Mark Robson, MD
Mark Robson, MD, is clinical director of the Clinical Genetics Service at Memorial Sloan Kettering Cancer Center (MSKCC) in New York and a medical oncologist with 20 years’ experience in clinical cancer genetics; however, under Cigna’s new policy on coverage for hereditary genetic testing, Robson is not qualified to order genetic tests for cancer susceptibility. In contrast, a freshly board certified prenatal counselor who has not undergone specialized cancer genetics training is qualified to do so. Robson finds this illogical. “According to Cigna, a prenatal genetic counselor who has never seen a cancer patient is allowed to order and certify a test simply because they have an MGC after their name. Whereas I, who have been doing this for a very long time, am not, because I have an MD after my name. That doesn’t really seem to make much sense to me.”
Cigna’s new policy is an extension of a previous Cigna requirement for the use of certified genetic counselors for breast, ovarian, and colorectal cancer genetic tests. Robson says it is illogical because an understanding of cancer susceptibility testing is an integral part of modern oncology. His position is shared by ASCO. In May, the professional society of those who care for cancer patients issued a statement in opposition to Cigna’s new policy, which it said “introduces an unnecessary barrier to the appropriate use of genetic testing services and has the potential to negatively impact care provided to patients with cancer.” The group contends that adding this requirement may result in patients opting out of potentially beneficial genetic testing because of the barrier of the additional referral. ASCO also contends that unnecessary additional services may increase costs.
“The question is ‘Who is capable of obtaining that informed consent or providing patients with enough information to give that informed consent?’” Robson said. “ASCO has stated quite firmly that medical oncologists are very much trained and capable of obtaining informed consent for genetic testing for cancer patients. It’s part of what we’re trained to do. It’s part of what the organization educates its membership to do, and it’s a part of oncologic care.”
Cigna counters that genetics testing has become exponentially more complicated over the years, to the point where many hours of training and regular updates are needed for healthcare professionals to have a reliable understanding of how to fully prepare patients for tests and provide the necessary interpretation afterward. The payer contends that not all oncologists have time to keep up with rapid advances in the field or to give patients all of the counseling that they need. In addition, the payer contends that physicians are increasingly ordering large panel gene tests that cost more and yield information that may not have value.
“We’re not trying to be a barrier here,” said Jeffrey Hankoff, MD, a medical officer at Cigna. “We’re not trying to interrupt the physician/patient relationship. We’re really trying to get to the point where we have an educated, knowledgeable patient and consumer who very well understands the implications of testing, what the tests mean, and, when the results come back, what the implications are not only for them but for everyone else in their family, and not just their children, but their sisters, their brothers, their aunts, their uncles, and so on.”
According to ASCO, other payers have introduced requirements for the use of certified genetic professionals. However, the organization notes that The Centers for Medicare & Medicaid Services has decided not to institute such a requirement for genetics testing. Robson said that in New York he has the convenience of having a number of certified genetic counselors on staff, but physicians elsewhere in the country do not have that luxury, he said, adding that shortages of certified counselors exist, especially in rural areas and in institutions caring for underserved populations. Cigna provides a list of available counselors in each state and also recommends the use of telephone-based counseling. Professional counselor organizations say their members are amply available geographically and by phone. Hankoff said the payer is not trying to make it difficult to find people who can qualify for acceptance as certified counselors.