In-house genetics counselors may be on the rise among fertility clinics. Amber Gamma, genetics counselor at IVI RMA America, discusses why the profession is trending toward in-house positions, how to address the challenges of funding their placement, and why you might want one of them on your side when it comes to litigation.
Listen to hear:
Which genetic counseling are more suited for in-house vs. external genetic counseling telemedicine companies.
How much these in-house positions earn, and how much they cost.
Tips on how to bill insurance for genetic counseling.
Amber’s response to Dr. Norbert Gleicher’s criticism of the overutilization of PGT-A.
What AI will take away from the genetic counseling field, and what will remain in their control.
Amber Gamma’s Info:
LinkedIn: https://www.linkedin.com/in/ambergamma/
Transcript
Amber Gamma 00:04
One of the biggest barriers, I think, to having an in house genetic counselor is that genetic counselors are not recognized as providers by CMS at this point. So that can make billing pretty challenging. That being said, we do still see that genetic counselors across the country bill, if you're working in a state that has licensure for genetic counselors, you're going to have, you know, a higher chance of success with billing and with significant reimbursements.
Griffin Jones 00:29
Does your fertility center have an in house genetic counselor? Are you thinking about having an in house genetic counselor? I talked with Amber Gamma. She's an in house genetic counselor for the RMA network. She has been in house elsewhere in the fertility field. She's been on the industry side. She has a master's in genetic counseling from Sarah Lawrence College. She is a board member of the genetic counseling professional group that subgroup within SRM. So I asked her what percentage of fertility clinics have their own in house genetic counselors, that number appears to be on the rise. She talks about the total number of genetic counselors there are in the field, I have her detail what those specific roles are versus which roles are better off for an external genetic counseling telemedicine company. I asked her what kind of revenue and in house genetic counselor brings in and how much they cost. She gives us tips on how to bill insurance companies for genetic counseling. I asked her to comment a little bit on Dr. Norbert Gleicher’s, criticism of the overuse of PGT-A. I don't get too deep into that, because I'm not qualified to but I wanted to see if she thinks that having more genetic counseling in house will utilize less testing or at least different kinds of testing. And then I needed that clarification from her that you may not need of the overlap between genetics counselors and genetic testing labs. I thought there was a lot more overlap. Maybe you do too. So I asked her to delineate that we talked about the advantages and disadvantages to genetic counselors, career mobility being in house versus with a much larger company. And then she concludes with the functions that artificial intelligence will probably take away from the genetic counselor in the next year or two. And what will have to remain within the genetics counselors purview enjoy this episode with Amber Gamma, Ms. Gamma. Amber, welcome to inside reproductive health.
Amber Gamma 02:16
Thank you. Thanks for having me.
Griffin Jones 02:17
I'm trying to think if you're the first genetic counselor that I've had on the show, and I'm gonna feel really bad either way, I guess that I haven't had one over 180 episodes, or that there have been one or two that I'm forgetting. And then I'm going to feel really bad. But welcome. I want to talk to you about genetic counselors in the field. And I want to talk to you about their role in external companies versus being in house for a fertility center, you are in house for e vrma. And can you give us some context about how many genetic counselors there even are in house in fertility centers in the US?
Amber Gamma 02:55
Yeah, so it is around, I would say 20, at the moment. So the National Society of Genetic Counselors does a professional status survey every year. And so in the latest professional status survey, there were about 50 genetic counselors that reported working in this field entirely. So that would encompass your in house genetic counselors, your PGT, labs, your gamete. Banks. So that is growing, it was about 40, a couple years earlier, so we're growing pretty rapidly. But in terms of the in house, GCS, that's definitely where I think we're starting to see a bit of an inflection point and some more growth
Griffin Jones 03:33
of those 20. Do you how many are with IE vrma? How many colleagues do you have at your own company?
Amber Gamma 03:40
So two, as of today, I was the only one before that.
Griffin Jones 03:44
And so the other 18 that might be out there? Do you have an idea what the kind of distribution is between if they're at large group networks? Or if that among independently owned Fertility Centers? Do you have any idea,
Amber Gamma 03:57
you do tend to see a fair number that work in academic centers? So within I'm based in New York City, within the New York City area, a lot of my colleagues are based at, you know, large academic Fertility Centers, you definitely will see genetic counselors in privately owned groups as well. So specifically on the West Coast, within the Seattle area, I have a few colleagues that work, you know, kind of in more private practice. And I will say it does tend to be pretty distributed to the coastal areas. At this point. I definitely do have some colleagues in South Dakota, Missouri, but largely, you'll tend to see that we do kind of fit along the coast a little bit more.
Griffin Jones 04:36
So we think that there's 50 in the field based on the National Society of Genetic Counselors survey, you mentioned that you've thought there's an inflection point going upward for in house Janet concert. That is say you think that there is a trend of more genetic counselors being brought in house tell us more about that.
Amber Gamma 04:58
I think that we're really reaching a point where reproductive genetics and genetics generally is becoming so important in the field of fertility medicine. And that is because of the technologies that are picking up steam within our field, but then also genetic testing technologies and other areas of medicine. So things like pediatrics, you'll have, you know, a lot more genetic testing that goes on for kiddos that have pretty complex medical issues. And then you may find a genetic cause for that child's medical issues. The couple still wants to have more children. So they're coming in for fertility care to be able to reduce that risk. So I think that we're starting to come across some more complex genetic situations where providers aren't necessarily feeling so comfortable dealing with those situations, and feeling confident in their counseling abilities to be able to guide that couple appropriately.
Griffin Jones 05:50
That makes sense why we would expect to see more genetic counselors in the field, you mentioned that it's up fifth, the from 40, a few years back, but why in house,
Amber Gamma 06:01
because for me thinking about an in house genetic counselor, it's really all about, you know, what you really deal with improving the patient experience, right? When we have a couple that comes in, and they've had previous genetic testing, for example, the genetic counselor that works at the PGT lab isn't really going to be focused so much on the appropriateness of the testing, how the how the results will be handled, what we would be thinking in terms of embryos that are eligible for transfer versus not eligible for transfer, the conversation that really happens with the genetic counselor, the PGT lab is more going to be focused on, you know, this is how we set up the PG TM testing this is the process that we're going to go through this is what's needed. But there is always a discussion that needs to happen about how is the couple wanting to use these results. You know, if you're finding things like variants of uncertain significance that are not black and white on genetic testing, how are we going to be handling those? Are we going to be testing for them? Are we not going to be testing for them? What are the couple's goals and testing for them? So those are all things that an in house clinic based genetic counselor can really explore thoroughly with a couple that may not necessarily be part of the PGT lab conversation.
Griffin Jones 07:18
How do you envision it being structured because if there is a an inflection point, and we start to see a growth there, then I guessing we would start to see divisions departments, or at least teams of some kind right now, you're with a really large company, RMA does several 1000 cycles in the US. And there's you said you have two colleagues right now. So there's three of you for this very large company, what will the structure go on to look like?
Amber Gamma 07:48
So there's just two of us at the moment? My second one is starting today. Yeah. So I think that's really going to be dependent on the company. And, you know, for example, obviously, working for such a large company, it's not like I've just been able to come in and take on all of the genetic counseling that happens, it's really been focused towards things that we feel like are more important to be in house versus things that could potentially be handled by genetic counselors that intelligent addicts companies, for example, right, those supporting the supporting organizations that can help bridge the gap if there are not in house genetic counseling services that are available. So over time, what we're really hoping to do as we build the team is be able to bring more in house to be able to provide a better patient experience that continuity of care. Because also in house GCS are very familiar with the clinic policies and how we do things and tele genetics companies, when you're working for multiple different clinics. Those genetic counselors don't feel like it's their role to really be able to say, well, this is what study your particular clinic. It's more this is the information that we have about this genetic testing results and the possible avenues that can be considered. So we're definitely hoping to build a team that can help improve, you know, the genetic counseling services that we provide by you know, potentially bringing more in house and be able to have the resources for our providers to go to you and for nurses to go to when they encounter situations and they need
Griffin Jones 09:22
guidance. Tell me more about those roles specifically and how you see them differentiating from the help that you might be augmenting with at Tella genetics companies, you talked about being a resource for the providers, being able to have more background for the processes that you're running at your clinic as opposed to here's just a particular type of tasks but as specific as you can be talk about what those roles will do versus what the external roles might do.
Amber Gamma 09:57
So for example, I think what a lot of people Little are facing right now is the issue of mosaicism on PG TA, right? So if, as an in house genetic counselor, I'm aware of what our philosophy is when it comes to mosaic results, what our transfer policies are, and our workflows. So things like consent forms that need to be signed, what needs to be in the patient's chart for our embryologist to say, Okay, this embryo is going to be transferred. And so it's a much more seamless process for our patients, right? They meet with me, I handle the consent form, everything is in the patient chart. And there's no questions along the way. If you're talking about, you know, an external genetic counselor at Atella genetics company, they're obviously working with many different clients. And as I said, as a separate entity, a lot of those genetic counselors report not feeling comfortable speaking to that particular clinics policy. So they're going to be saying, well, this is the information and this is the data that we have about transfer of these embryos, go back and speak to your physician and talk about what their clinic policies are, what pre transfer requirements may exist. And so as I mentioned, it just kind of creates that more seamless process for the patients, and having, you know, more of a way that they can feel, I think, supported through that process.
Griffin Jones 11:15
That makes sense to me, I'm trying to think of it in terms of economies of scale, and I'm comparing it to something that I know better, which is marketing firms, marketing agencies, and some corporations have in house marketing agencies, and some do it for reasons of cost effectiveness. And it's almost never more cost effective. So even if you think of very large agencies and very large corporations, you think of a Pepsi, and maybe they're with Saatchi and Saatchi, or universal McCann or group M, or one of these really large Madison Avenue agencies, there will be an entire division that's just on Pepsi, but they're employees of the agency. And so what about a genetics company that has a dedicated rep for a particular clinic or particular network where they are trained on that clinic groups philosophy that clinic groups, workflows, has access to put things in their chart notes, their transfer policy? Why wouldn't something like that be able to work?
Amber Gamma 12:23
I think that there are some questions to be asked about, you know, as a, as a healthcare entity, how much access you want to be able to give to external companies about things like patient information, etc. Right? So usually, in situations where we are referring out for those services, it may not be the case that that service has access to the entire patient chart, right? Because is that really appropriate? Do we really want to be giving that access just from like a HIPAA point of view and a regulation point of view? I think that this is more related to patient care as well, right. And so I know that having the relationships with nurses and physicians within the clinic and them knowing that they can come to me, and having spoken with patients and them knowing that I work for the clinic itself. Again, I just think provides a better patient experience overall. And we do see this reflected, you know, I there was a survey that was done at practice managers that was presented at ASRM last year about people that had hired in house genetic counselors. And the majority of those participants said we did it to try and improve the patient experience. And they felt like it had done that, you know, so we do tend to see that there is this feeling within the field as well that, you know, having the in house genetic counselor is beneficial to be able to improve patient care.
Griffin Jones 13:51
Are you working with all of the different offices of RMA right now, all of the providers across the United States? Yeah. How is that workflow managed.
Amber Gamma 14:03
So we have a very clear list of indications for which patients will come to see me and then we have workflows for other indications, you know, when May a patient be referred to an external service? And so we train our staff really, and we have resources available for the staff, and then it's just habit building over time, right. So, over time, the nurses and the physicians have learned, they can always reach out to me with a question, I'll always direct them in the correct way.
Griffin Jones 14:31
Well, that's how I mean so even if you have a policy of which patients you see and which patients are referred to an external agency, if you are the only person who this is their sphere within a very large organization, are you not getting pinged with emails constantly about what about this? What do you think about these things that aren't even part of your, your ticketed workflow?
Amber Gamma 14:54
Yeah, yeah, I do get a lot of those emails. And so that is a large part of my day as well. Well, it's just being able to provide that support to our providers and to our nurses. What are they asking you? They're asking me about carrier screening results. They're asking me about, you know, what do you think about this history or this genetic counseling note that we got? What do you think needs to be done for this patient? And yeah, I mean, depending on the day, it can be a lot of emails, right. But I think that's one of the beauties of having an in house genetic counselor is that those individuals know that there's someone that they can reach out to that they trust, and that they know is going to be very responsive to be able to get that answer.
Griffin Jones 15:34
You talked about There are criteria for which patients see you and which patients may be referred to an external company. What are the criteria for patients that are a good fit to be referred to me an external to an external company,
Amber Gamma 15:49
it's going to be your more routine things. So things like carrier screening results that don't show an increased reproductive risk. The it's the more complex things that come to me where those clinic policies really become important. So things like mosaic embryo transfers, segmental aneuploid, transfers, complicated PGGM cases. So your more routine stuff is going to be referred out and it's the more complicated stuff that we keep in house.
Griffin Jones 16:16
What kind of revenue does one in house genetic counselor bring in?
Amber Gamma 16:21
Yeah. So this is something that the genetic counseling professional group is working really hard on right now. One of the biggest barriers, I think, to having an in house genetic counselor is that genetic counselors are not recognized as providers by CMS at this point. So that can make billing pretty challenging. That being said, we do still see that genetic counselors across the country bill, if you're working in a state that has licensure for genetic counselors, you're going to have, you know, a higher chance of success with billing and with significant reimbursements. There's a few different strategies for revenue generation may be billing directly under the genetic counselor for appointments, a lot of genetic counselors and other areas, see patients in conjunction with a physician. And so the billing is done under the physicians name. There is also the opportunity to think about bundling in a fee. I know some of my colleagues at their institutions, there is a fee built into embryology fees as part of the IVF cycle that generates revenue and income for the position.
Griffin Jones 17:26
You mentioned some states where there is licensure for genetic counselors, do you know some of those states off the top of your head?
Amber Gamma 17:34
Yeah, um, so a lot of the states that I practice in New Jersey, California, Washington, Florida, Pennsylvania, New Hampshire, Connecticut, it's the majority of the states at this point, I think we're around 30 to 35. And then in a lot of states, like in my resident state, New York, there are active licensure efforts to be able to get bills passed and get licensure in place.
Griffin Jones 18:04
And so those are the states where it's easier to bill directly under the genetic counselor typically,
Amber Gamma 18:10
yeah, when you look at the data, you do see that the licensure does increase the chance of getting reimbursement from insurance companies.
Griffin Jones 18:19
And those where the genetic counselor is meeting in conjunction with the physician and billing on to the physician, does that typically happen in states where there isn't licensure for?
Amber Gamma 18:29
Yep, it'll it can happen as well. In states where there are licensure, it depends on your area of practice. So for example, if you're a genetic counselor working in pediatrics, all of your appointments are going to be happening in conjunction with the physician. prenatal appointments pretty often we see that and I would say it's less common within the field of infertility, but it's always something to consider. If you're thinking about getting a genetic counselor and thinking about billing strategies.
Griffin Jones 18:54
This may be a question for a billing person but I'll ask you in case you know it, do you know about the differences between the traditional insurance companies that united Blue Cross and how they bill genetic counselor time or don't, versus the employer benefits companies, carrot progeny kind body.
Amber Gamma 19:16
So we're really lucky actually progeny recently started to cover genetic counseling services. So we're seeing some changes there. You're big players like Aetna, UHC, Cigna. We do tend to see reimbursement from those insurance companies. I know in New Jersey horizon Blue Cross Blue Shield is a bit of a challenge, you know, to get reimbursements. And there are still some insurances that don't credential genetic counselors, but that doesn't necessarily mean that you won't get reimbursement. So sickness and example they don't credential genetic counselors as providers. But if you build genetic counseling services, we do see that you do get reimbursement in most cases.
Griffin Jones 19:57
I am going to do an episode soon. specifically about reimbursements and negotiating with insurance companies, I have a CEO coming on to talk about that topic. So we don't have to go all the way into a book, what other Can you give us for being able to get reimbursed for in house genetic counseling?
Amber Gamma 20:13
I mean, I think that as much as possible, if you're bringing in a genetic counselor, genetic counselors, it's a small community, we tend to be, you know, connected to each other. And one of the things that the genetic counseling professional group is trying to do is to be able to set up resources, that providers who want to bring an in house genetic counselor have access to on these types of topics. So being able to tap connections and these types of resources, always a good idea. I think the other thing when you're thinking about setting pricing is, you always want to consider that sweet spot of being able to try to get significant reimbursement from the insurance company. But if you're going to be balanced billing patients, and the case that the insurance does not cover the cost of that, you want to be able to have it be an amount that is so reasonable, you know, for the patient to be paying. So you know, when I've looked into this before, you'll see varying amounts I've seen, like around 100 150. And these are the types of amounts that people are playing around with to be able to see, okay, what do we get back? What are our patients being responsible for? So I would say it's an ongoing area of experimentation. And and there are federal advocacy efforts that are ongoing at the National Society of Genetic Counselors, to be able to try and get us recognized as providers by CMS. We're just working on getting ready to reintroduce that bill with the new Congress session. So, you know, I think once that gets passed, the billing landscape is really going to change.
Griffin Jones 21:40
How much does a genetic counselor cost? And what is the point where it's more cost effective than using someone externally? Yeah.
Amber Gamma 21:49
So you get when you look at the professional status survey data of the genetic counselors that are reporting working in this area, and this includes all settings, you'll see a salary of around 100,000 250,000 a year. I think one thing that we do have to keep in mind, as well as it's not just necessarily about revenue that has been brought in from the patient appointments. Having a genetic counselor in house also provides a level of protection for the practice. Because genetics is complicated, you make one mistake, and there's one lawsuit that's brought against, you know, a practice, that's going to be millions and millions of dollars. And so having a genetic counselor that can prevent that money from going out the door, when a lawsuit is settled, is going to be able to, you know, help offset some of the costs of actually having that genetic counselor in house. Also, we hear this pretty commonly, you know, the the concerns about the salaries of genetic counselors, there are other staff at fertility clinics that do not actively bring in revenue that are seen as crucial and important to patient care nurses being a perfect example. And over time, we've seen the importance of nursing within this field increase. And I do think that we are going to go the same way with genetic counselors.
Griffin Jones 23:06
I wouldn't say that nurses aren't tied to revenue, they're not tied to billing, you're not you're not billing for you're not billing the insurance company for the nurse. But if you have an REI that can do X 100 retrievals versus y 100 retrievals, the number of IVF coordinators that they use, typically variable to that. So I would say they're part of the capacity, do you for sure. Do you see genetic counselors is being able to improve the overall capacity in terms of the number of cycles that can be done with genetic testing?
Amber Gamma 23:44
I mean, I think that having a genetic counselor definitely reduces provider time and having to, you know, try and counsel on genetic tests, trying counsel on on results. And through that process, you're you're improving processes like informed consent, right. So when we think about just patient care from a genetic counseling role point of view, I would definitely say that it reduces provider time. We also know that genetic counselors within fertility clinics are not just limited to seeing patients, they're gonna have other roles as well. So this may include things like being part of a third party program, or helping to manage carrier screening workflows, or acting as liaisons for labs. And so all of these things can help reduce time that is spent by other staff within the fertility clinic on some of these matters. So if not about
Griffin Jones 24:35
revenue, but about scale, what size of practice group do you think is too small to bring in a genetic counselor again, III vrma is multinational RMA in the United States is still doing several 1000 IVF cycles and you now have one peer at your company. At what point do you think it makes sense to bring someone in?
Amber Gamma 24:58
I think if you're encountering a lot have genetic testing. And you are feeling like your staff does not have the confidence to be able to deal with that genetic testing and counsel appropriately on it. I think that's really when the discussion should be starting. So we're working on a an abstract for presentation that we're going to submit to ASRM this year, which has just been a survey of in house genetic counselors across the country. And when you look at the number of cycles per start, you know, in terms of the the clinics that do have genetic counselors, yeah, we're talking about clinics that do tend to be on the larger side, like more than 500 cycles a year, right. But you will see one or two clinics that definitely are on the smaller side that have genetic counselors. So part of it is going to be volume, but part of it is also going to be how important do you feel like having that in house support is for your patients? You know, as I mentioned, there may be more opportunities at academic Fertility Centers, if there are already genetic counseling resources within the institution itself to kind of form that relationship with those genetic counselors. But I think, you know, really, once you grow, and you're kind of encountering this more, and you feel like that level of confidence is coming down, that's really when you need to start having that discussion.
Griffin Jones 26:19
Does having genetic counselors in house and doing more of the genetic testing in house change the type of genetic testing that is done on the aggregate versus using a vendor. So
Amber Gamma 26:35
it, it will and it won't, the way that it won't, there is this common misconception or that has sometimes been encountered that as soon as you bring a genetic counselor in house, that all of a sudden you can do any type of genetic testing. And there's really two different types of genetic testing, you're going to have your screening testing, which is more like your carrier screening ahead of time. And that's definitely things that genetic counselors that are working with infertility clinics feel like it's within their scope of practice to order. One other thing that you may encounter is you may get a patient come in that has a complex medical history with a suspicious diagnosis, they haven't been able to make it into see a geneticist yet. And sometimes I do get requests about, you know, can we order this testing for this patient, but that's diagnostic testing, that's testing for the patient to be able to establish a diagnosis for them. So that is not genetic testing that you know, generally fertility GCS feel comfortable ordering, because it is not within our scope of practice. That being said, even on the carrier screening side of things, you tend to start picking up on things that may not have been picked up on before you were in house. And testing starts to be ordered for that. So a good example, you'll get a lot of PGDM cases these days for BRCA one, BRCA two, those two genes are associated with dominant conditions. But they're also associated with recessive conditions. So when you're meeting a couple, and one of them is positive for one of these two genes, one of the things that we usually think about doing is offering genetic testing for the reproductive partner, to be able to see if that partner is also a carrier, maybe he's not aware. And so those are the types of situations where you start to see more discussions happening. That may not have been happening before you had an in house genetic counselor.
Griffin Jones 28:24
How about with regard to the prevalence of even doing PG TA and reason I think to ask this is because I recently interviewed Dr. Norbert glacier. I think his episode will come out before this one does. But in either event, people should listen to that episode. And I want to make sure that I'm paraphrasing Dr. Glaciers argument, right. But in a nutshell, he views that PG TA is far over utilized for lack of scientific consensus and believes that at least in part, it's due to the influence of the lobbying for lack of a better term power of genetics testing companies that in his view, they have replaced the pharmaceutical manufacturers as the big spenders at the conferences and have a lot of influence that is based on their their sheer marketing power. And we didn't talk at all about genetics counselors being in house. So I wonder one if you share that view, if I'm representing it correctly, and people should listen to that to make sure that I am, but to if we might see a change in behavior, particularly with regard to PGA if it's not about being referred out to somebody else.
Amber Gamma 29:49
So I'm obviously very familiar with Dr. Fletcher's point of view on PG TA and I think it comes from I think he and I differ in our perspective. ofs, but we share a common criticism of PG TA. And that's really that if you're going to be bringing a test to market, you need to have a very good understanding about the clinical outcomes for all of the different possible results. So your chromosomally normal your PDT and negative embryos. We know a lot about that, because we transfer those routinely, your mosaic embryos, we've gotten a lot of data on those within the last seven to eight years. The one thing that we don't have a good understanding on for most of the labs, in terms of what they've actually published, is your whole chromosome abnormalities, right, you're plus 21, you're minus one. A lot of clinics don't transfer those. And when you think about the commercial PGT laboratories within the US, there's only one PG ta lab that has done a non-selection study, and has transferred over 100 of these chromosomally abnormal embryos, to be able to understand how many of them make babies, how many of them don't. So that was the Ashley TEKS study, they transferred over 100, and none of them made babies. So if you don't have a good understanding about the clinical validation of your PG ta platform, you can't say with confidence to patients, when you get and whole chromosome aneuploid results, what is the chance that that would make a baby? Right? I've worked with labs that have this information and that don't have it. My counseling with labs when they don't have this information is, yeah, I think there's a very high likelihood that that embryo isn't going to progress to a full term pregnancy. But because you can have these cases squeaked through, that's really what's fueled the glacier controversy, and sort of that perspective of things. But I think if we could get to a place where all of the PGT laboratories have this information, then I think that critique really dissolves, because we have the data to be able to tell us, you know, whole chromosome abnormal embryos with next generation sequencing technology, do they make babies? Do they not make babies?
Griffin Jones 31:58
But then the thought that comes to my mind as a dummy is why do they not have that information?
Amber Gamma 32:04
Because it's very challenging to do as a study, right? You know, when you think about the teak study, that was obviously, because there was a very close relationship between the PGT lab and the fertility clinic that was really working with them. So you know, other labs that don't have that type of relationship? How do you really build that relationship to be able to get that study going, and also, as a study, transferring the abnormal embryos, because we know that there is such a high likelihood that they won't result in successful pregnancies? So a lot of ethical questions that come up, right, and may not be something that all institutions are super gung ho about doing, even if we know that it is something that is so important to this field.
Griffin Jones 32:43
You talking about this? And what you said earlier about one of the advantages for genetic counselors being in house is that they know the fertility clinics transfer policy, they know that fertility clinics, philosophies on different things like mosaicism, how much influence will genetic counselors have over those things from the beginning going forward? And in other words, how much influence will they have over the transfer policy over the group's philosophy on mosaicism and other elements?
Amber Gamma 33:16
Hopefully, more. I mean, I know at my previous institution where I was before my current position. When I had first started there, the conversation about transferring mosaics came up. And the policy was set. And then two to three years later, I was monitoring the the research and the data that was coming out. And I brought it to the physicians and I said, Listen, our policy is not reflective of the data anymore. If we want to be an evidence based practice, we really have to reassess this. So I think that genetic counselors in house can be a huge resource for helping to direct clinic policies based on the evidence and based on understanding of genetic testing.
Griffin Jones 33:55
That brings me back to what you talked about with risk. And maybe that's one of the ways that you see in house genetic counselors being able to reduce legal risk. Tell us more about that. How would an in house genetic counselor team or even one help a clinic reduce their legal exposure?
Amber Gamma 34:17
Hmm. So I think embryo disposition is a pretty big conversation now with these intermediate PGT results. So I know some of my colleagues have been really important in discussions with their institution about what do we keep what do we not keep your third party risk assessment, so things like egg donor sperm donors, especially if you have in house gammy donor programs, they can be really pivotal and being able to, you know, assess family histories, and appropriateness of gamete donors, and also be able to interpret genetic testing that is being done for those individuals. And then just generally, you know, in your day to day practice, being able to make sure that everything is being covered from a genetics point of view, we're not missing anything, results are being interpreted correctly. Those are all ways that we can assess with that.
Griffin Jones 35:12
What are if it's so important, as you mentioned, then why are genetics companies closing their fertility divisions?
Amber Gamma 35:20
Genetic testing companies?
Griffin Jones 35:23
So why why did semaphore close their fertility division? Why didn't vitae close their fertility division? If this is such an important thing, and so important that we should bring it be bring more of it in house? Why are large companies parting ways?
Amber Gamma 35:39
Well, I think we have to separate out genetic testing versus genetic counseling. So that genetic testing labs are really the ones where we're seeing a lot of shifts at the moment. And that is having some downstream effects on tele genetics companies that those labs have working relationships with. But the challenge with genetic testing, especially when it comes to carrier screening, which we deal with a lot, has always been that there have been very, very thin margins for that testing. And things change, you know, around 2018 2019, in terms of how you can bill for that testing, you could no longer stack codes, your margins got thinner, we've also changed into an economic climate where capital investment is not as readily accessible. And so I think it's a combination of all of these things, right, and also individual business practice decisions, that are really influencing a lot of the layoffs that you're seeing across companies.
Griffin Jones 36:32
Well, maybe this is an elementary explanation that my audience doesn't need, but that I'm may have benefited from earlier, I thought there was a lot more overlap between genetics testing companies and the genetics, counseling services done by tele genetics companies. Can you talk about what overlap there isn't, isn't?
Amber Gamma 36:53
Yeah, so a lot of labs will have their own independent like their own group of genetic counselors that work for that lab. But then especially a lot of carrier screening labs, you'll see that they start to build these relationships, these contractual relationships with tele genetics companies. And that's just simply because they have such a large volume of testing coming in that their in house group cannot cover all of the genetic counseling demand. So they will contract with these tele genetics companies to be able to provide your results reviews for your patients. And so the lab is then directing money towards the tele genetics company through that contractual agreements, but they're separate entities.
Griffin Jones 37:35
Okay, so the closures and the reductions that we're seeing with genetics testing labs, we're not seeing that trend with genetic counselor companies.
Amber Gamma 37:48
So like I said, there are some downstream effects, right? Because if you have a contractual relationship with a genetic testing lab that disappears over a couple of months, then you're obviously going to have a gap right in terms of what revenue you're expecting as a company. So a good example is genome medical is a tele genetics company that had a relationship with in vitae when in vitae did a lot of their downsizing and their layoffs last year, there were some layoffs that happened at genome medical later on, right. So these are examples of things where we can see more downstream effects that hit tele genetics companies because of genetic testing lab decisions, but it's really all originating from that genetic testing lab,
Griffin Jones 38:28
not originating from what could be the origin cause one being Insurance Billing that if these lab companies are closing fertility divisions and citing the lack of insurance reimbursement, are we not seeing that same trend in for the counseling companies? Or for or for counseling period?
Amber Gamma 38:54
No, I mean, you know, because we talk about billing in terms of the billing codes, right. They're seen as completely separate services. They're built very differently. And, I mean, there are some areas of genetic testing where you see much more successful reimbursement. So oncology, for example, from a from a lab testing point of view, but we're not, we're not seeing the same level of increasing difficulty that we're seeing within the genetic testing world when it comes to billing for genetic counseling.
Griffin Jones 39:26
Is there a disadvantage to genetic counselors career mobility, working for a fertility clinic, as opposed to a much larger company, given all of the different tracks that a genetic counselor could go on to do?
Amber Gamma 39:40
I mean, the thing that I've always loved about my role is you can be a trailblazer. So I think this type of role is going to attract a genetic counselor that likes a certain level of independence and likes to be able to be very innovative. I always say I would have been a horrible pediatric surgeon had a counselor because even though we're all trained in the same way, the role is very different, right? Obviously, in fertility, I'm not working directly alongside a physician every single minute of my day, whereas when you're a pediatric genetic counselor, there's a lot more of that. So, you know, when you think about working for a large company, someone like maybe a tele genetics company, there are certain advantages to that role. You know, you tend to have a lot of patient facing moments. So if you're really into direct patient care, that's a good role for you. You know, your, your company can work with a lot of different clients, if you like being able to have the influence and the drive and have a hand in many different pots. That's where I feel like the in house fertility GC role is really good, because you have those opportunities, and your genetic counselors that PGT labs are also really wonderful genetic counselors that gammy thanks really wonderful, like all of my colleagues are, are very adept and very with it, it's just that our roles differ slightly right? Your gammy being GCS, they see their patient as being the gamete donor, not the intended parent. And so their role, even though we all work within the same field can be different from what I do on a day to day basis.
Griffin Jones 41:27
What specific functions will AI takeaway from genetic counselors in the next two years?
Amber Gamma 41:34
I mean, you're starting to see like some pretest, carrier screening counseling modalities coming up that are, you know, like videos, and I think are more primed to like aI involvement there. I think at the end of the day, genetic counseling is very much a process of building a relationship within a patient within, you know, half an hour to an hour, and being able to really connect with that patient and facilitate a decision about some sort of genetic test or some sort of genetic results. I question about if AI methods are going to be able to bridge that human connection. I mean, obviously, with chat GPT, things have evolved so quickly. But I think that at the end of the day, genetic counseling really offers an opportunity to be able to connect with a patient that I don't know that AI is really ever going to be able to provide in the same way.
Griffin Jones 42:26
Well, even with Chet GPT, it's like, how do we know that? That's real insight? You know, yeah, I think it's going to be a while before we can tell what insight artificial intelligence is able to provide, because we often can't tell what insight real intelligence is able to provide. And at the end of the day, you're helping someone to make a decision that isn't necessarily a plus b equals c, there's an excessively anti factor and people need help digesting it. And so what are actors envision the role of genetic counselor will become as more of the predictive analysis moves to artificial intelligence, what will the role of the genetic counselor become?
Amber Gamma 43:14
I think it's really going to be focusing on those more complex cases where like you said, the decision is very unique to that patient or to that couple, based on what their fertility history is, what their treatment journey has been, where they're at emotionally and financially, and you know, what their goals are in the short in the long term. Those are the areas that I feel like, genetic counselors are really going to be able to thrive and build that role. But I agree with you like there's more predictive things or more routine things, that I think there are opportunities for scale and opportunities for technological support, to be able to target the resources of in house genetic counselors, to the things that really need it.
Griffin Jones 44:01
There's probably a couple of AI companies listening, being like Go on, what are areas where you where would help to have more of that support.
Amber Gamma 44:11
I mean, if you think about how often we're doing carrier screening, there's a lot of you know, let's say that you have a couple where they're both negative on that carrier screening, what's important for them to know, it's important for them to know their results, but it's important for them to know that this test is not decreased all genetic risk, right. And those are the types of things where that conversation is going to look very similar from patient to patient. So that's the type of opportunity that you may think about creating technological support for same thing for low risk carrier couples. So one partner is a carrier or something the other partner isn't. That counseling session looks very similar, but just with some added information about the genetic results that was identified. And then again, risk is reduced if not eliminated, but again, those those types of conversations look very similar from patient to patient. Those are really going to be I think the first areas are the low hanging fruit for more technological support.
Griffin Jones 45:02
And we're How would you like to conclude knowing that of 180 episodes, this may be the first where I've even broached the topic of genetic counseling. And if there have been one or two others, I apologize, but knowing that most of our audience is probably not genetic counselors, I do get notes from them sometimes. And if there are topics that I'm not covering, please do reach out, because this is how conversations like this happen, and we're able to create more content and serve the broader audience. But the majority of our audience being Rei is being execs being practice owners, how would you like to conclude
Amber Gamma 45:39
just that genetic counselors are way more than just people that see patients, there are ways that can support physicians, practice managers, you know, clinical operations, directors, and many, many more ways than you think just by hearing about genetic counselors. So, you know, I think having a genetic counselor has been so beneficial for the people that have brought them in that I think it's really worth considering, okay, how can we make this happen in the future. And it's been an honor to potentially be the first genetic counselor that has been on the show.
Griffin Jones 46:12
And we're gamma. Hopefully, it's not the last time either. Thank you very much for coming on inside reproductive health. Thank you.
46:19
You've been listening to the inside reproductive health podcast with Griffin Jones. If you're ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health