WHO PAYS FOR GENOME SEQUENCING IN TREATING DISEASE?
Although it can be easily argued that genome sequencing can be used beneficially, probably the biggest detriment to implementing genomic medicine is: Who pays? Presently, many insurance companies will reimburse for sequencing the tumor genomes of cancer patients, and the genomes of those with diseases of undiagnosed causes, particularly if it can potentially result in cost savings. As noted earlier, many new drugs can cost $100,000 or more. (See Table 1 for several expensive drugs provided by Medicare.) Cancer genome or targeted gene panel sequencing may identify cancer gene mutations that accurately predict response to specific drugs, and this precision targeting of therapy can justify the costs of sequencing. Similarly, many children have diseases with undiagnosed causes, which can result in large diagnostic and treatment costs. Insurance companies will pay for the genome sequencing of the affected child, and sometimes of the parents and other family members, to help find the likely causative mutation. The identification of the involved gene may also identify novel applications of existing drugs for these diseases, and may be used to develop a test to screen other family members and others with similar symptoms.
Because it is still in its infancy, genome sequencing has not been fully demonstrated to be beneficial in most cases, and thus it is not always possible to justify payment from insurance companies. For situations where people have serious health problems that are not related to cancer or undiagnosed childhood diseases, genome sequencing is presently not usually available in the clinical setting. Such individuals will have to pay out-of-pocket or find researchers who are willing to take on such cases.
Table 1. Medicare spent $19.5 billion for drugs administered by physicians or “outpatients” (Part B drugs) in 2010. The 10 most expensive drugs per year are shown in this Table and account for 45% of the total costs of Part B drugs. (According to the Government Accountability Office, and can cost over $200,000 per treatment.
|Factor viii Recombinant||Hemophilia A||$216,833|
|Remodulin||Pulmonary arterial hypertension||$130,772|
|Ventavis||Pulmonary arterial hypertension||$84,205|
|Primacor||Acute decompensated heart failure||$62,790|
|Sandostatin LAR Depot||Acromegaly, diarrhea, and flushing caused by cancerous tumors and vasoactive intestinal peptide secreting adenomas||$22,748|