Thursday, October 20, 2022

Peer Reviewed Study of Payor Coverage vs Guidelines (Wong et al 2022)

Earlier this month, I noted that California had vetoed a biomarker-access bill regulating insurance - here.  Bills of this type have been promoted by oncology community stakeholders like American Cancer Society Cancer Action Network (ACS CAN)

See a subscription deep dive article on the California veto at Genomeweb, here.

What I had not seen before, a May 2022 article by Wong et al., supported by ACS/CAN.  This article looks at payor coverage by state in comparison to guideline recommendations, and found that payor coverage often fell short of guidelines.

Find Wong et al. 2022 here:

Aim: Commercial plan coverage policies for multigene panel tests may vary and could result in geographic variation in coverage due to the fragmented nature of the commercial insurance market. This study aimed to characterize the alignment of multigene panel tests coverage policies to that of clinical guidelines, overall and by state. 

Materials & methods: We reviewed NCCN Guidelines® for four tumors. Public coverage policies were identified via web search. Payer policies included those with the largest or second largest number of commercial lives in each state. Policies were classified as ‘more restrictive’ or ‘consistent’ with the guidelines. 

Results: Of 38 plans/policies reviewed, 71% were classified as ‘more restrictive’ than the guidelines, with variation in the number of commercial lives by state. Among these, 52% restricted on panel size and 63% restricted in all or select tumors. 

Conclusion: Most coverage policies were more restrictive. Clinical guideline clarity and state policies may improve alignment to guidelines and geographic variations.