Using employees' genetic information for diagnostic or therapeutic decision-making—known as genomic medicine—has the potential to lower health care costs through early diagnoses and treatments, but that promise comes with many caveats.
Earlier this year, the nonprofit Northeast Business Group on Health (NEBGH), an employer-led coalition, convened a roundtable with employers, clinical experts, benefits consultants and vendors to explore the relevance of genomic medicine to employers. The key takeaways are presented in a 24-page guide that NEBGH released Nov. 20, Genomic Medicine and Employers: Separating the Hope from the Hype.
"Employers are beginning to take a heightened interest in genomic medicine," said Candice Sherman, CEO of NEBGH. "They clearly want to better understand genomic medicine and know what guidelines they should follow in making relevant benefit decisions."
To Test or Not
The Society for Human Resource Management's 2018 Employee Benefits survey, which polled 3,218 HR professionals in early 2018, found that 18 percent of organizations provide genetic-testing coverage to predict the likelihood of diseases like cancer, up from 12 percent in 2016, the first year SHRM asked this question in its annual survey.
Genetic testing also can help with precision prescribing of medications, which takes into account genetic variations that affect drug response, its advocates say.
Employers are more likely to provide insurance coverage for genetic testing when doing so is backed by clinical evidence—Down syndrome screening for high-risk mothers, for example. But benefits consultants generally don't recommend genetic testing as part of routine health screenings.
Roundtable participant Jeffrey Levin-Scherz, North American co-leader at HR consultancy Willis Towers Watson, is among those who are cautious about widespread testing. "Screening populations at low risk leads to many false positives, and there is little imperative to test right now when tests are getting more accurate and less expensive over time," he pointed out.
When considering whether to revise health plan designs, "employers should ask how testing will be integrated with health care delivery, and make sure doctors ordering the tests do not have financial relationships with genetic-testing vendors," Levin-Scherz advised.
In an October 2017 advisory, consulting firm Mercer wrote that patients "may think that if they get certain types of genetic testing, they will learn very clearly whether or not they have a risk. But more often, the result of the test is to be given a probability of risk. That's much harder for a person to take and make a decision on, and can cause unnecessary worry, testing and even treatment."
However, the proliferation of genetic tests for inherited traits has caused a corresponding spike in consumer advertising by genetic-screening and counseling vendors, such as Color Genomics and 23andMe. "We see a lot of activity with employers being approached directly by employees," said Mary Kay O'Neill, a partner in Mercer's health practice and another roundtable participant. "As a result, employees may ask for benefits coverage."
Genomics vendors also may advocate directly to benefits leaders for test or treatment coverage, and self-insured employers can decide which genomic tests or procedures they will cover.
"For now, it may make sense for employers to turn a skeptical eye on the hype that surrounds genomic medicine and rely on their benefits consultants and health plans for guidance when making benefits decisions," said Mark Cunningham-Hill, medical director at NEBGH.
"Health plans have a very clinical process, searching the medical literature for evidence-based protocols for genomics," O'Neill noted.
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What to Ask
The guide provides questions that employers should ask when considering the costs and potential benefits of covering genetic tests.
To understand how their health plan approaches coverage of genomic medicine, employers should first ask:
- What is currently covered and not covered when it comes to genomics-based testing and treatments?
- How do these policies align or differ with the policies of other health plans?
- What are the costs of various tests or treatments that are covered and not covered, and what are the costs for the patient?
- Will a test or treatment improve the health of the patient or the patient's child? What is the impact on quality of life?
- Are there immediate or longer-term projected savings?
- Does our plan require a swift prior-authorization process for genetic prenatal testing during the first or second visit to the obstetrician?
- Which clinical or review body does our plan follow in deciding whether to cover a genomic test or treatment?
- What metrics does our plan use to evaluate a test or treatment?
Next, to more clearly define a benefits strategy, employers should ask these questions about their organization:
- Is our company a trendsetter when it comes to benefits, or do we tend to follow standards in our industry and among our peers?
- To what extent do we want to reward behaviors that could lower costs, such as genetic screenings for cholesterol?
- Are we likely to opt for a generous coverage policy for prenatal genetic testing to avoid complaints among prospective parents?
- When it comes to cancer, for example, how big a factor is cost in deciding what to cover?
- If our health plan does not cover a test ordered by an employee's doctor, how do we want to handle that physician's request?