AMA calls for clarity on how precision medicine is reimbursed

As genomic tests and therapies advance, proliferate and get easier to administer, the group wants payers to be more transparent about how providers can bill for them.
By Mike Miliard
03:50 PM
precision medicine

The American Medical Association wants an update to how insurance covers genomic tests and other precision medicine treatments. At AMA's interim meeting this week, members approved recommendations how the ever-growing array of genetic tests should be reimbursed: easily and transparently.

The policy calls for clarity around how such tests – which are easier to prescribe and perform than ever – are covered and paid for. Traditional procedures such as randomized controlled trials may be outmoded and unnecessarily burdensome, according group, and its physician leadership has called on payers to work more closely with makers of genetic and tests, clinicians and medical specialty societies to develop specific benchmarks to define the evidence and efficacy necessary for coverage.

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The association points out that advanced bioinformatics programs are increasingly showing the validity of genomic testing and therapeutics and are unlocking new insights into how health conditions are understood.

But there is "considerable variability among public and private payers with regard to the evidentiary requirements for coverage of genetic/genomic precision medicine," according to AMA. "Moreover, different insurers may review the same evidence yet reach conflicting conclusions about medical necessity and coverage of these services."

In recognition of what genomic advances can mean for patients and their families, payers should address those inconsistencies, the group said. They should be clear about what evidence is considered for precision medicine coverage their methods for updating it as the science evolves. And they should offer providers and the chance to review those criteria, offer feedback and suggest revisions.

"Precision medicine tests, technologies and therapeutics are increasingly being adopted into clinical practice as evidence of their effectiveness grows," said AMA Board Member William E. Kobler, MD, in a statement. "However, many patients do not have access to precision medicine because most public and private health insurers do not offer coverage for genetic or genomic services unless certain clinical criteria and evidentiary standards are met. As a result, access to this next generation of clinical testing services is often limited."

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