Access to clinically indicated genetic tests for pediatric patients with Medicaid: Evidence from outpatient genetics clinics in Texas |
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| Affiliation: | 1. Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX;2. Department of Genetics and Metabolism, Children’s Medical Center, Dallas, TX;3. Department of Pediatrics, Baylor College of Medicine, San Antonio, TX;4. Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX;1. The South African MRC/UCT Genomic and Precision Medicine Research Unit, Division of Human Genetics, Institute of Infectious Diseases and Molecular Medicine, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa;2. National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa;3. South African National Bioinformatics Institute, University of the Western Cape, Bellville, Western Cape, South Africa;4. Department of Paediatric Neurology, Red Cross War Memorial Children’s Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa;5. Division of Clinical Neurology, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom;6. Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL;7. Department of Pediatrics, University of Washington, Seattle, WA;8. Department of Genome Sciences, University of Washington, Seattle, WA;9. Brotman Baty Institute, Seattle, WA;10. Centre for Pediatric Neurological Disease Research, St. Jude Children’s Research Hospital, Memphis, TN;11. Department of Pharmacology, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL;12. Department of Pediatrics, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, IL;1. Department of Pediatrics, Columbia University Irving Medical Center, Columbia University, New York, NY;2. Department of Psychiatry, Columbia University Irving Medical Center, Columbia University, New York, NY;3. Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY;4. Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN;5. Department of Pediatrics, Michigan Medicine, Ann Arbor, MI;6. Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN;7. Departments of Pediatrics and Human Genetics, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI;8. Department of Medicine, Columbia University Irving Medical Center, Columbia University, New York, NY;1. Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, New South Wales, Australia;2. Australian Genomics, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;3. School of Population Health, UNSW Sydney, Sydney, New South Wales, Australia;1. Division of Child Neurology, Nationwide Children’s Hospital, Columbus, OH;2. Duke Clinical and Translational Science Institute, Duke University School of Medicine, Durham, NC;3. National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA;4. Association of Public Health Laboratories, Silver Spring, MD;5. Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, MI;6. New England Newborn Screening Program, Department of Pediatrics, UMass Chan School of Medicine, Worcester, MA;7. Laboratory Services Section, Texas Department of State Health Services, Austin, TX;8. Division of Genetics and Metabolism, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC;9. Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH;1. Institute of Biomedical and Clinical Science, University of Exeter Medical School, Royal Devon and Exeter Hospital, Exeter, United Kingdom;2. MRC Human Genetics Unit, Institute of Genetic and Cancer, The University of Edinburgh, Edinburgh, United Kingdom;3. National Heart and Lung Institute and MRC London Institute of Medical Sciences, Faculty of Medicine, Imperial College London, London, United Kingdom;4. Center for Genomic Medicine, Massachusetts General Hospital and Broad Institute of MIT and Harvard, Boston, MA;5. East Anglian Medical Genetics Service, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom;6. Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, United Kingdom;1. Vanderbilt University School of Medicine, Medical Scientist Training Program, Vanderbilt University, Nashville, TN;2. IRCCS, Istituto Auxologico Italiano, Center for Cardiac Arrhythmias of Genetic Origin and Laboratory of Cardiovascular Genetics, Milano, Italy;3. Department of Cardiovascular Medicine, Hôpital Bichat, APHP, Université de Paris Cité, Paris, France;4. Vanderbilt Center for Arrhythmia Research and Therapeutics (VanCART), Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN;5. Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine Kyoto, Japan;6. Department of Bioscience and Genetics, National Cerebral and Cardiovascular Center, Osaka, Japan;7. Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN;8. Vanderbilt Center for Arrhythmia Research and Therapeutics (VanCART), Departments of Medicine, Pharmacology, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN;9. Department of Cardiovascular Medicine, Shiga University of Medical Science, Shiga, Japan |
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| Abstract: | PurposeLittle is known about how Medicaid coverage policies affect access to genetic tests for pediatric patients. Building upon and extending a previous analysis of prior authorization requests (PARs), we describe expected coverage of genetic tests submitted to Texas Medicaid and the PAR and diagnostic outcomes of those tests.MethodsWe retrospectively reviewed genetic tests ordered at 3 pediatric outpatient genetics clinics in Texas. We compared Current Procedural Terminology (CPT) codes with the Texas Medicaid fee-for-service schedule (FFSS) to determine whether tests were expected to be covered by Medicaid. We assessed completion and diagnostic yield of commonly ordered tests.ResultsAmong the 3388 total tests submitted to Texas Medicaid, 68.9% (n = 2336) used at least 1 CPT code that was not on the FFSS and 80.7% (n = 2735) received a favorable PAR outcome. Of the tests with a CPT code not on the FFSS, 60.0% (n = 1400) received a favorable PAR outcome and were completed and 20.5% (n = 287) were diagnostic. The diagnostic yield of all tests with a favorable PAR outcome that were completed was 18.7% (n = 380/2029).ConclusionMost PARs submitted to Texas Medicaid used a CPT code for which reimbursement from Texas Medicaid was not guaranteed. The frequency with which clinically indicated genetic tests were not listed on the Texas Medicaid FFSS suggests misalignment between genetic testing needs and coverage policies. Our findings can inform updates to Medicaid policies to reduce coverage uncertainty and expand access to genetic tests with high diagnostic utility. |
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| Keywords: | Clinical genetics Genetic access Medicaid Outpatient Prior authorization |
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