Community Cancer Center Clearview Advances Point-of-Care Pretest Genetic Education Model | Precision Medicine Online

Oct 25, 2024

NEW YORK – Alabama-based community oncology network Clearview Cancer Institute has found that when patients' treating physicians provide pre-test genetic education, it helps the genetic counseling team meet increasing demand for genetic testing services.

Clearview implemented a point-of-care genetics services model in spring 2022, according to Amy George, certified genetic counselor at Clearview, to help increase the health system's capacity to provide pre-test genetic counseling to cancer patients undergoing testing to assess their inherited risk for cancer.

When George joined Clearview in 2012, she was the only genetic counselor on staff, but the team has now expanded to three genetic counselors. With cases referred by more than 50 providers across Clearview's 13 clinics, the demand on Clearview's genetic counselors was high when the point-of-care program began, George recalled.

The institute serves a large area of northern Alabama and southern Tennessee where there are few other cancer clinics. In 2023, for example, the network performed genetic testing on 1,580 patients to determine if they had a hereditary cancer syndrome, a 44 percent increase compared to the 1,100 patients tested the prior year.

"Our point-of-care model launched around the time guidelines recommended that genetic testing should always be offered to patients with certain types of cancer that we see all the time in clinic," George said. "Instead of having a model where every single patient has a pre-test appointment with a genetic counselor, which takes more time, and [our team] also only has so much capacity, we thought, 'Let's start having some of these conversations at the point-of-care for the more straightforward cases.'"

Currently, the National Comprehensive Cancer Network (NCCN) recommends genetic testing to gauge hereditary cancer risk for individuals with a family history of certain high-risk cancers or young-onset breast, ovarian, pancreatic, prostate, and colorectal cancers. If testing finds a mutation in a gene associated with hereditary cancer risk, genetic counselors also typically recommend cascade testing for the patients' family members to determine if they also harbor the same mutation and need more frequent cancer screening.

As more is understood about the inherited genetic mutations associated with cancer, the NCCN has continued to expand its guidelines to include more patients. Some experts have also called for universal genetic testing for hereditary cancer risk after research, such as the TAPESTRY study, has shown that the common practice of relying on patients' personal and family cancer history to determine who should get genetic testing may miss a large proportion of patients harboring cancer-linked mutations.

George and her colleagues brought together oncologists and advanced practice providers, such as nurse practitioners and physician assistants, from Clearview's clinics and gave them ongoing education about how to have these conversations and ensure their patients understood the value of genetic testing.

"As part of medical oncology care, a basic and foundational understanding of cancer genetics has become imperative," George said. "The utilization of this knowledge is helpful for tumor genomic profiling and analysis, in addition to germline genetics. We believe that identifying active oncology patients using single indicators, such as those with breast, ovarian, pancreatic, and prostate cancers, for germline genetic testing at the point of care for the purposes of efficiency, timeliness, and patient convenience, is well within the scope of practice for a medical oncologist and oncology advanced practice provider."

There's been concern in the genetic counseling community about institutions employing other providers to do the work that certified genetic counselors have to get a Master's degree to perform. However, at Clearview, the aim seems to be on marshalling oncologists and advanced practice providers alongside genetic counselors to build the infrastructure necessary to support growing genetic testing demand.

The goal was to have multiple pathways through which patients could access genetic testing information, while also saving patients and the genetics department time since patients wouldn't have to make a separate appointment.

In this model, a patient who had a cancer recognized in guidelines as being associated with a higher risk of an inherited cancer syndrome, specifically breast, ovarian, pancreatic, and prostate cancers, could have a shorter conversation about genetic testing with their medical oncologist or an advanced practice provider at the point of care. If they agreed to testing, their providers would send the request to the genetics department, which reviews each case to ensure testing is appropriate and that all clinical and family history information was collected before confirming the testing.

Currently, genetic counselors can't bill for services they provide to Medicare patients, and payment from commercial payors is also limited and often inconsistent. The difficult reimbursement environment for genetic counselors certainly impacts institutions' decisions to hire them and their billing practices for pre- and post-genetic testing consultations.

George noted that she hopes the Centers for Medicare and Medicaid Services "comes to acknowledge genetic counselors and their expertise as a reimbursable service. In the meantime, we as a company see the value of a cancer genetics program, with genetic counselor leadership, as a means to best serve our patients, their families, and the community."

At Clearview, this point-of-care model has not changed billing strategies, George said. If a provider does the pre-test consultation, the visit is billed under the provider. For appointments with the genetic counselors, George said, they typically combine their visits with the treating oncologist or advanced practice provider on the team or use the "incident-to" Medicare billing mechanism, which covers follow-up services performed under the direction of a physician, to bill for their services.

"When the results come in, we as the genetic counseling team handle those results, and all patients who are diagnosed with a hereditary cancer condition are then offered post-test genetic counseling," George said. "We can focus that face-to-face meeting time for the genetic counselors with the people who have been diagnosed with the hereditary cancer condition."

Ellen Matloff, CEO of My Gene Counsel, a company that uses digital tools to support the delivery of genetic testing results, said she supports care models like Clearview's that "help to safely and equitably scale genetic counseling."

She added that it can be time consuming for these providers to take on another responsibility, but the providers working together with genetic counselors is an effective way to save time.

"In today's very busy and stressful clinical environment it is challenging for healthcare providers to stay up to date on their own area of medicine, let alone take on another specialty area like cancer genetic counseling," Matloff said. "Cancer genetics is evolving rapidly, and most clinicians don't have time to stay current in this subspecialty. It is great that the oncologists, advanced practice providers, and genetic counselors are working together. This is necessary to manage the patient and their family members' care."

The multiple pathways at Clearview also free up time for genetic counselors to focus their pre-test appointments on patients who have a lot of questions or concerns about genetic testing. George said the best candidates for the point-of-care model might be those who might already be familiar with hereditary cancer or who are more agreeable to testing generally.

"For example, a patient who is unsure and has lots of questions or is really concerned about costs, [that] might not be the best patient for the point-of-care model," George said. "The beauty of having more than one way of doing something is you can offer a pathway that's the best for that particular patient."

For the more complex patients or those who want more detailed information, the genetic counselors are available for pre-test appointments. Many times, George said, these patients are concerned about cost or don't fully understand the reason for this testing, but once they have that longer meeting, they are more likely to agree to testing. "If someone declines testing and you don't know why they're declining, you can't address either the misinformation or misunderstanding or the root cause of the decline," George said.

Over the first two years of the program, George noted that there has been an increase in the number of patients who request genetic testing. While her team has not done a formal analysis of this increase in demand for testing, she noted that quarterly testing requests increased from 151 requests in Q2 2023 to 255 requests in Q2 2024. She added that, anecdotally, the majority of patients follow through with testing and follow-up appointments.

She estimated that around 10 percent of tested patients at Clearview are found to be at increased risk for hereditary cancer due to mutations in clinically actionable genes. This is consistent with data showing that hereditary cancer syndromes occur in about 10 percent of patients.

"This tells us we're testing the right group of people," George said. "But if we just diagnose the hereditary cancer condition in the initial patient and we don't utilize that information to its greatest potential, we're really missing a huge piece of the good that can come from that testing. We, the genetic counselors, [are] focusing not only on the patient but on their entire family."

Going forward, George hopes to encourage more providers to use the point-of-care model, noting that some providers at Clearview use the point-of-care pathway more than others. She hopes to continue educating providers at Clearview and to increase testing capacity as more providers feel comfortable having conversations about genetic testing.

George and her team conduct ongoing genetics education for oncologists and advanced practice providers at Clearview. They work with new providers during their onboarding to give them information about genetic testing and train them on the point-of-care model at Clearview. They also hold annual education sessions with the providers and send regular educational emails to keep their genetics knowledge up to date. She added that her team is always available to Clearview's oncologists to review cases or answer genetic testing-related questions.

Her team is also looking into developing more tailored education for the advanced practice providers at Clearview, who often don't have cancer genetics included in their training.

"We've curated a program that fits our needs and what our providers are comfortable with that also serves our patients," George said. "We're trying to keep providing a high standard of care and staying in line with national guidelines [for hereditary cancer testing], which are evolving at a rapid pace, but also keeping in mind the patients' desires. We're making sure we're prioritizing patient education and respecting patient autonomy."