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

Value in Health : the Journal of the International Society for Pharmacoeconomics and Outcomes Research
Julia R TrosmanKathryn A Phillips

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 ...Continue Reading

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Citations

Jul 8, 2020·Journal of the National Comprehensive Cancer Network : JNCCN·Michael P DouglasKathryn A Phillips
May 12, 2020·Value in Health : the Journal of the International Society for Pharmacoeconomics and Outcomes Research·Patricia A DeverkaKathryn A Phillips
May 12, 2020·Value in Health : the Journal of the International Society for Pharmacoeconomics and Outcomes Research·Julia R TrosmanKathryn A Phillips

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