Tech, lower prices drive genetic testing in comp

The use of genetic testing as a way to reduce drug interactions and improve health outcomes has been growing rapidly worldwide and is beginning to penetrate the workers compensation sector as stakeholders seek to mitigate the effect of opioids on injured workers or determine the best treatment regiments for occupational cancers, experts say.

Technology improvements and lower costs are expected to drive greater acceptance of genetic testing in the workers compensation sector, but significant barriers exist to widespread usage of genetic testing in the comp context, including cost, timeliness of results and the quality of available research, experts say. Privacy and bias laws also must be addressed.

Many people are familiar with genetic testing used to determine ancestry, but subsets of those tests include pharmacogenetic testing, which analyzes the genetic variants in an individual’s DNA to help tailor medications or identify genes associated with cancers, and toxicogenomic testing, which can determine an individual’s susceptibility to certain toxins.

Individual genetic profiles contain six enzymes that metabolize 90% of medications, and the U.S. Food and Drug Administration has approved pharmacogenetic labeling — listing the genetic variants that could affect an individual’s clinical response — for more than 200 drugs, according to Mason, Ohio-based Myriad Neuroscience, a division of Myriad Genetics Inc.

“Genetic testing is ever changing and expanding,” said Dr. Paul Peak, Memphis, Tennessee-based assistant vice president of clinical pharmacy at Sedgwick Claims Management Services Inc. “It is kind of hard not to see this as the future at some point when tests are fast enough and give doctors the quick insight they need.” 

Several studies have found cost and treatment benefits from genetic testing, but its use in workers comp has been limited. California’s Medical Treatment Utilization Review guidelines, as well as the American College of Occupational and Environmental Medicine guidelines, are silent on pharmacogenetic testing.

According to a spokesman for the California Workers Compensation Institute, gene analysis is coded on the workers comp fee schedule, but represents less than 0.1% of all of the services and payments under the schedule.

Broadspire Services Inc., a subsidiary of Atlanta-based claims management firm Crawford & Co., has found value in the use of pharmacogenetic testing as a tool for expediting recovery time for injured workers, said Erica Fichter, senior vice president of medical management.

“We have found that when the right medications are prescribed, injured workers recover faster from surgery, they respond better to physical therapy and they avoid setbacks like rehospitalization or adverse drug reactions that cause us to incur additional costs,” she wrote in an email.

Dr. Peak said when he sees genetic testing used in workers comp, it’s typically to identify the best treatment for occupational cancer claims or to ensure a patient is on the correct opioid medication.

A 2017 study conducted by Toronto-based workers comp claims management company Banyan Work Health Solutions Inc. — using claims data in Canada — found that pharmacogenetic testing at the beginning of a claim for issues including gastrointestinal disorders, cardiovascular health, pain management or mental health could result in a 5% to 14% potential cost savings. 

Genetic testing has also been used in chronic pain treatment in workers comp, according to a 2015 study published in the International Journal of Biomedical Sciences, which noted that genetics have a significant effect on pain perception, and that the likelihood of addiction to opioids is about 50% related to an individual’s genetic profile.

In early 2019, University of Florida researchers released a study finding that when therapy was guided by pharmacogenetic testing it improved pain control for individuals with chronic pain.

Pharmacogenetic testing has potential in the workers compensation space, said Maria Chianta, national director of managed markets medical liaison for San Diego-based specialty laboratory Millennium Health LLC.

If pain medication dosage is ineffective for a comp patient, it may lead to an emergency room visit, or if an adverse reaction occurs, an individual could wind up even more ill, she said.

“That can get into months of costs and adversely impact the patient’s quality of life,” said Ms. Chianta. “These outcomes aren’t ideal not only because of the effects they have on the patient, but they do end up becoming a burden on the system.”

There are a number of pros for using genetic testing in a workers comp program, said Bert Randall, president of Baltimore law firm Franklin & Prokopik P.C. “Creating a more individualized medication and prescription program presents an opportunity for cost cutting, particularly in occupational disease claims,” he said.

However, significant barriers exist, including questions by clinicians of when genetic testing should be used, and whether the results will change the course of treatment, said Dr. Robert Goldberg, chief medical officer and senior vice president for Healthesystems LLC in Tampa, Florida.

“There are a lot of questions about clinical management that testing could just confuse versus help clarify,” he said. “If you’re testing inappropriately, it can lead you in the wrong direction.”
 
Test costs, which have dropped from more than $1,000 per test to the $200 to $500 range in the past few years, is an issue, as is physician buy-in and the length of time it can take to receive results, which can be several weeks, Dr. Peak said. But, it’s “hard not to see this as the future, at some point when the tests are fast enough to give doctors the quick insight that they need,” he said.

Had a genetic test been available to determine whether Lyrica — the most costly drug in the workers comp system for Sedgwick — was effective for certain people, Dr. Peak said he believes it would have been used because of the cost benefit.

“If you’re talking about lifetime cost of a really expensive medication, I think genetic testing definitely could be a tool,” Dr. Peak said. “But there’s not enough of those medications to prove the point yet.” 

In one case where a workers compensation claimant was taking Soliris — at a cost of more than $1 million per month — to treat renal failure he said was brought on by workplace fumes, genetic testing revealed that the worker had a genetic variant that made it unlikely that he would suffer a recurrence of the condition and could stop the medication, said Chicago-based workers comp attorney Amy Bilton, partner at law firm Nyhan, Bambrick, Kinzie & Lowry P.C., who was the defense attorney.

“In our case, it was literally all or nothing for the lifetime (medication) question, and it hinged on the genetic testing,” said Ms. Bilton. “Medications are always right on the forefront of expense. That’s obviously an extreme example, but that’s what a lot of these cases come down to — extreme examples.”

While sufficient research exists and had been validated with regard to using pharmacogenetic testing for oncology treatment, opioid-related pharmacogenetic research is lacking, said Dr. Goldberg.

“Lung cancer is the best example of an occupationalrelated cancer where genetic testing can help with chemotherapy,” he said. “Otherwise it’s the rare patient that might benefit from genetic testing. In most injury treatment, I think it’s very unlikely that it’s worthwhile.

If it’s a question of whether a patient is on too much medication, you probably should be reducing it anyway.”

However, Dr. Goldberg and Dr. Peak both noted codeine is an exception.

“With codeine, the body metabolizes it into morphine, and if it’s metabolized too fast and an individual gets higher doses, it can cause respiratory depression,” said Dr. Peak. Individuals who fail to metabolize the codeine fast enough don’t receive the pain control benefits.

Genetic testing may be used to prevent placing doctors in a precarious situation when an individual on higher doses of opioids is consistently unable to receive pain relief, said Jeremy Ingle, vice president of business development at Synergy Laboratories in Mobile, Alabama.

“In those situations, an employee may not metabolize (the opioid) properly,” he said. “Having a genetic test can unequivocally say” that the dosage needs to be adjusted.

More research is on the way. In June, the National Institutes of Health announced that it will invest $42 million over the next five years for clinical trials to assess the benefits, applicability and efficacy of applying genomic medicine interventions to improve management of diseases such as high blood pressure, depression and chronic pain. The trials are scheduled to begin in 2020.

“Until we know more about the influence of genes vs. environment, it’s really dangerous to launch into genetic testing for diagnoses and treatment until we have the science to validate the use of the technology,” said Dr. Goldberg. “I think as we get further along in science in the next five, 10, 20 years, I think it will become a more important tool.”