Friday, July 23, 2010

Expanding our reach through collaboration

In the 2009 Vision Survey of NSGC members, respondents rated billing and reimbursement efforts as the top strategic initiative the NSGC should pursue over the next 3-5 years. On federal and state levels, progress is clear with 13 states having passed licensure legislation and many more preparing to introduce bills. We are actively seeking a congressional sponsor to introduce federal legislation to amend the Social Security Act to recognize genetic counselors as providers under Medicare. However, efforts with private payers have been initiated mostly by individual NSGC members, so the time has come to organize a strategic effort to approach private payers to cover genetic counselors’ services.

In our preliminary talks with payers we have encountered two repeated concerns from their leadership, 1. there is limited formal data to demonstrate the importance of covering genetic counselors’ services, and 2. not all of their health plan’s members will have access to a genetic counselor. As a not-for-profit professional association, we have finite resources to address these challenges.

One way to expand our organization’s resources is through strategic partnerships, and there is an organization that has experience and assets in working with payers. In June, The NSGC Board approved a collaboration with Informed Medical Decisions (IMD), which is a for-profit company that offers telephone-based genetic counseling by ABGC-certified genetic counselors. IMD has already had success in writing contracts and policies for third-party payers to cover and, in for some tests, require pre-test genetic counseling prior to authorizing genetic testing.

The NSGC Payer Task Force will lead an effort on the NSGC side to approach third-party payers with IMD to write coverage policies to cover genetic counseling. IMD has agreed to share lessons learned from its own negotiations with payers as well as outcomes data on genetic counseling patients that payers will want to see. They also provide a solution to the concern payers express about access to genetic counselors in areas where face-to-face counseling may not be available.

We recognize that many members will have concerns that payers will favor telephone counseling over face-to-face counseling. Therefore, one important point to emphasize is that the NSGC and IMD will approach payers to cover genetic counseling provided by Certified Genetic Counselors. IMD policy does not advocate for telephone-only access to genetic counseling and does provide referral to local genetic counselors when positive results or family situations indicate that an in-person visit is optimal. There will be no favoring of telephone over phone counseling and we will provide guidance to payers regarding counseling scenarios where telephone counseling is inappropriate. In fact, for many payers, phone services are more expensive and easier to game than face-to-face services, so they do not have an inherent incentive to favor telephone services. In addition, once genetic counseling is a covered service, it opens the door for coverage in a variety of service delivery models, so we expect the demand for genetic counseling services overall to grow.

The collaboration with IMD is non-exclusive, so others parties could join us if we deem it beneficial to the NSGC, and we will perform regular evaluations of the NSGC/IMD effort to assess whether the NSGC is achieving tangible, beneficial outcomes for its members. No money is changing hands as part of this collaboration, and the NSGC is under no obligation to continue the effort if the objectives established at the beginning are corrupted in any way.

The NSGC leadership recognizes that this is a big change for the NSGC. While we regularly accept sponsorship dollars for companies’ advertising and exhibits, this is the first time we will work with a for-profit company with the goal of achieving a specific strategic objective. We know that there is risk in lending our credibility to another organization and have put the appropriate controls and people in place to monitor progress and ensure our goals are being achieved. We believe fundamentally that we need to band together as genetic counselors to demonstrate that we bring critical value to patients and providers. NSGC’s collaboration with an organization that is, after all, a provider organization of genetic counselors with no financial ties to other genetic services such as testing, will help us achieve our goal of promoting the role of genetic counselors as quickly and effectively as possible.

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