Insurance denials and diagnostic rates in a pediatric genomic research cohort

PURPOSE

This study aimed to assess the amount and types of clinical genetic testing denied by insurance and the rate of diagnostic and candidate genetic findings identified through research in patients who faced insurance denials.

METHODS

Analysis consisted of review of insurance denials in 801 patients enrolled in a pediatric genomic research repository with either no previous genetic testing or previous negative genetic testing result identified through cross-referencing with insurance prior-authorizations in patient medical records. Patients and denials were also categorized by type of insurance coverage. Diagnostic findings and candidate genetic findings in these groups were determined through review of our internal variant database and patient charts.

RESULTS

Of the 801 patients analyzed, 147 had insurance prior-authorization denials on record (18.3%). Exome sequencing and microarray were the most frequently denied genetic tests. Private insurance was significantly more likely to deny testing than public insurance (odds ratio = 2.03 [95% CI = 1.38-2.99] P = .0003). Of the 147 patients with insurance denials, 53.7% had at least 1 diagnostic or candidate finding and 10.9% specifically had a clinically diagnostic finding. Fifty percent of patients with clinically diagnostic results had immediate medical management changes (5.4% of all patients experiencing denials).

CONCLUSION

Many patients face a major barrier to genetic testing in the form of lack of insurance coverage. A number of these patients have clinically diagnostic findings with medical management implications that would not have been identified without access to research testing. These findings support re-evaluation of insurance carriers' coverage policies.

Disclosures of Sexual and Physical Abuse across Repeated Interviews

This study examined the recorded interviews of 132 children between 3 and 16-years of age who were involved in a forensic investigation evaluating allegations of sexual and/or physical abuse. As part of this investigation, two interviews were conducted over a 5-day period. The interviews were analyzed to examine how frequently these children disclosed substantiated allegations of abuse when asked directly about these experiences in one or both interviews. Results revealed that 39.2% of children with substantiated sexual abuse and 55.6% of those with substantiated physical abuse denied these experiences in one or both interviews. The denial rate was highest among school aged children (6- to-10-year- olds), as over a third of the girls and more than half of the boys in this age group denied the substantiated allegations in one or both interviews. Recantations were also relatively common, as 24% of the children who disclosed sexual and/or physical abuse prior to the assessment denied the allegations in one or both interviews. The youngest children (3- to 5-year-olds) were most likely to be inconsistent in their denials/disclosures across interviews. Custody status and relation to the perpetrator also predicted denials/disclosures of sexual, but not physical abuse. Overall, the data suggest that denials of both sexual and physical abuse are quite common and higher than rates found in most archival file reviews.

The negations of conjunctions, conditionals, and disjunctions

How do reasoners understand and formulate denials of compound assertions, such as conjunctions and disjunctions? A theory based on mental models postulates that individuals enumerate models of the various possibilities consistent with the assertions. It therefore predicts a novel interaction: in affirmations, conjunctions, A and B, which refer to one possibility, should be easier to understand than disjunctions, A or B, which refer to more than one possibility; in denials, conjunctions, not(A and B), which refer to more than one possibility, should be harder to understand than disjunctions, not(A or B), which do not. Conditionals are ambiguous and they should be of intermediate difficulty. Experiment 1 corroborated this trend with a task in which the participants selected which possibilities were consistent with assertions, such as: Bob denied that he wore a yellow shirt and he wore blue pants on Tuesday. Experiment 2 likewise showed that participants' own formulations of verbal denials yielded the same trend in which denials of conjunctions were harder than denials of conditionals, which in turn were harder than denials of disjunctions.