHealthcare will implement a national online prior–authorization program for outpatient genetic and molecular testing for fully–insured members of the company's United- Healthcare Commercial plans. "Many payers and health systems struggle with the same issues—how to keep up with the technical advances in genetic testing and understanding which test is the right one for a par- ticular patient's situation," said Harry Glorikian, senior executive, board director, and consultant in the life sci- ences/healthcare industry. Large payers might address the issue through a dedicated group of genetic counselors, medical genet- icists, or Ph.D.–level scientists and M.D.s with significant genetics train- ing and the resources to manage reim- bursement for their member base, said Glorikian, who is author of Commer- cializing Novel IVDs: A Comprehensive Manual for Success. However, many payers rely on third-party companies for utilization management and pre-authorization services, such as Concert Genetics and Evicore, to control reimbursement for genetic tests. The third-party provid- ers perform technology assessments and test comparisons that payers and providers can use in clinical deci- sion-making. Bringing Developers, Providers Together "On the one hand, you have the diag- nostics companies that are developing tests to meet patient and physician needs. On the other, you have the pay- ers that want to reimburse for tests that have value and improve patient outcomes while containing costs," Glorikian said. "The problem is that the two groups aren't speaking the same language or providing the information the other needs," he added. "Payers want data that shows the test has analytical validity, clinical validity, and clinical utility. They want a clearly defined patient population that the test will benefit. If a genetic test can improve patient outcomes and can save the payer money, the test has value." Through the Genetic Testing Solu- tion, Anthem said it will immediately approve, with confirmation of cov- erage, requests for test coverage that meet clinical criteria. Where requests fail to meet evidence-based criteria, genetic analysts may contact the order- ing physician to provide additional clinical information that may lead to Making the Grade Anthem, UnitedHealthcare Move toward Quicker Prior Authorizations for Some Tests By Alex Philippidis "Many payers and health systems struggle with the same issues—how to keep up with the technical advances in genetic testing and understanding which test is the right one for a particular patient's situation." —Harry Glorikian, healthcare and life sciences consultant

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