How Medicare coverage of genetic counseling could decrease care costs and improve quality

December 26, 2018

A new bill recently introduced to Congress would not only reduce barriers to genetic counseling for Medicare patients, but also could significantly decrease costs of caring for elderly and low-income patients.

A new bill recently introduced to Congress would not only reduce barriers to genetic counseling for Medicare patients, but also could significantly decrease costs of caring for elderly and low-income patients.

The bill-known as the “Access to Genetic Counselor Services Act of 2018” (H.R. 7083)-would reimburse certified genetic counselors for counseling provided to Medicare patients. Currently, certified genetic counselors are not recognized by CMS as providers, even though genetic counseling is a covered benefit. As a result, today, genetic counseling for Medicare patients can only be provided:

  • Under direct supervision of a physician

  • To patients who are established patients of the physician practice

The implications of expanded access to genetic counseling services for Medicare patients are significant. There are three ways the bill has the potential to improve quality of care and health outcomes while making a deep impact on costs:

  • The bill would help to eliminate disparities in care for low-income and elderly patients. Many patients don’t live in areas where genetic counseling is easily accessible under the current guidelines. Improved access to genetic counseling, including telephonic counseling, supports increased availability of potentially life-saving information and treatments. It also ensures those who qualify for tests, as well as their providers, are fully informed before and during the testing process. 

  • The bill would change the way in which providers and genetic counselors interact with one another-and that could drive down costs related to genetic tests and therapies. Each day, up to 10 new genetic tests are introduced. Yet only a fraction of patients who could benefit from these advancements have access to them. Meanwhile, patients who wouldn’t benefit from genetic tests and therapies often are still being tested, primarily due to a lack of genetics education on multiple fronts.

Consider that one out of every three genetic tests is ordered incorrectly. This leaves payers and providers vulnerable to orders for the wrong test at the wrong time for the wrong patient-and the increased financial and emotional toll these decisions have for health plans and their members. The availability of direct support from certified genetic counselors to Medicare patients helps ensure decisions around genetic testing and therapies are based on clinical evidence. It’s an approach that improves quality of care while reducing costs.

  • The bill would support more informed decision-making around genetic testing and therapies. Our work with a national health plan found that when genetic counseling is a required component of the medical necessity determination process, approximately one out of five individuals who receive counseling with proper informed consent decide not to pursue genetic testing. In some cases, this is because a complete understanding of the member’s family medical history reveals that testing is unlikely to provide any benefit. A decision not to proceed with testing both reduces unnecessary costs and helps the patient avoid unnecessary and potentially harmful treatments-a fact that most health plan members understand after genetic counseling and appreciate.

One area in which access to genetic counselors can make a difference is in response to requests for BRCA testing. One in 400 people carry BRCA1 or BRCA2, gene mutations that impact a person’s chances of developing breast and ovarian cancer. With celebrity attention and media coverage around BRCA, many patients are asking their providers about getting tested, but they may not be eligible or likely to benefit from the test. With appropriate genetic counseling and prior authorization processes in place, patients and providers can become better educated on eligibility, resulting in cost savings and better outcomes. When testing is avoided because it is not medically appropriate, the cost savings can be thousands of dollars per test.

A Fiscally Responsible Approach

In 2019, U.S. healthcare spending is expected to climb six percent, with CMS predicting an eight percent increase in Medicare spending by 2020. Uncontrolled growth in healthcare expenditures nationally requires new approaches to care based on evidence and consideration of healthcare costs. H.R. 7083helps address these challenges:

  • It will improve quality of care and quality of life for elderly and disadvantaged patients at reduced costs.

  •  It will ensure that our elderly and low-income neighbors’ access to care isn’t limited by geographic location.

  • It provides a starting point for informed decision making and discussion with providers across the nation-a move that benefits not only Medicare patients, but all patients.

As the bill is reviewed by Congress, it’s important for legislators to keep in mind not only the bill’s potential to improve access to specialized care, but also its prospects for decreasing downstream care costs for Medicare patients through better informed decision-making.

Rebecca Sutphen, MD, FACMG, is cofounder and chief medical officer for InformedDNA.