John Fox, MD, MHA

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Earlier this year, pharmaceutical giant Bayer 

 an international awareness and education campaign encouraging patients with advanced cancer to receive genomic testing as a way to help inform treatment options. They’re in good company. In the past few years, organizations such as the 

. have launched campaigns and initiatives focused on testing, according to releases from their respective newsrooms. Others like the 

Harvard Business School Kraft Precision Medicine Accelerator

, have coalesced stakeholders around efforts focused on increasing patient education and awareness.

As a medical professional, I’m gratified to see so many organizations working to promote genomic testing for people with advanced cancer. As a former executive at a private insurance company, though, I worry that for these campaigns to be effective, they need to target another audience.

While many stakeholders in our healthcare environment impact overall patient access, one of the biggest obstacles to widespread adoption of genomic testing isn’t just patient and physician awareness. It’s also insurers.

As it stands, private insurer coverage for comprehensive genomic profiling (CGP), a broad diagnostic approach which uses one sample to evaluate hundreds of potential mutations in a tumor, lags Medicare and guideline adoption. And there is a tremendous amount of evidence demonstrating that CGP helps enable personalized medicine and represents a major step forward in the fight against cancer.

For decades, we’ve tackled tumors using a one-size-fits-all model by bombarding them with cytotoxic or toxic chemotherapy and radiation. However, in recent years, our understanding of cancer biology and specifically, the genomic drivers of cancer, has increased dramatically. Therapeutics companies are harnessing this knowledge and have made incredible strides in developing personalized medicines that treat many cancers based on genomics. However, the only mechanism to determine if a patient is eligible for one of these therapies is to do genomic testing in the first place.

In 2014, my former company, Priority Health, became the first private insurer to cover CGP including tests by the Boston-based genomic pioneer, Foundation Medicine, for members with most types of advanced-stage cancer. This included coverage for patients interested in participating in target-specific clinical trials like ASCO’s TAPUR trial. In the five years since, we’ve seen the impact of that decision firsthand, and it has been meaningful for patient care.

New Research Program Looks To Accelerate Precision Medicine

Since we began covering CGP, hundreds of Priority Health members have been tested to analyze their tumors. For many of our members, the information revealed by these tests allowed their doctors to prescribe targeted treatment options. In fact, a study I co-authored in the 

Journal of Managed Care & Specialty Pharmacy

 found that 84% of stage 4 cancer patients who received a CGP test were found to have clinically-relevant genomic abnormalities that were not detected by conventional testing. More than three out of four of them were then matched to FDA-approved therapies that they previously were not aware of.

Some insurers have hesitated to cover CGP because of concerns over cost. Though the cost of the genomic sequencing is $3,000 to $4,000, the one-time cost of testing is nominal compared to the on-going cost of cancer drugs.  Some payers preclude coverage for fear that the targeted drugs that could be prescribed using the insights from a genomic test can cost tens of thousands of dollars a month. Others preclude coverage because there are no FDA approved drugs for many mutations, which is not the case for target mutations in drug clinical trials. At Priority Health, we reasoned that striving to offer the best care for cancer patients required that we not overlook the evidence that demonstrates patients can consistently achieve a better outcome when matched to a treatment that targets the genomic drivers.

Additionally, CGP can actually help insurers reduce coverage costs. When a test identifies a genomic weakness for which no approved drug is widely available, that information can sometimes be used to help place a patient in a clinical trial. Often, when patients are accepted into clinical trials, a portion of the cost of their care is taken over by the trial sponsor. Our study found that each patient placed in a clinical trial saves payers an estimated $25,000.

That is why a growing number of leaders in our industry-including CMS and the Department of Veterans Affairs-have made the decision to provide access to CGP testing.

But private insurers still lag, which presents some heartbreaking inequities. For instance, while a 65-year-old grandmother on Medicare may have CGP covered, it is unlikely that her 35-year-old daughter with three young children can expect her private insurance offers the same.

Excluding coverage is not supported by the evidence. Our experience at Priority Health over the past five years has demonstrated conclusively that it’s the smart thing to do-for patients, for pocketbooks, and for progress.

It’s time for private insurers to do the right thing and cover comprehensive genomic profiling – now. 

John Fox, MD, MHA, is the vice president, Clinical Transformation at Spectrum Health in Grand Rapids, Michigan, and was formerly the senior medical director and vice president of Medical Affairs for Priority Health, also in Grand Rapids.

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One of the biggest obstacles to widespread adoption of genomic testing isn’t just patient and physician awareness. It’s also insurers.

Author | John Fox, MD, MHA

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