Insurers Feel Their Way Through Genomic Profiling

Feb. 14--TRAVERSE CITY -- Genetic tests for chronic medical conditions could one day be as common as they now are for determining paternity or guilt in a crime.

Like fingerprints, genes are unique to each person. Records from before the year 200 B.C. include details about using fingerprints as evidence during burglary investigations. The swirls on the tips of our fingers have figured heavily in modern crime-solving. Genetic tests in police work are far newer -- they appeared in the investigator's repertoire only decades ago, but they're well-established as reliable scientific evidence.

Genetic testing to help cure disease still is a relatively young science. Insurers are feeling their way through the evolving research, trying to determine who can benefit from which tests at what price.

Priority Health recently announced it will cover the cost of comprehensive genomic profiling for clients diagnosed with aggressive forms of cancer. Priority says it is the first insurer in the nation to cover such testing, which details a broad range of genetic markers. Most insurers cover tests for specific markers, but not the all-inclusive test Priority now offers to clients who suffer from aggressive cancers.

"We're providing additional information to physicians," said John Fox, M.D., senior medical director and associate vice president of medical affairs at Priority Health. "There are a lot of drugs available today for a very specific markers. But rare tumor types, there might be markers that we just don't know about yet."

"The decision to cover comprehensive genomic profiling is about improving the health and lives of our members," Fox said. "By covering comprehensive genomic profiling in specific circumstances, we can help identify potentially more effective targeted treatment options for those diagnosed with aggressive or difficult to treat cancer."

Priority Health's largest competitor in the state, Blue Cross Blue Shield of Michigan, covers some specific genetic tests, but doesn't cover comprehensive genomic testing.

"Selective genetic testing is covered by Blue Cross Blue Shield," said Dr. George Kipa, deputy chief medical officer of Blue Cross Blue Shield of Michigan. "For specific cases that have been shown to be useful and actionable, we cover genetic testing."

"We've been very interested in the field of genetic testing. We don't cover whole-spectrum genomic testing, which has a low level of reliability," Kipa said.

Fox said Priority's decision to cover the all-inclusive version of genetic testing is aimed at patients who may have only one opportunity to undergo such a test. Ravaged by disease, they may not have the time to take a series of tests for specific types of gene markers. The comprehensive profile will give doctors information about all the patient's genetic markers in a single test.

The comprehensive profile also will provide physicians with information to help determine if a patient is eligible to participate in clinical trials. Such drug trials typically require that a patient have a particular genetic marker or mutation to take part.

"It's better than no information at all," Fox said. "It's certainly for patients who are short on time. When patients have failed all existing medications, we're covering this test."

Blue Cross Blue Shield of Michigan's Kipa said research to date hasn't demonstrated proven benefits of wide-spectrum genetic testing. But once a particular disease or cancer is identified in a patient, the proven accuracy of a specific genetic test can guide doctors toward the most effective treatment, he said.

"There's a lot of research going on in this field," Kipa said.

Blue Cross Blue Shield of Michigan held a series of conferences across the state last year that led to the creation of The Genetic Testing Resource and Quality Consortium. The consortium is funded by Blue Cross Blue Shield of Michigan and coordinated through the Department of Pathology at the University of Michigan Medical School.

The group aims at keeping track of the exponential growth in genetic testing and at improving the quality of care for patients who can benefit from such testing.

The consortium's goals are listed as: Determining which tests are clinically actionable; reducing or eliminating tests that are not clinically actionable; improving the quality of molecular diagnostic testing by evaluating and disseminating best practices for ordering and performing clinically-indicated tests; educating and equipping providers with the tools, resources and expert analysis of outcomes research to test, advise and treat their patients.

"We need to figure out what the right approach is," Kipa said.

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