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LILLEY CULLENM, DELILLE MINERVE, MIRZA KAMRANM, PARILLA MEGAN. Toward a More Just System of Care in Molecular Pathology. Milbank Q 2022; 100:1192-1242. [PMID: 36454130 PMCID: PMC9836258 DOI: 10.1111/1468-0009.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/09/2022] [Accepted: 06/23/2022] [Indexed: 12/02/2022] Open
Abstract
Policy Points American health care policy must be critically assessed to establish the role it plays in sustaining and alleviating the health disparities that currently exist in molecular genetic testing. It is critical to understand the economic and sociocultural influences that drive patients to undergo or forgo molecular testing, especially in marginalized patient populations. A multipronged solution with actions necessary from multiple stakeholders is required to reduce the cost of health care, rebalance regional disparities, encourage physician engagement, reduce data bias, and earn patients' trust. CONTEXT The health status of a population is greatly influenced by both biological processes and external factors. For years, minority and low socioeconomic patient populations have faced worse outcomes and poorer health in the United States. Experts have worked extensively to understand the issues and find solutions to alleviate this disproportionate burden of disease. As a result, there have been some improvements and successes, but wide gaps still exist. Diagnostic molecular genetic testing and so-called personalized medicine are just now being integrated into the current American health care system. The way in which these tests are integrated can either exacerbate or reduce health disparities. METHODS We provide case scenarios-loosely based on real-life patients-so that nonexperts can see the impacts of complex policy decisions and unintentional biases in technology without needing to understand all the intricacies. We use data to explain these findings from an extensive literature search examining both peer-reviewed and gray literature. FINDINGS Access to diagnostic molecular genetic testing is not equitable or sufficient, owing to at least five major factors: (1) cost to the patient, (2) location, (3) lack of provider buy-in, (4) data-set bias, and (5) lack of public trust. CONCLUSIONS Molecular genetic pathology can be made more equitable with the concerted efforts of multiple stakeholders. Confronting the five major factors identified here may help us usher in a new era of precision medicine without its discriminatory counterpart.
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Affiliation(s)
| | | | - KAMRAN M. MIRZA
- Loyola University Chicago, Strich School of Medicine
- Loyola Medical Center
| | - MEGAN PARILLA
- Loyola University Chicago, Strich School of Medicine
- Loyola Medical Center
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Sireci AN, Patel JL, Joseph L, Hiemenz MC, Rosca OC, Caughron SK, Thibault-Sennett SA, Burke TL, Aisner DL. Molecular Pathology Economics 101: An Overview of Molecular Diagnostics Coding, Coverage, and Reimbursement: A Report of the Association for Molecular Pathology. J Mol Diagn 2020; 22:975-993. [PMID: 32504675 PMCID: PMC7267794 DOI: 10.1016/j.jmoldx.2020.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/27/2020] [Accepted: 05/18/2020] [Indexed: 11/26/2022] Open
Abstract
Widespread indications for use of molecular diagnostics in various aspects of clinical medicine have driven proliferation of testing. The rapid adoption and continuous technological evolution of molecular diagnostics have often strained the development and maintenance of a functional underlying framework of coding, coverage, and reimbursement policies, thereby presenting challenges to various stakeholders, including molecular professionals, payers, and patients. A multidisciplinary working group convened by the Association for Molecular Pathology Economic Affairs Committee was tasked to describe the complex landscape of molecular pathology economics and highlight opportunities for member engagement. In this article, on the basis of review and synthesis of government regulations and procedures, published payer policy documents, peer-reviewed literature, and expert consensus, the Working Group navigates the ecosystem of molecular pathology economics in terms of stakeholders, coding systems and processes, coverage policy determination, and pricing mechanisms. The composition and interrelatedness of various working groups and committees are emphasized to highlight the functional underpinnings of the system. Molecular professionals must be conversant in the language and complex inner workings of molecular pathology economics to lead successful, viable laboratories and advocate effectively for policy development on their behalf. This overview is provided to be a resource to molecular professionals as they navigate the reimbursement landscape.
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Affiliation(s)
- Anthony N Sireci
- EAC101 Working Group, a Working Group of the Association for Molecular Pathology Economic Affairs Committee, Rockville, Maryland; Loxo Oncology, a wholly owned subsidiary of Eli Lilly, Stamford, Connecticut
| | - Jay L Patel
- EAC101 Working Group, a Working Group of the Association for Molecular Pathology Economic Affairs Committee, Rockville, Maryland; Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, Utah
| | - Loren Joseph
- EAC101 Working Group, a Working Group of the Association for Molecular Pathology Economic Affairs Committee, Rockville, Maryland; Division of Clinical Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthew C Hiemenz
- EAC101 Working Group, a Working Group of the Association for Molecular Pathology Economic Affairs Committee, Rockville, Maryland; Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, California; Department of Pathology, Keck School of Medicine of USC, Los Angeles, California
| | - Oana C Rosca
- EAC101 Working Group, a Working Group of the Association for Molecular Pathology Economic Affairs Committee, Rockville, Maryland; Department of Pathology and Laboratory Medicine, Northwell Health System, Staten Island University Hospital, Staten Island, New York
| | - Samuel K Caughron
- EAC101 Working Group, a Working Group of the Association for Molecular Pathology Economic Affairs Committee, Rockville, Maryland; The MAWD Pathology Group, Lenexa, Kansas
| | | | - Tara L Burke
- Association for Molecular Pathology, Rockville, Maryland
| | - Dara L Aisner
- EAC101 Working Group, a Working Group of the Association for Molecular Pathology Economic Affairs Committee, Rockville, Maryland; Department of Pathology, University of Colorado School of Medicine, Aurora, Colorado.
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Spillmann RC, McConkie-Rosell A, Pena L, Jiang YH, Schoch K, Walley N, Sanders C, Sullivan J, Hooper SR, Shashi V. A window into living with an undiagnosed disease: illness narratives from the Undiagnosed Diseases Network. Orphanet J Rare Dis 2017; 12:71. [PMID: 28416019 PMCID: PMC5392939 DOI: 10.1186/s13023-017-0623-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/04/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Patients' stories of their illnesses help bridge the divide between patients and providers, facilitating more humane medical care. Illness narratives have been classified into three types: restitution (expectation of recovery), chaos (suffering and loss), and quest (unexpected positive effect from illness). Undiagnosed patients have unique illness experiences and obtaining their narratives would provide insights into the medical and emotional impact of living with an undiagnosed illness. Adults and children with undiagnosed diseases apply to be evaluated by the Undiagnosed Diseases Network (UDN). Written illness narratives from 40 UDN applicants, including 20 adult probands who applied for themselves and 20 parents who applied for their children, were analyzed for: 1) narrative content and 2) narrative type. RESULTS Narrative content: could be grouped into three themes: 1) Expectations of the UDN: the majority felt they had no further healthcare options and hoped the UDN would provide them with a diagnosis, with the adults expecting to return to their previously healthy life and the parents wanting information to manage their child's healthcare. 2) Personal medical information: the narratives reported worsening of symptoms and some offered opinions regarding the cause of their illness. The proband narratives had few objective findings, while parental narratives had detailed objective information. 3) Experiences related to living with their undiagnosed illness: frustration at being undiagnosed was expressed. The adults felt they had to provide validation of their symptoms to providers, given the lack of objective findings. The parents worried that something relevant to their child's management was being overlooked. Narrative type: All the narratives were of the chaos type, but for different reasons, with the probands describing loss and suffering and the parents expressing fear for their child's future. The parental narratives also had elements of restitution and quest, with acceptance of "a new normal", and an emphasis on the positive aspects of their child's illness which was absent from the probands. CONCLUSIONS These narratives illustrate the chaos that coexists with being undiagnosed. The differences between the proband and parental narratives suggest that these two groups have different needs that need to be considered during their evaluation and management.
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Affiliation(s)
- Rebecca C. Spillmann
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Allyn McConkie-Rosell
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Loren Pena
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Yong-Hui Jiang
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Kelly Schoch
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Nicole Walley
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Camilla Sanders
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Jennifer Sullivan
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
| | - Stephen R. Hooper
- Department of Allied Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina USA
| | - Vandana Shashi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC USA
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Sireci AN, Aggarwal VS, Turk AT, Gindin T, Mansukhani MM, Hsiao SJ. Clinical Genomic Profiling of a Diverse Array of Oncology Specimens at a Large Academic Cancer Center: Identification of Targetable Variants and Experience with Reimbursement. J Mol Diagn 2016; 19:277-287. [PMID: 28024947 DOI: 10.1016/j.jmoldx.2016.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/23/2016] [Accepted: 10/05/2016] [Indexed: 12/11/2022] Open
Abstract
Large cancer panels are being increasingly used in the practice of precision medicine to generate genomic profiles of tumors with the goal of identifying targetable variants and guiding eligibility for clinical trials. To facilitate identification of mutations in a broad range of solid and hematological malignancies, a 467-gene oncology panel (Columbia Combined Cancer Panel) was developed in collaboration with pathologists and oncologists and is currently available and in use for clinical diagnostics. Herein, we share our experience with this testing in an academic medical center. Of 255 submitted specimens, which encompassed a diverse range of tumor types, we were able to successfully sequence 92%. The Columbia Combined Cancer Panel assay led to the detection of a targetable variant in 48.7% of cases. However, although we show good clinical performance and diagnostic yield, third-party reimbursement has been poor. Reimbursement from government and third-party payers using the 81455 Current Procedural Terminology code was at 19.4% of billed costs, and 55% of cases were rejected on first submission. Likely contributing factors to this low level of reimbursement are the delays in valuation of the 81455 Current Procedural Terminology code and in establishing national or local coverage determinations. In the absence of additional demonstrations of clinical utility and improved patient outcomes, we expect the reimbursement environment will continue to limit the availability of this testing more broadly.
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Affiliation(s)
- Anthony N Sireci
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Vimla S Aggarwal
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Andrew T Turk
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Tatyana Gindin
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Mahesh M Mansukhani
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Susan J Hsiao
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.
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Lynch JA, Berse B, Petkov V, Filipski K, Zhou Y, Khoury MJ, Hassett M, Freedman AN. Implementation of the 21-gene recurrence score test in the United States in 2011. Genet Med 2016; 18:982-90. [PMID: 26890451 DOI: 10.1038/gim.2015.218] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/17/2015] [Indexed: 01/17/2023] Open
Abstract
PURPOSE We examined hospital use of the 21-gene breast cancer test in the United States. We report state-level differences in utilization and propose a model for predicting implementation of guideline-recommended genomic testing. METHODS Genomic Health provided test orders for calendar year 2011.We summarized utilization at the hospital and state levels. Using logistic regression, we analyzed the association between the likelihood to order the test and the hospital's institutional and regional characteristics. RESULTS In 2011, 45% of 4,712 acute-care hospitals ordered the test, which suggests that 25% of newly diagnosed invasive female breast cancer cases were tested. Significant predictors of testing included participation in National Cancer Institute (NCI) clinical research cooperative groups (odds ratio (OR) 3.73; 95% confidence interval, 2.96-4.70), advanced imaging (OR, 2.19; CI, 1.78-2.68), high-complexity laboratory (OR, 2.15; CI, 1.24-3.70), affiliation with a medical school (OR, 1.57; CI, 1.31-1.88), and reconstructive surgery (OR, 1.23; CI, 1.01-1.50). Significant regional predictors included metropolitan county (OR, 3.77; CI, 2.83-5.03), above-mean income (OR, 1.37; CI, 1.11-1.69), and education (OR, 1.26; CI, 1.03-1.54). Negative predictors included designation as a critical-access hospital (OR, 0.10; CI, 0.07-0.14) and distance from an NCI cancer center (OR, 0.998; CI, 0.997-0.999), with a 15% decrease in likelihood for every 100 miles. CONCLUSION Despite considerable market penetration of the test, there are significant regional and site-of-care differences in implementation, particularly in rural states.Genet Med 18 10, 982-990.
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Affiliation(s)
- Julie A Lynch
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,RTI International, Research Triangle Park, Durham, North Carolina, USA
| | - Brygida Berse
- RTI International, Research Triangle Park, Durham, North Carolina, USA.,Boston University School of Medicine, Boston, Massachusetts, USA.,Veterans Health Administration, Bedford, Massachusetts, USA
| | - Valentina Petkov
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kelly Filipski
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Yingjun Zhou
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Muin J Khoury
- Office of Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Epidemiology and Genomics Research Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael Hassett
- Dana Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew N Freedman
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf 2015; 24:103-10. [PMID: 25589094 PMCID: PMC4316850 DOI: 10.1136/bmjqs-2014-003675] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Diagnostic errors are major contributors to harmful patient outcomes, yet they remain a relatively understudied and unmeasured area of patient safety. Although they are estimated to affect about 12 million Americans each year in ambulatory care settings alone, both the conceptual and pragmatic scientific foundation for their measurement is under-developed. Health care organizations do not have the tools and strategies to measure diagnostic safety and most have not integrated diagnostic error into their existing patient safety programs. Further progress toward reducing diagnostic errors will hinge on our ability to overcome measurement-related challenges. In order to lay a robust groundwork for measurement and monitoring techniques to ensure diagnostic safety, we recently developed a multifaceted framework to advance the science of measuring diagnostic errors (The Safer Dx framework). In this paper, we describe how the framework serves as a conceptual foundation for system-wide safety measurement, monitoring and improvement of diagnostic error. The framework accounts for the complex adaptive sociotechnical system in which diagnosis takes place (the structure), the distributed process dimensions in which diagnoses evolve beyond the doctor's visit (the process) and the outcomes of a correct and timely "safe diagnosis" as well as patient and health care outcomes (the outcomes). We posit that the Safer Dx framework can be used by a variety of stakeholders including researchers, clinicians, health care organizations and policymakers, to stimulate both retrospective and more proactive measurement of diagnostic errors. The feedback and learning that would result will help develop subsequent interventions that lead to safer diagnosis, improved value of health care delivery and improved patient outcomes.
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Affiliation(s)
- Hardeep Singh
- Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Dean F Sittig
- University of Texas School of Biomedical Informatics and the UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, Texas, USA
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Lynch HT, Snyder C, Stacey M, Olson B, Peterson SK, Buxbaum S, Shaw T, Lynch PM. Communication and technology in genetic counseling for familial cancer. Clin Genet 2013; 85:213-22. [PMID: 24355094 DOI: 10.1111/cge.12317] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 12/13/2022]
Abstract
When a cancer predisposing germline mutation is detected in an index case, the presence of the underlying syndrome is confirmed and the potential for predictive testing of at-risk relatives is established. However, the reporting of a positive family history does not routinely lead to communication of information about risk to close, much less distant relatives. This review summarizes information technology utilized to address penetration or 'reach' of knowledge of risk within extended families, including the use of telephone and video counseling to reach distant patients, and anticipate novel internet-based processes for communication between investigators and relatives.
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Affiliation(s)
- H T Lynch
- Department of Preventive Medicine and Public Health, Creighton University, Omaha, NE, USA
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Eligibility criteria in private and public coverage policies for BRCA genetic testing and genetic counseling. Genet Med 2012; 13:1045-50. [PMID: 21844812 DOI: 10.1097/gim.0b013e31822a8113] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE : Coverage policies for genetic services for hereditary cancers are of interest because the services influence cancer risk reduction for both persons with cancer and their family members. We compared coverage policies for BRCA genetic testing and genetic counseling among selected payers in the United States to illuminate eligibility criteria variation that may explain differential access by insurance type. We compared these policies with policies for breast cancer screening with magnetic resonance imaging to consider whether payers apply a unique policy approach to genetic services. METHODS : We conducted a case study of large private and public payers selected on number of covered lives. We examined coverage policies for BRCA genetic testing, genetic counseling, and screening with magnetic resonance imaging and the eligibility criteria for each. We compared eligibility criteria against National Comprehensive Cancer Network guidelines. RESULTS : Eligibility criteria for BRCA testing were related to personal history and family history of cancer. Although private payers covered BRCA testing for persons with and without cancer, the local Medicare carrier in our study only covered testing for persons with cancer. In contrast, Arizona's Medicaid program did not cover BRCA testing. Few payers had detailed eligibility criteria for genetic counseling. Private payers have more detailed coverage policies for both genetic services and screening with magnetic resonance imaging in comparison with public payers. CONCLUSION : Despite clinical guidelines establishing standards for BRCA testing, we found differences in coverage policies particularly between private and public payers. Future research and policy discussions can consider how differences in private and public payer policies influence access to genetic technologies and health outcomes.
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Abstract
For several major cancers, drug selection already pivots on biomarker results (e.g., trastuzumab for breast cancer, and gefitinib and erlotinib for lung cancer). Fast-paced advances in genomic and proteomic laboratory technologies could enable the widespread use of molecular testing before therapy selection in any field of medicine. This article describes two potentially large obstructions to such innovation. First, laboratory tests have traditionally been commodities with low prices, prices that matched the resources required to operate the laboratory technology itself. Assuming that the marginal costs of molecular laboratory technology will fall, there will be a widening chasm between estimated test revenue and the costs of innovative and definitive clinical trials, and regulatory approval for new tests. Without corrective action, even cost-saving laboratory tests could be in shortfall, because they will not be created through upfront investment. Second, it is argued that while diagnostic tests, drugs and surgical procedures should meet a fundamental standard for payer coverage (‘will health outcomes be improved?’), molecular diagnostics could require different analysis pathways than those that are used to evaluate interventions.
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