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EXAMINING EVIDENCE IN U.S. PAYER COVERAGE POLICIES FOR MULTI-GENE PANELS AND SEQUENCING TESTS

Published online by Cambridge University Press:  25 October 2017

James D. Chambers ,
Cayla J. Saret ,
Jordan E. Anderson ,
Patricia A. Deverka ,
Michael P. Douglas  and
Kathryn A. Phillips
James D. Chambers
Affiliation:
Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicinejchambers@tuftsmedicalcenter.org
Cayla J. Saret
Affiliation:
Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center
Jordan E. Anderson
Affiliation:
Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center
Patricia A. Deverka
Affiliation:
American Institutes for Research, Department of Research and Evaluation
Michael P. Douglas
Affiliation:
University of California at San Francisco, Department of Clinical Pharmacy
Kathryn A. Phillips
Affiliation:
University of California at San Francisco, Department of Clinical Pharmacy UCSF Philip R. Lee Institute for Health Policy and UCSF Helen Diller Family Comprehensive Cancer Center
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Abstract

Objectives: The aim of this study was to examine the evidence payers cited in their coverage policies for multi-gene panels and sequencing tests (panels), and to compare these findings with the evidence payers cited in their coverage policies for other types of medical interventions.

Methods: We used the University of California at San Francisco TRANSPERS Payer Coverage Registry to identify coverage policies for panels issued by five of the largest US private payers. We reviewed each policy and categorized the evidence cited within as: clinical studies, systematic reviews, technology assessments, cost-effectiveness analyses (CEAs), budget impact studies, and clinical guidelines. We compared the evidence cited in these coverage policies for panels with the evidence cited in policies for other intervention types (pharmaceuticals, medical devices, diagnostic tests and imaging, and surgical interventions) as reported in a previous study.

Results: Fifty-five coverage policies for panels were included. On average, payers cited clinical guidelines in 84 percent of their coverage policies (range, 73–100 percent), clinical studies in 69 percent (50–87 percent), technology assessments 47 percent (33–86 percent), systematic reviews or meta-analyses 31 percent (7–71 percent), and CEAs 5 percent (0–7 percent). No payers cited budget impact studies in their policies. Payers less often cited clinical studies, systematic reviews, technology assessments, and CEAs in their coverage policies for panels than in their policies for other intervention types. Payers cited clinical guidelines in a comparable proportion of policies for panels and other technology types.

Conclusions: Payers in our sample less often cited clinical studies and other evidence types in their coverage policies for panels than they did in their coverage policies for other types of medical interventions.

Keywords

Payer coverage policiesEvidenceMulti-gene panels and sequencing tests
Type
Policies
Information
International Journal of Technology Assessment in Health Care , Volume 33 , Issue 4: Mini-Theme: Stories of HTA Impact , 2017 , pp. 534 - 540
Copyright
Copyright © Cambridge University Press 2017 

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