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Cost Considerations in Breast Cancer Genetic Testing

Insights From:Adam M. Brufsky, MD, University of Pittsburgh Cancer Institute; Claudine J. Isaacs, MD, Lombardi Comprehensive Cancer Center; Harold J. Burstein, MD, PhD, Harvard Medical School
Published: Thursday, Jul 21, 2016


Transcript:

Adam M. Brufsky, MD, PhD:
Reimbursement has been a very interesting issue over the years. I think that in the early days for genetic testing, the tests were very expensive—$5000, $6000 per test. Only one company did it, and I think that the company was very good trying to get reimbursement. But insurers really were very, very strict about who would get reimbursement or not. What’s happened over the last several years, with next-generation sequencing in these multi-gene panels, is the testing has gotten a lot less expensive. Things that used to be $5000 can be $1000, $1500. And, in fact, I think most companies now—if after several appeals—don’t pay for the test. The testing isn’t paid for by their insurance; the cost to the patient really can be fairly minimal.

Again, it can be significant to a lot of people, it can be a couple hundred dollars. But, on the other hand, it’s not now $5000. At most, it is maybe a couple hundred, $300, $400, $500 maximum out-of-pocket expense. It really has gotten a lot less than it used to be. Therefore, as the tests get even cheaper, I think that will be even less of a problem in terms of reimbursement. I think where the issue really is, is not so much in reimbursement for the test; it’s reimbursement for the counseling that occurs afterwards. Because, remember, you have a test, you have certain pathogenetic mutations, you’ll get other non-pathogenetic mutations of variants of unknown significance. And what to do with that really requires a lot of effort, a lot of human manpower, like to sit down and counsel people. That’s really the real cost of genetic testing, not so much the test anymore.

I think my own personal experience has been very good with this. Insurers understand this is something that has really become part of the standard of care for a lot of people with cancer in families at risk for cancer in this country. So, as the tests get cheaper, that particular aspect is not going to be that much of a problem.

Harold J. Burstein, MD, PhD: The price of genetic testing is plummeting, and that’s a great thing for patients and for people interested in hereditary cancers. People draw analogies to Moore’s Law in computer technology, where the price of computing power has been declining exponentially. And the price of genetic testing for tumors—whether it’s for sequencing to look for targetable mutations or for hereditary cancer testing—has also been plummeting. So, at the moment, we’re talking about testing that’s usually on the order of $1000 to $2000 and is frequently less expensive than that. Some of the testing can be a little bit less expensive if you do a more tailored panel of genes. If you know exactly which ones you’re looking for, you can keep it simple, but wider panels cost a little bit more money. Interestingly, the technology to do them is awfully similar.

As we are getting to this era where more and more people are getting testing, I think a couple of things are going to happen. The first is the price pressure and competition is going to further drive down the price of genetic testing. The second is that this branded testing may disappear into commoditized testing. Nobody asks what brand of complete blood count (CBC) testing you had. You just get a CBC, and before too long, that’s the kind of thing we’re going to be doing for genetic testing—subject to, obviously, appropriate quality measures.

So, I think for most people, the expectation is that the price is going to come down. Now, having said that, many patients meet criteria for genetic testing. These are well established. For women with strong family history, specific kinds of breast cancers at specific ages, there’s near universal coverage in the United States for genetic testing for specific genes and hereditary syndromes. We’re not seeing problems with out-of-pocket expenses for most women who warrant genetic testing.

The price of testing when you say things like it’s $1000 to $2000—or something in that ballpark range—that’s the retail price, but that’s not the out-of-pocket expenses. For most patients who have standard healthcare coverage or insurance, the out-of-pocket expensing is negligible or very low.

Claudine Isaacs, MD: We’ve seen individuals where they have fairly striking family histories, but their insurance will not cover the testing. And that is obviously a dilemma and a problematic area to encounter. What we also see is that some insurances will cover for testing. They will cover for a certain extent of testing, but not others, and that can help drive the recommendations and can help inform what we recommend patients, how they would proceed with testing. So, there is significant variability from insurance to insurance in terms of what’s covered. Medicare covers differently than other insurances. Individual insurances will also cover differentially, so that does impact the decision making. Patients can also have some out-of-pocket costs, and those can vary from company to company. Frequently, what we also do within the setting of our genetic counseling session is to discuss the finances with them or to send this out to the company to get this preapproved or preauthorized by their insurance. And if there are issues, we’ll go back and we’ll look which companies are the best fit for that particular patient and which ones will minimize out-of-pocket costs for the patient.

Transcript Edited for Clarity
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Transcript:

Adam M. Brufsky, MD, PhD:
Reimbursement has been a very interesting issue over the years. I think that in the early days for genetic testing, the tests were very expensive—$5000, $6000 per test. Only one company did it, and I think that the company was very good trying to get reimbursement. But insurers really were very, very strict about who would get reimbursement or not. What’s happened over the last several years, with next-generation sequencing in these multi-gene panels, is the testing has gotten a lot less expensive. Things that used to be $5000 can be $1000, $1500. And, in fact, I think most companies now—if after several appeals—don’t pay for the test. The testing isn’t paid for by their insurance; the cost to the patient really can be fairly minimal.

Again, it can be significant to a lot of people, it can be a couple hundred dollars. But, on the other hand, it’s not now $5000. At most, it is maybe a couple hundred, $300, $400, $500 maximum out-of-pocket expense. It really has gotten a lot less than it used to be. Therefore, as the tests get even cheaper, I think that will be even less of a problem in terms of reimbursement. I think where the issue really is, is not so much in reimbursement for the test; it’s reimbursement for the counseling that occurs afterwards. Because, remember, you have a test, you have certain pathogenetic mutations, you’ll get other non-pathogenetic mutations of variants of unknown significance. And what to do with that really requires a lot of effort, a lot of human manpower, like to sit down and counsel people. That’s really the real cost of genetic testing, not so much the test anymore.

I think my own personal experience has been very good with this. Insurers understand this is something that has really become part of the standard of care for a lot of people with cancer in families at risk for cancer in this country. So, as the tests get cheaper, that particular aspect is not going to be that much of a problem.

Harold J. Burstein, MD, PhD: The price of genetic testing is plummeting, and that’s a great thing for patients and for people interested in hereditary cancers. People draw analogies to Moore’s Law in computer technology, where the price of computing power has been declining exponentially. And the price of genetic testing for tumors—whether it’s for sequencing to look for targetable mutations or for hereditary cancer testing—has also been plummeting. So, at the moment, we’re talking about testing that’s usually on the order of $1000 to $2000 and is frequently less expensive than that. Some of the testing can be a little bit less expensive if you do a more tailored panel of genes. If you know exactly which ones you’re looking for, you can keep it simple, but wider panels cost a little bit more money. Interestingly, the technology to do them is awfully similar.

As we are getting to this era where more and more people are getting testing, I think a couple of things are going to happen. The first is the price pressure and competition is going to further drive down the price of genetic testing. The second is that this branded testing may disappear into commoditized testing. Nobody asks what brand of complete blood count (CBC) testing you had. You just get a CBC, and before too long, that’s the kind of thing we’re going to be doing for genetic testing—subject to, obviously, appropriate quality measures.

So, I think for most people, the expectation is that the price is going to come down. Now, having said that, many patients meet criteria for genetic testing. These are well established. For women with strong family history, specific kinds of breast cancers at specific ages, there’s near universal coverage in the United States for genetic testing for specific genes and hereditary syndromes. We’re not seeing problems with out-of-pocket expenses for most women who warrant genetic testing.

The price of testing when you say things like it’s $1000 to $2000—or something in that ballpark range—that’s the retail price, but that’s not the out-of-pocket expenses. For most patients who have standard healthcare coverage or insurance, the out-of-pocket expensing is negligible or very low.

Claudine Isaacs, MD: We’ve seen individuals where they have fairly striking family histories, but their insurance will not cover the testing. And that is obviously a dilemma and a problematic area to encounter. What we also see is that some insurances will cover for testing. They will cover for a certain extent of testing, but not others, and that can help drive the recommendations and can help inform what we recommend patients, how they would proceed with testing. So, there is significant variability from insurance to insurance in terms of what’s covered. Medicare covers differently than other insurances. Individual insurances will also cover differentially, so that does impact the decision making. Patients can also have some out-of-pocket costs, and those can vary from company to company. Frequently, what we also do within the setting of our genetic counseling session is to discuss the finances with them or to send this out to the company to get this preapproved or preauthorized by their insurance. And if there are issues, we’ll go back and we’ll look which companies are the best fit for that particular patient and which ones will minimize out-of-pocket costs for the patient.

Transcript Edited for Clarity
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