CMS cuts threaten access to critical diagnostic tests

Some rural patients and outpatient health care providers may face some new obstacles when a Medicare reimbursement change goes into effect Jan. 1. The Health and Human Services' Office of Inspector General found a few years ago that Medicare pays 18 percent to 30 percent more than other insurers for some lab tests, and the program pays about $7 billion a year overall for clinical diagnostic laboratory tests, Virgil Dickson reports for Modern Healthcare. That led to the Protecting Access to Medicare Act of 2014, which aims to save almost $4 billion over 10 years by only allowing Medicare to pay the same rate for tests as private payers.

The tests that will take the biggest hit in reimbursement rates are genetic tests that offer risk scores for breast and colon cancers. Reimbursement will increase for tests that check for genetic disorders found in Ashkenazi Jews, Noonan spectrum disorders, oncology tumor testers, lung oncology tests, and mRNA breast oncology tests.

Some doctors and clinicians are worried that higher prices will lead to a decrease in patients agreeing to be tested for certain cancers, which could increase cancer diagnoses and deaths. "The lab community is lobbying both the CMS and Congress to push the pause button on the cuts over concerns that the CMS didn't use sound methodology to determine the new rates, Dickson reports.


The problem, the lab community says, is that the CMS exempted many labs from reporting what private insurance companies pay for the tests. The labs the CMS collected their data from were the biggest ones that received volume discounts from test manufacturers, leading to an inaccurate picture of what labs usually cost. Smaller, more rural labs often pay much more for tests.


John Cullen, a rural doctor from Valdez, Alaska, told Dickson that he's worried that his patients' care may suffer if he's not able to get reimbursement for some of the more expensive same-day testing. Many of his patients must travel more than 100 miles to get access to health care, and can't afford to come back later for test results.

"Unlike the hospital industry, which is suing the CMS to stop a planned cut to the federal discount drug program known as 340B, labs for now aren't pursing legal action, but may reconsider," Dickson reports.