Genetic Test Utilization and Cost among Families of Children Evaluated for Genetic Conditions: An Analysis of USA Commercial Claims Data

Hadley Stevens Smith (), Matthew Lakoma, Madison R. Hickingbotham, Dawn Cardeiro, Katharine P. Callahan, Monica H. Wojcik, Ann Chen Wu and Christine Y. Lu
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Hadley Stevens Smith: Harvard Pilgrim Health Care Institute
Matthew Lakoma: Harvard Pilgrim Health Care Institute
Madison R. Hickingbotham: Harvard Pilgrim Health Care Institute
Dawn Cardeiro: Point32Health
Katharine P. Callahan: The Children’s Hospital of Philadelphia
Monica H. Wojcik: Harvard Medical School
Ann Chen Wu: Harvard Pilgrim Health Care Institute
Christine Y. Lu: Harvard Pilgrim Health Care Institute

Applied Health Economics and Health Policy, 2025, vol. 23, issue 3, No 13, 519-530

Abstract: Abstract Introduction Healthcare payers in the USA increasingly cover genetic testing, including exome sequencing (ES), for pediatric indications. Analysis of claims data enables understanding of utilization and costs in real-world settings. The objective of this study was to describe genetic test utilization, diagnostic outcomes, and costs for children who received ES as well as for those who received less comprehensive forms of genetic testing, along with their families. Patients and Methods We analyzed linked family claims data for commercially insured members of a large regional health plan. The sample included children younger than 18 years of age who had at least 1 year of continuous plan enrollment and at least one claim for genetic testing from 2016 to 2022, as well as their family members. We compared outcomes for children who ever had a claim for ES (ES cohort) with those for children who had claims for only less comprehensive genetic testing (other genetic testing (OGT) cohort). We evaluated the frequency of ICD-10 codes indicating genetic diagnoses, health care utilization, and out-of-pocket costs in relation to the timing of the index genetic test using t-tests and inverse-probability-of-treatment weighted regression models to control for observable clinical and demographic characteristics associated with type of testing received. Results Our sample included 182 children (mean comorbidity index 4.78) in the ES cohort and 1789 children in the OGT cohort (3.63; p

Date: 2025
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DOI: 10.1007/s40258-024-00942-9

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