The Cost of Biomarker Testing: Moving from Support-based to Sustainable Solutions

Biomarker testing is expensive. Yet, when identifying specific genetic mutations in cancer has the power to guide treatment plans, reduce adverse effects from treatment, and improve health outcomes, cost should be the last thing patients and providers focus on. However, the cost of biomarker testing continues to drive insurance approvals and determine whether Medicaid beneficiaries or patients with limited to no insurance even get tested.

In a study published in the Journal of the National Comprehensive Cancer Network examining the relationship between Medicaid (versus commercial) insurance coverage and biomarker testing, targeted therapy, and overall survival in patients with advanced non-small cell lung cancer, Medicaid beneficiaries were less likely to undergo biomarker testing or receive any first-line biomarker-driven therapy.

The complexities of testing coverage for these patients become even more complicated when providers request testing on both blood and tissue (ie, liquid biopsy), or elect to conduct comprehensive biomarker testing rather than a single marker testing. These decisions often result in additional layers of scrutiny and a lengthy process of denials and approvals by insurance plans. Yet, according to the American Cancer Society Cancer Action Network (ACS CAN), patients who received broad panel biomarker testing experienced an average additional up-front cost increase of $1,200 compared to patients who received narrow panel biomarker testing, patients who received broad panel biomarker on average experienced a cost savings of about $8,500 per month in total cost of care, a substantial overall savings in treatment costs over time.

As cost continues to drive access to testing and type of testing performed (if any), the burden is placed squarely on the shoulders of cancer programs and practices to navigate patients through the complex biomarker testing process and find immediate resources to help patients pay for co-pays and/or out-of-pocket expenses of testing. While financial advocates and patient navigators are quickly becoming well-versed in finding local and immediate resources to support patients in need, such as vendor financial assistance programs and/or charitable care programs, the challenge has now become how can biomarker testing become standard of care for all patients with cancer and ensure sustainable, comprehensive coverage?

To answer this question and much more, the Association of Community Cancer Centers (ACCC) and its program partners—ACS CAN and LUNGevity, with support from Foundation Medicine and Exact Sciences—launched a series of focus groups earlier this year aimed at making the case for increasing access to comprehensive genomic profiling for Medicaid beneficiaries. 

Policy Approach

The biomarker testing policy landscape continues to evolve and organizations like the ACS CAN, LUNGevity, and others nationwide are working to enact state legislation that would provide comprehensive biomarker testing coverage for all patients who require it. Coalition building and alliances with providers, patients, state oncology societies, and other stakeholders who can share case studies, verbal testimonies, and personal stories are also playing a tremendous role in building support and momentum for advocacy. Advocating on the grounds of health equity has proven a powerful tool to gain support for comprehensive coverage, and providers are making the case for comprehensive coverage for all.

There has also been success with administration advocacy. As Hilary Gee Goeckner, MSW, director of State and Local Campaigns at the ACS CAN describes, “Part of our legislative campaigns is doing prep[aration] work with Medicaid directors ahead of time to talk about the legislation and what it would mean for the Medicaid program,” she said. “A really important part of that is figuring out what is already covered and making it clear that this is not about covering something brand new, but that essentially, all Medicaid programs and private insurance are covering some of this testing already.” According to Goeckner, for some patients, it is about closing the gap and making sure that coverage keeps pace with the science, and that Medicaid is covering comprehensive testing when it is supported by the guidance.

Moving Beyond Charitable Care

Currently, many cancer programs and practices have created an automatic system which involves a financial counselor or advocate whenever a biomarker testing order is created, not only for Medicaid beneficiaries or patients who otherwise cannot afford testing. Financial advocates will conduct a prior authorization or explore what coverage the patient may have and assist patients with completion of financial assistance forms to provide support through testing companies and local charitable organizations.

At Southern Ohio Medical Center (SOMC) in Portsmouth, Ohio, they submit a financial assistance form with each test that is ordered. But as Wendi Waugh, RT (R) (T), CMD, CTR, administrative director of SOMC Cancer Services and Community Health and Wellness explains, this can still be problematic for many reasons. “We are utilizing the testing company’s financial assistance program. All of our applications are done outside of our organization, so, we are dependent on the charity care that the testing company has available.” Beyond this, Waugh describes how communication and education gaps among patients, particularly among the Medicaid population, can get in the way. In cases of reflex testing, some patients receive calls or are asked for information, but they do not understand and have not yet had a discussion about testing with a medical oncologist or physician. The completion of advanced beneficiary notices poses another challenge. “In our case, we are using a private company and we’re trying to get an advanced beneficiary notice executed that the patient is signing [that states] ‘if my insurance doesn’t pay for it, I will.’ As a Medicaid patient, that’s scary. Ultimately that patient did not sign the notice, and didn’t get tested,” said Waugh.

As biomarker testing quickly becomes a standard of care practice, the need to move beyond dependence on testing companies and charitable care for biomarker testing coverage becomes critical. ACCC will continue to work with its partners and cancer programs and practices nationwide on greater advocacy and legislative efforts to reach long-term, sustainable solutions and improve access to biomarker testing for Medicaid beneficiaries.

ACCC’s education program Improving Access to Biomarker Testing in Medicaid Populations is made possible by support from Foundation Medicine and Exact Sciences.