Payers’ Views on Expanding Their Role in Precision Medicine

Abstract

This qualitative study explores the views of US private health care payers regarding evidence and policy challenges of precision medicine, as well as their potential roles in its implementation.

Introduction

Precision medicine (PM), the application of genetics and genomics in health care, is an example of innovation transforming care and outcomes. US private health care payers play a central role in access to PM because coverage and reimbursement affect adoption and affordability.¹ Literature, including our multiyear payer research, has conceptualized payers as PM evidence reviewers, coverage decision-makers, and stakeholders in implementation.^2,3

However, a 2025 study by Abbasi et al,⁴ as well as officials from the US Food and Drug Administration, urged a greater payer role in medical innovations, including early dialogue with industry and informing evidence generation.⁴ PM may be particularly suited for a broader payer role because it presents challenges to payers and health systems considering its adoption.⁵ Challenges include commercialization outpacing evidence⁶ and legislative, commercial, and public pressures on coverage decisions, complicating PM adoption by payers and health systems.^7,8,9 We examined payers’ perspectives on these trends and implications for payers’ potentially expanding role.

Methods

For this qualitative study, we conducted a semistructured group interview with the University of California, San Francisco (UCSF) Center for Translational and Policy Research on Precision Medicine (TRANSPERS) Payer Research Board, a longstanding cohort of senior executives representing private payers (eMethods in Supplement 1).¹⁰ Hereafter, all participating individuals representing private payers are referred to as payers. The UCSF institutional review board determined this study exempt. All participants provided verbal informed consent before the interview. We adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.

Interview topics included PM-relevant diseases, evidence and policy challenges, and potential roles for payers across the PM ecosystem (eMethods in Supplement 1). The 90-minute interview was conducted on February 4, 2026, and recorded and transcribed verbatim. Two investigators (J.R.T. and C.B.W.) performed thematic analysis and resolved discrepancies by discussion and consensus. Analyses were conducted using Microsoft Excel version 2603 (Microsoft Corporation) from March 5 to April 26, 2026.

Results

Of 15 TRANSPERS board members, 12 participated, including 10 (6 large national and 4 regional) insurers and 2 organizations supporting payers’ coverage decision-making. Themes derived from the interview were categorized into 4 domains (Table). First, participants described opportunities and willingness to inform innovation priorities earlier in the PM lifecycle. Although oncology remained important, participants identified unmet needs in autoimmune disease, women’s health, pediatrics, obesity and metabolic disease, Alzheimer disease, and neurodegenerative conditions. They also emphasized diagnostic features that could improve therapeutic decision-making, including tests that help deselect ineffective treatments.

Table. Factors and Implications of the Expanding Role of Payers in Precision Medicine.

Domain	Factors for expanding role as conveyed by participants	Implications for payer expanding role as expressed by participants
Informing innovations in PM	Unmet needs for PM in multiple disease areas, eg, autoimmune, women’s health, pediatrics, obesity and metabolic disease, Alzheimer disease, neurodegenerative disease Need for new diagnostic features, eg, to guide deselection of ineffective therapies	Willingness to articulate high-priority innovation needs and high-burden disease areas to researchers and developers
Precoverage and postcoverage evidence generation	Necessity for earlier precoverage evidentiary alignment with researchers Variation in coverage across payers exploited by diagnostics companies to get additional coverage Need, but limited mechanisms, for postcoverage clinical performance assessment	Considering development of consistent evidentiary expectations for initial coverage decisions and postcoverage evaluations Willing to play a role with claims-based assessments within constraints of payer costs and regulatory limitations of involvement Considering the next generation of coverage-with-evidence-development approaches
Nonevidentiary pressures on coverage decision-making	State laws mandating biomarker coverage and legislation restricting prior authorization have considerable impact on coverage decisions Social media amplification of coverage and insurance challenges, negative campaigns toward payers, erosion of public trust	Payer dialogue with legislators and policymakers Encouraging studies to evaluate impact of legislation on outcomes and care quality Public, proactive, transparent communication regarding payer coverage decision-making
Alternative commercialization strategies pursued by diagnostic companies	Financial assistance programs for tests not covered Pseudo–standard of care formation facilitated by commercialization before evidence maturity Creative and variable billing approaches	Earlier payer dialogue with innovators and health systems adopting novel diagnostics Need for frameworks assessing outcomes of alternative commercialization approaches Multipayer alignment on coding expectations and standardization of coding

Abbreviation: PM, precision medicine.

Second, participants conveyed a need for earlier evidentiary alignment with product developers and more robust postcoverage evaluation. Participants noted that developers often approach them after study completion and with evidence not addressing payer-relevant questions. They also noted variation across payer policies as a leverage that diagnostics companies use to seek broader coverage. Participants supported clearer evidentiary expectations for precoverage and postcoverage assessment. Although they did not view evidence generation as a payer responsibility, they saw potential roles in sharing quality metrics, contributing claims-based analyses within cost and regulatory constraints, and considering next-generation coverage-with-evidence-development models.

Third, participants emphasized nonevidentiary pressures on coverage decision-making. Legislation mandating biomarker coverage and restricting prior authorization was viewed as increasingly influential. Participants also described public distrust and social media amplification of coverage disputes as pressures that shift coverage debates away from scientific evidence. Thus, participants saw a need for dialogue with policymakers, engagement in studies evaluating the effects of legislation on outcomes and quality, and proactive public communication about coverage decision-making.

Fourth, participants described challenges of diagnostic companies’ alternative commercialization strategies, including patient financial assistance for noncovered tests, marketing before evidence maturity, and creative billing (using alternative billing codes not intended for a test or multiple codes for different components of 1 test). Participants suggested earlier payer dialogue with innovators and health systems, frameworks to assess outcomes of alternative commercialization models, and multipayer alignment on coding expectations.

Discussion

The findings of this qualitative study suggest that participating TRANSPERS members representing private payers saw value and opportunity in expanding their role in PM beyond coverage, identifying unmet innovation needs, clarifying evidentiary expectations, supporting postcoverage assessment, communicating with policymakers, and addressing commercialization practices bypassing evidence-based coverage pathways. Although participants did not view evidence generation as payers’ responsibility, they identified roles in clarifying evidence needs and supporting postcoverage assessment. These roles may strengthen evidence for individual access decisions and population-level evaluation of outcomes and quality, but their impact may depend on structured dialogue among payers, researchers, developers, and policymakers that preserves stakeholder independence. Greater transparency regarding evidence, quality, safety, and value considerations underlying payer decisions may improve public understanding and trust. Collectively, these efforts may contribute to a more predictable and evidence-informed environment for evaluating and adopting PM.

This study has some limitations. The cohort of participating private payers with PM expertise may not represent public or other private payers. Participant selection from this established TRANSPERS board, nonparticipation by some board members, and longstanding relationships between participants and investigators may have influenced perspectives expressed, including through social desirability or other group-interaction effects. As a group interview, it was designed to identify themes and hypotheses for future studies rather than assess agreement.

The findings of this qualitative study suggest that the changing PM environment is conditioning participating private payers to consider roles beyond coverage decision-making. This consideration may also be relevant to other medical innovations. Clarifying opportunities and boundaries of this evolving role will be important for the future translation of PM into care.

Supplement 1.

eMethods.

Supplement 2.

Data Sharing Statement