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Published on: August 9, 2024
Payers' Views on Insurance Coverage for Confirmatory Diagnostics After a Noncovered Multicancer Early Detection
Julia R Trosman1,2,3, Christine B Weldon1,3, Allison W Kurian4
11UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), San Francisco, CA.
Summary
Most US private payers would cover confirmatory diagnostics after a positive multicancer early detection (MCED) test, but often with restrictions. Developing clear coverage policies and addressing patient cost-sharing are crucial for MCED adoption.
Area of Science:
- Health Economics
- Oncology
- Health Policy
Background:
- Multicancer early detection (MCED) tests are emerging in clinical practice but lack widespread payer coverage.
- Understanding payer coverage for necessary confirmatory diagnostics after a positive MCED test is critical for oncology professionals.
- This study examines US private payer perspectives on coverage for confirmatory testing following non-covered MCED tests.
Purpose of the Study:
- To assess US private payer views on coverage for confirmatory diagnostics after a positive, non-covered MCED test.
- To identify potential barriers and payer strategies related to confirmatory testing coverage.
- To inform oncology professionals and policymakers about payer perspectives on MCED follow-up care.
Main Methods:
- Conducted semistructured interviews with 16 US private payers (national and regional insurers, coverage decision support organizations).
- Employed thematic analysis, supplemented by frequency counts, to analyze payer responses.
- Focused on coverage policies and perspectives regarding confirmatory diagnostics post-MCED testing.
Main Results:
- While no payers covered MCED tests, 63% would cover confirmatory testing, often with clinical restrictions (70%).
- Few payers (19%) would cover repeat testing if cancer wasn't diagnosed; none had formal post-MCED policies.
- Most payers acknowledged patient barriers but few planned to reduce cost-sharing for confirmatory tests.
Conclusions:
- Explicit coverage policies for confirmatory diagnostics are needed, extending beyond MCED to similar novel tests.
- Oncology professionals need to be aware of payer coverage nuances for positive MCED results.
- Addressing patient cost-sharing is a national policy issue essential for growing MCED adoption.
