Access to Genetic Testing
Barriers proposed by health care insurers, including the Centers for Medicare and Medicaid Services (CMS), may impact women’s ability to receive genetic testing. One proposal requires that genetic counseling must be provided by an individual “certified” in genetic counseling before genetic testing is ordered. The American College of Obstetricians and Gynecologists (ACOG) strongly opposes these restrictions because they impose unnecessary barriers to timely care. Moreover, ACOG opposes such attempts to restrict the scope of practice of obstetrician–gynecologists, who are fully qualified to provide pre-test counseling to their patients. As described in the College Statement of Policy, Certification and Procedural Credentialing, reaffirmed in 2015, graduate medical education in obstetrics and gynecology, certification by the American Board of Obstetrics and Gynecology, and maintenance of certification, is “validation of the medical, surgical, imaging, and laboratory knowledge and patient care skills relevant to the practice of the specialty.” Included in this experience and certification, particularly related to the laboratory knowledge component, is genetic testing. This position is aligned with the American Medical Association Policy H-460.902, “Opposition to Genetic Testing Restrictions Based on Specialty.” This policy specifically opposes limiting the ordering of genetic testing based solely on physician specialty or other non-medical criteria and the requirements for utilization of nonaffiliated medical specialists or non-physicians prior to ordering genetic testing. Furthermore, with relatively few genetic counselors in the United States, requiring all persons for which genetic testing is indicated to undergo pre-testing counseling by a “genetics professional” would markedly limit access to genetic testing. This may be especially true in rural areas. A requirement for pre-testing counseling in an area in which “genetics professionals” are not available may leave patients without timely access to care.
Preauthorization requirements before testing pose more barriers. Some health insurers require obstetrician–gynecologists or other providers to obtain prior authorization for all genetic testing. Reference laboratories will no longer be able to obtain the authorizations. Rather, prior authorization must be obtained through the physician’s office. While these policies hope to ensure that genetic testing is performed for appropriate clinical indications, these requirements place additional burdens on physicians and their staff, negatively impacting access to genetic testing. This is particularly significant if recommended testing involves a narrow time window, such as prenatal genetic testing or screening. ACOG supports testing for appropriate clinical indications, but views shifting of preauthorization requirements solely to the providers as an unfunded mandate that leads to inefficiency in the health care system.
We are deeply concerned that these initiatives will prevent women from receiving needed care. ACOG reaffirms its position that obstetrician–gynecologists are fully trained and qualified to counsel patients regarding genetic issues, particularly related to the prepregnancy period and pregnancy, and those related to gynecologic, breast, and colon cancers. Ordering of genetic testing should not be restricted by a requirement for pre-testing genetic counseling by a separate provider. ACOG opposes changes in preauthorization policies and procedures that shift burdens to physician practices while potentially impeding women from undergoing timely indicated genetic testing.
Approved by the Executive Board: January 2018