Abstract
Chris Anderson, Editor in Chief
It’s no secret that diagnostic companies often feel they get the short end of the stick when it comes getting reimbursement from the likes of Medicare, Medicaid, and the private insurance companies. For medical centers using next-generation sequencing, or other sequencing techniques to provide a more precise diagnosis for their patients, the road has been equally—if not doubly—hard.
There are two elements at play: the costs of the tests themselves; and hard evidence that the tests effectively diagnose a specific condition while also providing for better outcomes.
Granted, some tests that rely on genetic information, like noninvasive prenatal testing (NIPT), are getting reimbursed. For NIPT, its less invasive—and, hence, less risky—testing method has spurred uptake by OB-GYNs, and the prospect of reducing medical costs when the other methods go wrong have caused most payers to jump on board.
But what of NGS-based diagnostics? While it is certainly an area that is awash in data, not enough of them are the kind of data that insurers seek when making decision on what procedures and tests they are willing to pay for.
When it comes to developing that evidence, Joydeep Goswami, president of clinical NGS and oncology at Thermo Fisher Scientific thinks the insurance companies themselves can play a role in bringing NGS-based diagnostics into broader clinical practice.
“I feel the payers, especially the larger payers, can push the field forward much faster than individual hospitals or medical centers can. Because they can run multicenter trials with patients that are in their system to collect the kind of data that would provide the utility of the technology much faster, if they were so inclined. That is an area where we are trying to convince payers that they should take the lead,” he said.
Granted, this would be a step outside the normal comfort zone for insurers. But in today’s healthcare environment, it is an investment that could be in their best interests. With more and more targeted therapies, and combination therapies for cancer coming to light, getting these patients on the right treatment is an area ripe for savings. After all, name me an insurance company that is in favor of paying for a wrong—and likely very expensive—cancer treatment.
Making this commitment should be somewhat easier for insurers, too, as in the past decade the move away from a fee-for-service model to value-based care payment structures has seen them sitting at the same table with healthcare providers as partners instead of adversaries.
So, if healthcare is truly going to transition to providing precision care to its patients leveraging NGS, then it is time for insurers to make a concerted effort to support these efforts. Doctors on the front lines know the benefit of these methods intuitively. Insurers should partner with them to prove it.