A general rule of thumb is for employers to let their health plans make the decisions about what to cover in genomic medicine, but they should still be well versed in the options. (Image: Shutterstock)

The world of genomic medicine and genetic testing is rapidly growing, leaving many employers to scramble what they’ll cover for their workers, according to “Genomic Medicine and Employers: Separating the Hope from Hype,” a report by the Northeast Business Group on Health.

“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. We developed this guide to provide a solid orientation on genomic medicine and give employers and HR a good place to start.”

Related: Why you should know what ‘pharmacogenetics’ is

Most of the spending has been for prenatal tests, followed by hereditary cancer tests, but about 10 new genetic tests are entering the market daily, for a total of about 75,000 tests to consider, the report cites a study in Health Affairs. More and more vendors are now advertising directly to consumers, causing more workers to ask their employers to cover it as a workplace benefit.

However, employers should think twice about offering workers broad coverage of consumer genetic tests, the report cites Dr. Jeffrey Levin-Scherz, North American co-leader at Willis Towers Watson.

“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,” Levin-Scherz says. “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.”

A general rule of thumb is for employers to let their health plans make the decisions about what to cover in genomic medicine, Mary Kay O’Neill a partner in Mercer’s health practice, told NEBGH.

“Health plans have a very clinical process, searching the medical literature for evidence-based protocols for genomics,” O’Neill says. “Health plans review the clinical literature on these tests or procedures fairly frequently. And while employers may read about one plan announcing it will pay for a genetic test while another plan may not yet do so, in most cases, the variation is temporary and attributable to differences in when plans review their policies.”

To understand how their health plan approaches coverage of genomic medicine, employers should ask the following questions:

  1. What is currently covered and not covered when it comes to various genomics-based testing and treatments?
  2. How do these policies align or differ with the policies of other health plans?
  3. What is the cost of various tests or treatments that are covered and not covered, and what is the cost for the patient?
  4. Will a test or treatment improve the health of the patient or the patient’s child? What is the impact on quality of life?
  5. Are there immediate or longer-term projected savings?
  6. Does your plan require a swift prior authorization process for genetic prenatal testing during the first or second OB visit?
  7.  Which clinical or review body does your plan follow in deciding whether to cover a genomic test or treatment?
  8. What metrics does your plan use to evaluate a test/treatment?

Employers should also consider these questions about their own company:

  1. Is your company a trendsetter when it comes to benefits or do you tend to follow standards in your industry and among your peers?
  2.  To what extent do you want to reward specific behaviors that could lower costs such as genetic screenings for cholesterol?
  3. Are you likely to opt for a generous coverage policy for prenatal genetic testing to avoid complaints among prospective parents?
  4.  When it comes to cancer, for example, how big a factor is cost in deciding what to cover?
  5. If your health plan does not cover a specific test ordered by an employee’s doctor, how do you want to handle that physician’s request?

“Genomic medicine is an exciting area and many promising discoveries await us. However, employers should not be expected to have the clinical expertise needed to make coverage decisions about genomic medicine,” says Mark Cunningham-Hill, medical director at NEBGH.

“For now, it may make sense for employers to turn a skeptical eye on the hype that surrounds this area and rely on their benefits consultants and health plans for guidance when making benefits decisions,” Cunningham-Hill says.