From the Past to the Present: Insurer Coverage Frameworks for Next-Generation Tumor Sequencing

Julia R. Trosman*, Christine B. Weldon, William J. Gradishar, Al B Benson III, Massimo Cristofanilli, Allison W. Kurian, James M. Ford, Alan Balch, John Watkins, Kathryn A. Phillips

*Corresponding author for this work

Research output: Contribution to journalArticle

4 Scopus citations

Abstract

Next-generation sequencing promises major advancements in precision medicine but faces considerable challenges with insurance coverage. These challenges are especially important to address in oncology in which next-generation tumor sequencing (NGTS) holds a particular promise, guiding the use of life-saving or life-prolonging therapies. Payers’ coverage decision making on NGTS is challenging because this revolutionary technology pushes the very boundaries of the underlying framework used in coverage decisions. Some experts have called for the adaptation of the coverage framework to make it better equipped for assessing NGTS. Medicare's recent decision to cover NGTS makes this topic particularly urgent to examine. In this article, we discussed the previously proposed approaches for adaptation of the NGTS coverage framework, highlighted their innovations, and outlined remaining gaps in their ability to assess the features of NGTS. We then compared the three approaches with Medicare's national coverage determination for NGTS and discussed its implications for US private payers as well as for other technologies and clinical areas. We focused on US payers because analyses of coverage approaches and policies in the large and complex US health care system may inform similar efforts in other countries. We concluded that further adaptation of the coverage framework will facilitate a better suited assessment of NGTS and future genomics innovations.

Original languageEnglish (US)
Pages (from-to)1062-1068
Number of pages7
JournalValue in Health
Volume21
Issue number9
DOIs
StatePublished - Sep 2018

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Keywords

  • insurance coverage
  • next-generation sequencing
  • precision medicine
  • precision oncology
  • reimbursement
  • tumor sequencing

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health

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