Are Labs to Blame for a $1,000 Pap Smear?

Arecent editorial in the New England Journal of Medicine about a “$1,000 Pap smear” has generated a great deal of discussion in the laboratory community. The Oct. 17 editorial, written by Cheryl Bettigole, M.D., a New Jersey-based family practitioner, states that laboratories sometimes charge her patients $1,000 or more for a Pap smear that until recently cost only $20 or $30. The high charges are mostly due to “add on” tests, such as those for HPV and sexually transmitted diseases, as well as sophisticated lab tests for a variety of yeasts. While Bettigole says clinicians deserve much of the blame for ordering unnecessary tests, she believes that labs are also to blame, arguing that labs have learned that one easy way to increase revenue is to make it easy for clinicians to order more tests. “In the past year, I have been visited by multiple laboratory representatives touting ‘improved’ tests, virtually all of which involve combination panels that can be easily ordered and that contain extensive lists of fairly esoteric tests,” she writes. “The single-vial women’s health test is being heavily marketed by multiple laboratories. It includes not only the Pap and HPV tests but also tests for multiple infections—including some we would rarely have tested for in the past—for which we often have no evidence of benefit.” “The final step in creating these astronomical bills for women without health insurance is that some laboratories charge uninsured women vastly inflated amounts, while offering insurers steep discounts from these ‘usual fees,’” she continues. “Although some laboratories offer discounts to uninsured patients, others do not, leading to the phenomenon well documented in other areas of medicine in which the uninsured pay premium rates, often having to set up multiyear payment plans for services for which a health maintenance organization would have paid a fraction of the charges.” Scott McGoohan, vice president of reimbursement and scientific affairs for the American Clinical Laboratory Association (ACLA), argues that the decision about which tests to order lies with the referring physician and labs should not be blamed for overtesting. “ACLA supports the medically reasonable and necessary use of diagnostic testing, and precisely which diagnostic tests are ordered is a matter of physician judgment in a given clinical scenario,” he says. “Laboratories are not responsible for the ordering of laboratory tests, nor can they receive reimbursement from the government for testing which is not deemed to be medically reasonable and necessary.”