Many Doctors Not Discussing Genomic Test Costs with Patients

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As the use of genomic testing increases, cost is becoming a growing concern. But many doctors are not discussing the prices of these tests with their patients, leaving them at risk of unexpected medical bills, according to researchers from the National Cancer Institute. Their findings are reported in the latest issue of JNCI: The Journal of the National Cancer Institute (“Factors associated with oncologist discussions of the cost of genomic testing and related treatments”). Their study was based on the 2017 National Survey of Precision Medicine in Cancer Treatment, which included 1,220 oncologists who reported discussing genomic testing with their patients. Only half (50%) said they often discussed costs with their patients. About one-quarter (23.7%) reported never or rarely discussing the costs of genomic testing. Another quarter (26.3%) said they “sometimes” discussed costs.

Further analysis showed that oncologists with training in genomics or those subject to electronic medical record (EMR) alerts for genomics tests more often had cost discussions with patients. Other factors statistically significantly associated with more frequent cost discussions included the patients’ having solid tumors (rather than only hematological cancers), using next-generation sequencing gene panel tests, having higher patient volume, and working in practices with higher percentages of patients insured by Medicaid, or self-paid or uninsured.

“Interventions targeting modifiable oncologist and practice factors, such as training in genomic testing and use of EMR alerts, may help improve cost discussions about genomic testing and related treatments,” the study authors write.

The costs of cancer care have been rising in the US. A growing number of cancer patients have difficulty paying medical bills, face financial distress, and delay or forgo medical care because of cost.Recent trends in health insurance benefit design, with higher deductibles, copayments, and coinsurance rates,are also raising the financial burden even among those with health insurance. Uninsured patients, meanwhile, can be responsible for the entire cost of cancer care.

High patient out-of-pocket costs for cancer treatment have been the subject of many recent headlines and much discussion among experts.In 2009, the American Society of Clinical Oncology (ASCO) highlighted the important role of oncologists in discussions about the expected patient out-of-pocket costs of cancer care.The Institute of Medicine also identified cost discussions as an element of high quality care,and cost consciousness has been proposed as a core competency for medical education.But, as this study shows, these discussions are still too uncommon.

Patient out-of-pocket costs are especially relevant in oncology in light of the rise of molecularly targeted therapies. As of 2016, more than 200 targeted therapies, half in oncology, were available in the United States and more than 2000 more are in late-stage development.Targeted therapies can cost more than $100,000 annually.And the genomic tests to identify targetable variants can also be expensiveand are not always covered by health insurance. As the study authors write, “Even with health insurance coverage, cancer patients face cost-sharing for genomic testing and treatment, as high as 30% of the list price for tests and treatments.”

As the cost of cancer care rises, discussions about costs are increasingly important to help patients prepare for high expenses. This study helps shed light on this issue by analyzing data from a nationally representative survey of oncologists and looking at potentially modifiable factors associated with the frequency of cost discussions.

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