An emerging category of laboratory tests may help improve care and treatment outcomes for cancer patients, according to a recent survey by the nonprofit CancerCare, but insurers and employers do not always cover the tests or require prior authorization for them.
The January survey of 295 people diagnosed with cancer between 2019 and 2022 found that biomarker testing — which describes tests that use a sample of tissue, blood or other body fluid to check for certain genes, proteins and other molecules that may be a sign of a diseases or conditions like cancer, according the National Cancer Institute — was used to tailor therapy in 93% of patients surveyed.
As a result of biomarker testing, CancerCare said 20% of respondents avoided unnecessary chemotherapy, 20% avoided radiation and 10% became eligible for a clinical trial.
Questions over cost, utility
Gaining access to biomarker testing proved difficult for many respondents, however. While the majority, 71%, of patients said their insurance plans covered biomarker tests, one-quarter said they were required to obtain prior authorization for the tests. Nearly one-third of respondents said their insurance did not cover the tests.
A number of factors may explain why health plans may not cover biomarker testing. Cost and a lack of understanding about the benefits of biomarker tests among employee benefits decision-makers are two such factors, Ellen Miller-Sonet, senior VP and chief strategy and policy officer at CancerCare, said in an email to HR Dive.
On the cost front, Miller-Sonet cited 2022 research by consulting firm Milliman, which found that expanding biomarker testing coverage would increase commercial plan premiums between 14 cents to 51 cents per plan member per month.
“This is a complicated area of medicine, and unless people have been exposed to what drives advances in cancer treatment, they may not appreciate how important it is,” Miller-Sonet said. “Thus, benefits decision-makers may think coverage of biomarker testing is not a needed benefit, and not worth the investment.”
Payers may rely on a wide variety of inputs to determine whether to cover certain tests, according to a 2020 ADVI Health analysis, such as whether a particular test has been reviewed by the Food and Drug Administration and which tumor types are being evaluated.
The category of patients for whom it is medically advisable to receive biomarker testing includes, but is not limited to, those with nonsmall cell lung cancers, colon cancers and melanomas, said Jeff Levin-Scherz, population health leader, health and benefits, North America at WTW.
“It’s not that everybody with cancer unequivocally should have biomarker tests, but there are certain kinds of cancers and certain kinds of drugs used for those cancers where treatment without these tests is not optimal,” Levin-Scherz said, adding that the tests can increase confidence that patients receive the best possible treatment.
Where insurance companies have required prior authorization for the tests, the motivation may be to preserve resources and keep costs low by ensuring biomarker tests are not given to patients for whom there is likely no clinical benefit, Levin-Scherz said. And while others may not provide coverage of biomarker tests at all, “there’s clearly a movement toward covering these tests as they become more indicated in care,” he added.
Considerations for employers
State governments also play a role in the potential of expansion of biomarker test coverage. A total of six states have enacted laws requiring coverage of comprehensive biomarker testing in state-regulated plans, while two others — Georgia and Maryland — have passed such laws, according to the American Cancer Society’s Cancer Action Network.
But these laws only apply to health plans that are not subject to the federal Employee Retirement Income Security Act, said Magda Rusinowski, VP at the Business Group on Health. Many employer-sponsored health plans are governed by ERISA, and the federal law preempts state mandates, she explained.
With respect to CancerCare’s findings, Rusinowski said it is important for employers to understand the perspective of patients but that the survey results do not necessarily provide all the details of the clinical decisions that influenced individual coverage decisions.
“Cancer is not one disease, and coverage decisions are made at the level of particular treatment or test and not necessarily more broadly,” Rusinowski said. Employers, she continued, “rely on experts to assess individual situations and tests.”
Cancer treatment is also a fast-moving space, Rusinowski said, meaning that medical practice may change even within the span of a few years. But she added that she was “very surprised” that CancerCare found more than 70% of patients received coverage for biomarker testing; “This is higher than what [the Business Group on Health’s] surveys show in terms of coverage.”
In general, employers are interested in finding better treatment options for cancer, which the Business Group on Health identified in a 2022 survey of large employers as the top cost driver for employer-sponsored health plans in 2023, Rusinowski said. Biomarker testing is a “fairly prominent” component of a broader employer desire to deploy more innovation and customization to cancer care, she added.
But without insurance coverage, biomarker testing could lead to high out-of-pocket costs for patients, with 15% of cancer patients in a 2019 Cancer Action Network survey stating that they had paid $500 or more out of pocket for the tests.
“Without coverage, patients will need to look for and qualify for patient assistance programs from nonprofit organizations or manufacturers,” Miller-Sonet said. “This takes time, know-how and access to digital tools, which many patients don’t have. This is where lack of coverage for biomarker testing becomes an equity issue, leading to disparities in outcomes and mortality.”
Correction: A previous version of this story gave the incorrect title for the Employee Retirement Income Security Act.
