POWER PERSPECTIVE

Medicare to Cover Genetic Sequencing in Cancer Patients

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“President's Cancer Panel”

Plus: a positive trend regarding prescription Rx rebates

Maybe you are like me and have had your cancer “sequenced” so you and your doctor can know if a targeted treatment or a clinical trial is right for you. Too often only wealthier patients have been able to afford this because insurance—either private or Medicare—wouldn’t pay for it. But now, things are changing. Yay! Also some other changes are in the works that could lower what we pay in co-pays for expensive oral cancer medicines. Progress. But we all need to keep sounding off and pushing.

Here at Patient Power we are very pleased to share the news that Medicare has decided to provide payment for some “Next Generation (gene) Sequencing” for patients with advanced cancers. Here’s what that means and why it’s important.

Cancer is driven by changes in our DNA. These can be changes we’re born with or changes caused by the environment, such as too much exposure to ultra-violet light causing skin cancer. The genetic makeup of a tumor, these changes in the DNA, can be the cornerstone of precision medicine based on the specific, individual and personal characteristics of a patient’s cancer. According to the National Cancer Institute, “In some cases, knowledge of the genetic alterations in your cancer can help determine a treatment plan. Some treatments—particularly, some targeted therapies—are effective only for people whose cancer cells have specific genetic alterations that cause the cells to grow out of control.”  

Today, what’s called “Next Generation Sequencing,” can be done faster, more accurately and at less cost than ever before.

The specific wording from the Centers for Medicare and Medicaid services regarding this expanded coverage says: Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when ordered by a treating physician and then performed in a certified laboratory.  This covers recurrent, relapsed, refractory, metastatic, or advanced stages III or IV cancer. It also applies when a patient has decided to seek further treatment.

One of the companies that supplies genetic analysis says this provides coverage across all solid tumors.

There are some technical considerations regarding repeat testing, approved laboratories and approved uses of the genetic analysis, but this greatly expands coverage for this important tool for precision medicine.

“This is a great first step, so patients with life-threatening conditions get the precise treatments they need and deserve, and avoid the unwanted side effects of more general, and often less effective, treatments. Here at Patient Power we are pleased to have submitted official comments on this proposed new coverage and to have played at least a small role in encouraging this change.”

However, this is just a start.  “Our hope is private insurance companies will follow suit, and more cancers will be covered so state-of-the art care can be delivered. The goal is so ‘the right patient gets the right care.’”

As we reported here last week, the President’s Cancer Panel determined that health insurance is a key factor in ensuring modern cancer therapeutics are affordable to patients. “As health insurance access has expanded, fewer Americans report forgoing needed drugs because of cost. Future policies should support, not undermine this progress.”

This is an important step that moves insurance coverage forward to further support access to the latest diagnostics and decisions regarding treatments.

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While we’re on the subject of insurance, in November, we reported on a problem with insurance coverage, namely that many healthcare plans get rebates for prescription drugs, but charge patients co-pays based on the full retail price. But we have some good news to pass along. Earlier this month the Washington Post reported that UnitedHealthcare will pass rebates for prescription drugs directly to the 7 million people enrolled in its fully insured employer plans.

According to the Post, “These rebates—which have grown dramatically in recent years—are typically (and controversially) pocketed by employers or insurers instead of used to lower out-of-pocket costs for enrollees. Because the size of the rebates aren’t made public, customers often don’t know they’re paying far more for drugs than the price negotiated by their plan.”

The decision will only affect a small portion of the patients covered by UnitedHealthcare, but it is the start of a trend in the right direction.

As always, I welcome your comments and your own story of financial and drug access battles. Write to me at comments@patientpower.info

Andrew Schorr
Co-Founder, Patient Power LLC

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

 

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Page last updated on March 22, 2018