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Journal of Genetic Counseling

, Volume 24, Issue 1, pp 122–133 | Cite as

Exploring Barriers to Payer Utilization of Genetic Counselors

  • Nan DoyleEmail author
  • Allison Cirino
  • Amber Trivedi
  • Maureen Flynn
Original Research

Abstract

Access to genetic counselors’ services is neither universal nor automatic, due in part to the gatekeeper role of healthcare payers – the companies and agencies that purchase healthcare services on patients’ behalf and control the bulk of healthcare spending. This pilot study surveyed and analyzed the relative importance of barriers to expanded payer coverage of genetic counselors’ services. Surveys were mailed to 263 medical directors and quality assurance directors at health insurance carriers throughout the United States. Respondents provided demographic information and indicated the importance of nine possible barriers, plus an optional write-in “other.” Twenty-two surveys were analyzed. “Evidence that use of genetic counselors improves health outcomes” led the list of factors having a significant/very significant influence on coverage policy. Sixteen respondents (73 %) rated this factor “4” or “5” on a Likert scale; it also received the most #1 rankings and the highest score using a weighted-mean analysis. Provider practice guidelines, CMS/Medicare regulations, and genetic counselor licensure-all of which are outside of payers’ direct control-also ranked highly. The research demonstrates that although the potential barriers to expanded reimbursement for genetic counselors are numerous and complex, some are more consistently identified as important and therefore more deserving of legislative and advocacy resources to effect change. Future research should endeavor to increase survey response and include providers as well as payers. (222 words)

Keywords

Genetic Counselor Insurance Payor Payer Coverage Policy Reimbursement Outcomes 

Notes

Acknowledgements

Gratitude is due to survey respondents, for taking the time to provide data that suggest a path forward; and to Boston University MS Genetic Counseling faculty and Capstone Committee members, for spirited discussion, practical help, and good humor.

Conflict of Interest Statement

Nan Doyle, Allison Cirino, Maureen Flynn and Amber Trivedi declare that they have no conflict of interest.

References

  1. Aetna Corporation (2010, September 15). http://newshub.aetna.com/press-release/member-and- consumer-health/aetna-supports-first-national-study-community-based-use-gen.testingGoogle Scholar
  2. Aetna Corporation “Clinical policy bulletin No. 0189: genetic counseling,” April 8, 2012; and “Clinical policy bulletin No. 0140: Genetic testing,” March 12, 2013; retrieved from https://doi.org/www.aetna.com
  3. Bruell, A. (2012, June 14). DMA survey shows snail mail, phone beat digital in response rates. Ad Age Media News. Retrieved from www.adage.comGoogle Scholar
  4. Clark, S., Bluman, L. G., Borstelmann, N., Regan, K., Winer, E. P., Rimer, B. K., & Skinner, C. S. (2000). Patient Motivation, Satisfaction, and Coping in Genetic Counseling and Testing for BRCA1 and BRCA2. Journal of Genetic Counseling, 9(3), 219–235.CrossRefGoogle Scholar
  5. Costain, G., Esplen, M.J., Toner, B., Scherer, S.W., Meschino, W.S., Hodgkinson, A., Bosssett, A.,S. (2014). Evaluating genetic counseling for individuals with schizophrenia in the molecular age. Schizophr Bull 40 (1), 78–87.CrossRefGoogle Scholar
  6. Department of Health and Human Services Secretary’s Advisory Committee on Genetics, Health, and Society. (2008) “U.S. System of Oversight of Genetic Testing: A Response to the Charge of the Secretary of Health and Human Services.”Google Scholar
  7. Duquette, D., Lewis, K., McLosky, J., & Bach, J. (2012). Using core public health functions to promote BRCA best practices among health plans. Public Health Genomics, 15(2), 92–97.CrossRefGoogle Scholar
  8. EmblemHealth “Policy MG.MM.AD.08Cv2: Genetic counseling and testing,” June 20, 2012; retrieved from https://doi.org/www.emblemhealth.com
  9. Forst, L. E., Burke, J., Bacic, S., & Amor, D. J. (2008). Increased genetic counseling support improves communication of genetic information in families. Genetic Medecine, 10(3), 167–72.CrossRefGoogle Scholar
  10. Gustafson, S. L., Pfeiffer, G., & Eng, C. (2011). A large health system’s spproach to utilization of he genetic counselor CPT 96040 code. Genet Med, 13(12), 1011–1014.CrossRefGoogle Scholar
  11. Harrison, T. A., Doyle, D. L., McGowan, C., Cohen, L., Repass, L., Pfau, R. B., & Brown, T. (2010). Billing for medical genetics and genetic counseling services: a national survey. J Genet Couns, 19, 38–43.CrossRefGoogle Scholar
  12. Harvard University, Mossavar-Rahmani Center for Business and Government at the John F. Kennedy School of Government. (2007, March 11). Healthcare delivery covered lives summary of findings. Cambridge: MA.Google Scholar
  13. Heimler, A. (1997) “An Oral History of NSGC.” Retrieved from https://doi.org/www.nsgc.org/about.
  14. Illinois Genetic Counselor Licensing Act (225 ILCS 135) (2004). Retrieved from https://doi.org/www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=2632&ChapterID=24.
  15. Katz, S. (2007). “The changing roles of medical directors.” American College of Physician Executives. Retrieved from www.acpe.orgGoogle Scholar
  16. Klitzman, R., Chung, W., Marder, K., Shannugham, A., Chin, L. J., Stark, M., Leu, C., & Appelbaum, P. S. (2013). Attitudes and practices among internists concerning genetic testing. J Genet Couns, 22(1), 90–100.CrossRefGoogle Scholar
  17. Looney, W. (2013). Pathways to progress. Pharmaceutical Executive 33 (2), 15–24. Google Scholar
  18. Massachusetts Board of Registration of Genetic Counselors, License Requirements and Procedures: M.G.L. c.112§§252 through 258 (2009). Retrieved from https://doi.org/www.mass.gov/eohhs/gov/departments/dph/programs/hcq/dhpl/genetic-counselor/notice-of-genetic-counselors-licensure.html
  19. Menasha, J. D., Schecter, C., & Willner, J. (2000). Genetic testing: a physician’s perspective. Mount Sinai Journal of Medicine, 67(2), 144–51.Google Scholar
  20. Miller, C. E. (2013). March) “Importance of Clinical Information for Optimal Genetic Test Selection and Interpretation.”. Retrieved from https://doi.org/www.aruplab.com/files/resources/education/ARUP_IFL-Presentation-Handout2013.pdf.Google Scholar
  21. Miller, C. E., Krautscheid, P., Baldwin, E. E., LaGrave, D., Openshaw, A., Hart, K., & Tvrdik, T. (2011, March). Value of genetic counselors in the laboratory. Salt Lake City, UT: ARUP Laboratories.Google Scholar
  22. Parrott, A., & Ware, S. M. (2012). The role of the geneticist and genetic counselor in an ACHD clinic. Pediatric Cardiology, 34(1), 15–20.CrossRefGoogle Scholar
  23. Priority Health (2013, October 18) Medical Policy No. 91540-R8: Genetics: counseling, testing, screening. Retrieved from https://doi.org/www.priorityhealth.com.
  24. Reid, R. J., McBride, C. M., Alford, S. H., Price, C., Baxevanis, A. D., Brody, L. C., & Larson, E. B. (2012). Association between health-service use and multiplex genetic testing. Genetic Medicine, 14(10), 852–9. doi: https://doi.org/10.1038/gim.2012.52.CrossRefGoogle Scholar
  25. Stanek, E.J., Sanders, C.L., Taber, K.A., Khalid, M., Patel, A., Verbrugge, R.R., Agatep, B.C., Aubert, R.E., Epstein, R.S., Frueh, F.W. (2012). Adoption of pharmacogenetic testing by U.S. physicians: results of a nationwide survey. Clinical Pharmacology & Therapeutics, DOI 10.1038/clpt2011:306 450–458CrossRefGoogle Scholar
  26. Sturdevant, M. (2013). August 20). The Hartford Courant: Cigna to require counseling before extensive genetic tests for cancer. Retrieved from https://doi.org/insurancenewsnet.com/.Google Scholar
  27. Tuckson, R. (2012). Personalized medicine: trends and prospects for the new science of genetic testing and molecular diagnostics. United Health Group: Center for Health Reform and Modernization.Google Scholar
  28. Wang, G., Beattie, M. S., Ponce, N. A., & Phillips, K. A. (2011). Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling. Genetic Medicine, 13(12), 1045–1050.CrossRefGoogle Scholar

Further Reading

  1. American Medical Association, “2007 Update: Competition in Health Insurance: A Comprehensive Study of U.S. Markets.” https://doi.org/www.ama-assn.org.
  2. Cohen, S. A., Gustafson, S. L., Marvin, M. L., Riley, B. D., Uhlmann, W. R., Liebers, S. A., & Rousseau, S. A. (2012). Report from the National Society of Genetic Counselors Service Delivery Model Task Force: a proposal to define models, components, and modes of referral. Genetic Counseling, 21, 645–651.CrossRefGoogle Scholar
  3. Dutton, G. Reimbursement in personalized medicine. Genetic Engineering & Biotechnology News 31 (21):48–50.CrossRefGoogle Scholar
  4. Frabotta, D. (2002). Searching for significance: plans and providers trudge through the labyrinth of genetic information in search for appropriate coverage and care. Managed Healthcare Executive. July 1.Google Scholar
  5. Latchaw, M., Ormond, K., Smith, M., Richardson, J., & Wicklund, C. (2010). Health insurance coverage of genetic services in Illinois. Genetic Medicine, 12, 525–531.CrossRefGoogle Scholar
  6. Teutsch, S., et al. (2011). “Genetics education and training of health care professionals, public health providers, and consumers”. Final report of the United States Department of. Health and Society: Health & Human Services Secretary’s Advisory Committee on Genetics. Retrieved from https://doi.org/oba.od.nih.gov/oba/SACGHS/reports/SACGHS_education_report_2011.pdf.Google Scholar

Copyright information

© National Society of Genetic Counselors, Inc. 2014

Authors and Affiliations

  • Nan Doyle
    • 1
    Email author
  • Allison Cirino
    • 2
  • Amber Trivedi
    • 3
  • Maureen Flynn
    • 1
  1. 1.Division of Graduate Medical SciencesBoston University School of MedicineBostonUSA
  2. 2.Cardiovascular Genetics CenterBrigham and Women’s HospitalBoston,USA
  3. 3.InformedDNASt PetersburgUSA

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