The landscape of payment for genetic testing has been changing, with an increase in the number of laboratories offering testing, larger panel offerings, and lower prices. To determine the influence of payer coverage and out-of-pocket costs on the ordering of NGS panel tests for hereditary cancer in diverse settings, we conducted semi-structured interviews with providers who conduct genetic counseling and order next-generation sequencing (NGS) panels purposefully recruited from 11 safety-net clinics and academic medical centers (AMCs) in California and North Carolina, states with diverse populations and divergent Medicaid expansion policies. Thematic analysis was done to identify themes related to the impact of reimbursement and out-of-pocket expenses on test ordering. Specific focus was put on differences between settings. Respondents from both safety-net clinics and AMCs reported that they are increasingly ordering panels instead of single-gene tests, and tests were ordered primarily from a few commercial laboratories. Surprisingly, safety-net clinics reported few barriers to testing related to cost, largely due to laboratory assistance with prior authorization requests and patient payment assistance programs that result in little to no patient out-of-pocket expenses. AMCs reported greater challenges navigating insurance issues, particularly prior authorization. Both groups cited non-coverage of genetic counseling as a major barrier to testing. Difficulty of access to cascade testing, particularly for family members that do not live in the United States, was also of concern. Long-term sustainability of laboratory payment assistance programs was a major concern; safety-net clinics were particularly concerned about access to testing without such programs. There were few differences between states. In conclusion, the use of laboratories with payment assistance programs reduces barriers to NGS panel testing among diverse populations. Such programs represent a major change to the financing and affordability of genetic testing. However, access to genetic counseling is a barrier and must be addressed to ensure equity in testing.

中文翻译：

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付款人覆盖率和自付费用对在不同环境中订购遗传性癌症的 NGS 面板测试的影响

基因检测的支付方式一直在发生变化，提供检测的实验室数量增加，提供更多的面板和更低的价格。为了确定付款人覆盖率和自付费用对在不同环境中订购遗传性癌症的 NGS 面板检测的影响，我们对进行遗传咨询和订购下一代测序 (NGS) 面板的提供者进行了半结构化访谈有目的地从加利福尼亚州和北卡罗来纳州的 11 个安全网诊所和学术医疗中心 (AMC) 招募，这些州拥有不同的人口和不同的 Medicaid 扩展政策。进行主题分析以确定与报销和自付费用对测试订购的影响相关的主题。特别关注设置之间的差异。来自安全网诊所和 AMC 的受访者报告说，他们越来越多地订购面板而不是单基因测试，并且测试主要从几个商业实验室订购。令人惊讶的是，安全网诊所报告说与成本相关的测试障碍很少，这主要是由于实验室在事先授权请求和患者支付援助计划方面提供的援助几乎不会导致患者自付费用。AMC 报告称，在保险问题上面临更大的挑战，尤其是事先授权。两组都将遗传咨询的不覆盖列为检测的主要障碍。难以进行级联测试，特别是对于不住在美国的家庭成员，也令人担忧。实验室支付援助计划的长期可持续性是一个主要问题；安全网诊所特别关注在没有此类计划的情况下获得测试的机会。各州之间几乎没有差异。总之，使用具有支付援助计划的实验室减少了在不同人群中进行 NGS 小组测试的障碍。此类计划代表了基因检测的融资和可负担性的重大变化。然而，获得遗传咨询是一个障碍，必须加以解决以确保检测的公平性。