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Major insurance providers are looking seriously at covering pharmacogenetic testing

The buzz in the insurance world right now is all about trying to figure out whether genetic testing is ready for prime time when it comes to treating some of the big drivers of benefits costs, such as depression and chronic pain.

From what I’ve heard and read over the last few months, I think the answer is not so much “if” but “when.” I don’t think it will be very long before benefits plans routinely cover pharmacogenetic testing as part of the treatment plan for a whole range of conditions.

We’ve talked about pharmacogenetic testing in this blog before, when it was “out there” as a new development and a future possibility. Now, much sooner than many of us might have expected, it’s starting to become a reality for the sorts of conditions that drive the costs of drug plans, absenteeism and disability claims.

The basic idea is simple enough. Each person has a different genetic makeup and may well respond differently to different drugs. Some people will benefit from one drug, but not another. Some people will have side effects from one, and less so from another. Some people require higher doses, some lower. And so on. The promise of pharmacogenetics is to give treating physicians a simple test that will allow them to prescribe the best drug, at the most effective dosage, the first time – without trial and error.

As our friends at Benefits Canada report, at least three major insurance carriers are in the process of running pilot programs in pharmacogenetic testing. Sun Life is working with the Centre for Addiction and Mental Health (CAMH) on a study examining the effectiveness of this type of testing in helping patients on short- and long-term disability choose the medications that will be most effective. Manulife is preparing to roll out a pilot project examining ways to pinpoint the best treatments for chronic pain, depression and anxiety. And Great-West Life is piloting a project focused on chronic pain and mental health.

RBC has gone even further and now covers the cost of pharmacogenetic testing to its group benefits clients.

Let’s be clear, though: pharmacogenetic testing is out there now, and it’s being used every day for a wide range of conditions. It’s almost routine in the treatment of many cancers, for example, and very effective in helping doctors decide what type of treatment will be most effective, in identifying the most appropriate chemotherapy drugs, and in calculating optimal dosages.

In those areas of medical science that have seen the most intensive effort – such as breast cancer – researchers have been able to isolate a few “biomarkers,” which are basically the Holy Grail of pharmacogenetics. What that means is basically that if you have a particular variant of a gene, you get a particular treatment. If you don’t, you get a different treatment. Other biomarkers can more accurately define the form a disease, or variations in a patient’s metabolism, or any of a long list of differences from one patient to another.

We’re not there yet with most medical conditions. But, in many cases, pharmacogenetics can already narrow down the list of available treatments, rule out some treatments, suggest others, manage side effects and tailor dosages more appropriately.

If we look at just one area, such as depression, the potential benefits of “tailor made” prescribing become pretty obvious. Depression is clinically defined as a set of specific symptoms, and patients can have a bewildering array of different combinations of them. Then the physician has to decide whether to treat with drugs, or other approaches such as cognitive behavioural therapy (CBT). If they determine that drugs are the way to go, there are five classes of anti-depression drugs. In just one of those classes, the selective serotonin re-uptake inhibitors (SSRIs), there are again many specific formulations – each of them slightly different. Clearly, anything that will help physicians to pick the best treatment the first time is going to make a big difference in the patients recovery.

Pharmacogenetic testing is already listed as an eligible medical expense under the Income Tax Act, if ordered by a physician, which means you can claim it under a health-care spending account.

The basic question that the insurers are working to answer right now is whether the current science has come far enough to make pharmacogenetic testing routine for most patients diagnosed with things like depression or chronic pain.

And, of course, should it be routinely covered by benefits plans?

The answer – and here again I’m pretty sure the answer is not “if” but “when” – is that if the pilot projects currently underway show that patients benefit significantly, testing will soon become a part of most or all benefits plans. Significant benefit to patients, of course, also means fewer claims for ineffective drugs, and quicker recovery which, in turn, means lower overall claims costs.

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