Testing for BCRA gene: Should insurers require a referral?

| Oct 18, 2016 | Firm News

Angelina Jolie made big news a few years ago when she announced she had undergone both a prophylactic mastectomy and hysterectomy. Jolie’s mother died from breast cancer and as a result, Jolie decided she wanted to know whether she, too, carried the BRCA gene–the gene that indicates a predisposition to both breast and ovarian cancer. When her diagnosis was confirmed, Jolie opted for both surgeries, ensuring that she would not meet the same fate as her mother.

What is the cost of cancer?

While Ms. Jolie is probably in a financial position to pay for these surgeries whether or not she obtained a prior referral, most women do not have that kind of fiscal freedom. Now insurers are making news by beginning to require referral not from doctors themselves, but from genetic counselors, adding another step to an already arduous insurance morass.

Should insurers be able to do this?

The obvious question is whether this level of referral meets the standard of care for the patient. In the past, physicians could simply make a referral for the test; if a patient is now required to wait many months–and by some accounts up to a year–to be able to see a genetic counselor before the test is even ordered, it raises concerns that women may simply forget, or later decline, the testing because of the timeline involved: Few people keep a medical appointment that has been made up to a year in advance.

How are physicians reacting?

If such a requirement means a woman does not get the needed testing and therefore the opportunity for preventive surgery, are the insurance companies–and by extension the physicians–courting medical malpractice? Do women have any opportunity to circumvent the “referral for a referral”? Physician groups are balking at the requirement and saying that is deprives patients of a reasonable “standard of care.” It will certainly take time, and perhaps lengthy litigation, before insurers are forbidden to require “double referrals” before administering care to a patient in need.