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Evaluation and Promotionof BRCA Best Practicesamong Michigan HealthPlansDecember 9, 2010Debra Duquette, MS, CGC1, Karen Lewis, MS2, CGC, Mary Anne Ford, MHSA3,Jenna McLosky, MS, CGC1, and Janice Bach, MS, CGC1Michigan Department of Community Health1Priority Health2Michigan Association of Health [email protected]

Genomics Applications in Practice and Prevention(GAPP): Translation Programs in Education,Surveillance, and Policy Goal: move human genome applications into healthpractice to maximize health benefits and minimize harmthrough non-research activitiesPromoting Cancer Genomics Best Practicesthrough Surveillance, Education and PolicyChange in the State of Michigan Ultimate Impact: A reduction in early cancer deaths(before age 50) through statewide surveillance andimplementation of systems of care for inherited breast,ovarian, colorectal and other Lynch syndrome (HNPCC)related cancers that use best practice recommendationsfor family history assessment, cancer genetic counselingand testing

Our Program’s Goals2008-2011¾ Develop and implement a model for surveillance ofinherited cancers and use of relevant genetic tests;and share with other cancer registries and nationalprograms¾ Identify model provider education programs toincrease use of appropriate screening, counselingand evidence-based genetic tests; and share withpublic health and/or clinical practice organizations¾ Identify a model health insurance policy for BRCA1& 2 cancer genetic testing; and share with healthplans in Michigan and other statesFunding for this project was made possible by Cooperative Agreement #5U38GD000054 fromthe Centers for Disease Control and Prevention. The contents are solely the responsibility of theauthors and do not necessarily represent the official views of CDC.

2005 U.S. Preventive Services Task ForceBRCA RecommendationWomen whose family history is associated with anincreased risk for deleterious mutations in BRCA1 orBRCA2 genes should be referred for genetic counselingand evaluation for BRCA testing.(Grade B Recommendation)USPSTF also recommends against routine referral for women whosefamily history is not associated with increased spstf05/brcagen/brcagenrs.htm

Reduction in early cancer deaths in Michigan residentsfrom appropriate use of cancer genetic services and testsHealth Plan Champion;Michigan Associationof Health Plans (MAHP)SurveillanceMichigan CancerSurveillance Program(MDCH)12 ClinicalCancer GeneticsSitesMDCHGenomics ProgramMichigan CancerGenetics AlliancePolicyEducationMichigan Cancer Consortium

Resources USPSTF BRCA Recommendations Health Plan Champion Michigan Association of Health Plans Michigan Cancer Consortium Michigan Cancer Genetics Alliance MDCH Genomics Program999999ActivitiesReview Michigan health plan policies forconsistency with USPSTF BRCA recommendationDisseminate USPSTF guidelines to health plansthrough multiple venuesTrack BRCA counseling and testing at 12 clinicalcancer genetics clinics for members with andwithout health plan policies consistent withUSPSTFRecognize health plans consistent with USPSTFProvide technical assistance to health plansConduct a workshop for health plans and cancergenomics expertsPolicyPerformanceMeasure Use of familyhistory, geneticcounseling andBRCA 1/2 testing(as recommendedby USPSTF) andrelated clinicalservices increasesfrom baselinePromote Use ofIdentified HealthInsurance PolicyModel

Policy Objectives and Outcomes Understand current status of Michigan healthinsurance policies for BRCA1/2 testing withrespect to USPSTF guidelines– 11 out of 23 health plans with written policies for BRCA– 8 in alignment with USPSTF recommendations Increase the number of health plans that havepolicies consistent with USPSTF guidelines– Increased the number that have policies consistent withUSPSTF recommendations from 4 to 8 health plans

Surveillance of Health PlanBRCA 1/2 PoliciesMethods: Contracted with“health planchampion” andMichigan Associationof Health Plans(MAHP) Identified total of 24Michigan health plans– 17 members ofMAHP Using multiple searchtypes (i.e. websites,key administrationcontacts, list servs,newsletters,conferences) requestand/or identify policiesConduct ongoingsurveillance to determine:1. Does the health plan have awritten BRCA counseling andtesting policy?2. If written policy, does it includecoverage for female memberswith a significant family historyof breast and/or ovarian cancerwithout a personal history(aligned with USPSTF)?3. Does the policy ‘require’ or‘strongly recommend’counseling by a qualified healthcare professional or geneticcounselor prior to BRCAtesting?Consideraligned withUSPSTFif all threecriteria arefulfilled

Network of MichiganClinical CancerGenetics ClinicsCollecting all BRCAcounseling cases fromOctober 2007- March 2011seen by a board certifiedgenetics professionalTrack specific health plancoverage for BRCAcounseling and testing

Michigan Health Plan Policies Consistent with USPSTFand Cancer Genetic Counseling VisitsHealth PlanBRCA1/2writtenpolicy (Y/N)Consistent withUSPSTFDistribution (%) ofPatients at 8 ClinicalSites Receiving CancerGenetic Counseling*Number ofMichiganMembers*AetnaY (2008)Y89 (2.7)280,000BCBSM; BCNY (2009)Y1,919 (57.5)4.6 million;625,000CignaY (2009)Y36 (1.1)pendingBeaumont EmployeeY (2008)Y91 (2.7)34,818MolinaY (2008)Y9 (0.3)230,000United HealthY (2009)Y85 (2.6)805,000Health Alliance PlanY (2010)Y416 (12.5)470,000Priority HealthY (2008)Y106 (3.2)600,00012 Health PlansNN99 (3.0) 1 million1 Health PlanYN2 (0.06)187,00081 (2.5)500,000 419 (12.6) 1.5 million(no genetic counselingrecommendation)MedicaidYN(only personal historycoverage)MedicareYN(only personal historycoverage)* Patients may be counted more than once because of multiple insurers

Honoring Health Plans Aligned withUSPSTF Grade B Recommendation Michigan Association of Health Plans(MAHP) 25th Anniversary Conferenceheld on July 17-20, 2010– Announcement regarding regulationsrequiring new health insurance plansto cover preventive care for USPSTFGrade A & B Recommendations onJuly 14, 2010Pinnacle Awards to honor health plansaligned with USPSTF Grade B BRCARecommendation on September 21,2010– 4 health plansCME Best Practices event to educatehealth plan directors on December 8,2010– 2 health plans1 health planMAHP Summer 2011Conference and2011 Pinnacle Awards

Promoting USPSTF Grade B BRCARecommendation to Health Plans Educate health plans aboutUSPSTF Grade B BRCARecommendation and BestPractices Health plan conferences CME events Displays Provider tools Articles in newsletters

Notification to Health Plans NotAligned with USPSTF MDCH staff provided individualizedpackets to Michigan health plans at keyevents in 2010– Discuss in person with key health planadministrators– Emphasize USPSTF Grade BRecommendation– Provide summary of project andpartnership with CDC and MAHP– Highlight three criteria required to receivehonors– Report individualized information for eachhealth plan regarding their assessment– Encourage to contact MDCH or MAHP fortechnical assistance

Educational Materials forHealth PlansPacket of educationalmaterials includes:¾ 2005 USPSTF BRCARecommendation¾ Michigan Informed Consent Law forPre-symptomatic and PredictiveGenetic testing¾ Cancer Family History Guide ¾ Directory of Michigan Cancer GeneticCounseling Services¾ Model BRCA Policies with permissionfrom: Aetna Priority Health UnitedHealthcare

Summary Understand current status of Michigan healthinsurance policies for BRCA1/2 testing with respect toUSPSTF guidelines– 11 out of 23 health plans with written policies for BRCA coverage– 8 in alignment with USPSTF recommendations Covers over 7.34 million Michigan residents 1.15 million Michigan residents uninsured (2008) Increase the number of health plans that have policiesconsistent with USPSTF guidelines– Increased the number of health plans that have policies consistentwith USPSTF recommendations from four to eight out of 23 Michiganplans, extending coverage to over 6.35 million Michigan residents

AcknowledgementsClinical SitesBeaumont Hospital: Whitney Ducaine, LindsayDohany & Dr. Dana ZakalikHenry Ford Health System: Katie Biro, AmyDecker & Dr. Jacquelyn RobersonKarmanos Cancer Institute: Nancie Petrucelli,Jennifer Barrick & Dr. Michael SimonOakwood Hospital: Dr. Julie Zenger HainUniversity of Michigan: Dr. Sofia Merajver &Kara MillironUniversity of Michigan: Dr. Gruber, VictoriaRaymond& Jessica EverettInformed Medical Decisions, Inc: Dr. RebeccaSutphenBattle Creek-Trinity Health: Sue DeRuiterMichigan State University: Rhonda ScanlonSt. John-Providence East: Tracey HallSt. John-Providence West: Samira AhsanSpectrum Health: Jeffrey BissonnetteMichigan Association of Health Plans(MAHP)Mary Anne FordCheryl OrtweinRick MurdockHealth Plan “Champion”Karen Lewis, Priority HealthOffice of Public Health Genomics, CDCMichigan Department of CommunityHealthJenna McLoskyJanice BachBeth AndersonSarah MangeJeremy HardyFunding for this project was made possible by Cooperative Agreement #5U38GD000054 from the Centers forDisease Control and Prevention. The contents are solely the responsibility of the authors and do not necessarilyrepresent the official views of CDC.