Home 5 Lab Industry Advisor 5 Essential 5 Newly Proposed PAMA Rates for 2018 Confirm Lab Industry’s Worst Fears

Newly Proposed PAMA Rates for 2018 Confirm Lab Industry’s Worst Fears

by | Oct 16, 2017 | Essential, Fee Schedules-nir, National Lab Reporter, News-nir, Reimbursement-nir

From - National Intelligence Report CMS's newly issued preliminary Clinical Laboratory Fee Schedule (CLFS) for 2018 dashes the lab industry's hopes for PAMA relief by making two things… . . . read more

CMS’s newly issued preliminary Clinical Laboratory Fee Schedule (CLFS) for 2018 dashes the lab industry’s hopes for PAMA relief by making two things painfully clear:

  • There will be no delay in plans to implement the new PAMA payment system for lab tests on Jan. 1, 2018; and
  • The agency is sticking to its approach of excluding hospital labs from its pricing formula.

The Context

The idea behind PAMA is to base Medicare payments for particular lab tests on the weighted median of private payor rates for particular tests. Since 2014, CMS has been gathering data from “applicable laboratories” to figure out what those rates actually are. The proposed CLFS for 2018 represents the agency’s first cut at setting prices using the new formula.

While embracing the idea of market-based pricing, the lab industry has objected to CMS for not including hospital and community labs in its definition of “applicable laboratories.” Because these labs charge higher rates, excluding their pricing data was bound to artificially skew rates in a downward direction, they insisted

The CLFS Bloodbath

The CMS’s pricing proposal not only confirms the lab industry’s concerns but provides for cuts even deeper and more widespread than feared. The 2018 CLFS would cut the rates of approximately 75% of lab tests. The only saving grace is that 58% of the rate cuts will be phased in due to CMS’s 10% per year cap on reductions from 2018 to 2020. CMS claims that the new rates will save Medicare Part B about $670 million in CY 2018.

“If these draft rates were finalized, the impact would be devastating,” according to American Clinical Laboratory Association President Julie Khani. “We fear the impact on laboratories serving the most vulnerable Medicare beneficiaries, laboratories serving rural areas, and those with high Medicare volumes would be the most severely impacted.”

Here’s an overview of the key things lab managers need to know about the proposed CLFS:

1. Reference Labs Suffer the Deepest Cuts

Although the rate cuts would have widespread effects, they fall particularly hard on big reference labs like Quest Diagnostics and Laboratory Corporation of America. In a note to investors, Piper Jaffray analyst William Quirk writes that the expected revenue decline of approximately 8% in the first three years is even worse than Wall Street’s initial expectations of a 6% drop in 2018 followed by a flat 2019-2020. So it is hardly surprising that word of the CLFS sent the share prices of both firms sharply down.

Both labs have also issued statements criticizing the preliminary rates as not being market-based because they exclude payment data from hospital labs. According to Quest CEO Steve Rusckowski, “hospitals and physician office labs comprise half of Medicare clinical lab fee schedule volume and lab spending, but only accounted for 8.5% of the reported lab volume used by CMS to calculate the rates.”

Mixed Bag for Molecular Dx

Newfangled proprietary tests offered by a limited number of labs fared better than reference lab tests provided by large numbers of hospital and reference labs. A notable example is molecular diagnostic tests. Thus, while a few molecular tests did suffer deep cuts (including tests for Lynch syndrome (CPT 81435) and TRB gene rearrangement direct probe (CPT 81341)), molecular assays were hit with generally smaller declines and even a few rate increases.

Molecular DX Test Winners & Losers

TestProprietary Manufacturer(s)2017 RateProposed 2018 PAMA Rate
CPT 81519 (Oncotype DX for breast cancer recurrence)Genomic Health$3,443.36$3,873

CPT 81525

(Oncotype DX for colon cancer recurrence)

Genomic Health$3,126$3,116

CPT 0008M

(Prosigna for breast cancer recurrence)

Nanostring$3,443$900
myRisk Hereditary Cancer (based on CPT 81211 and 81213)Myriad Genetics$2,781$2,949
CPT 81490 (Vectra DA rheumatoid arthritis test)Myriad Genetics$591$841
CPT 81450 (hematological malignancies)$541.81$648.40
CPT 81445 (targeted next-generation sequencing of 5 to 50 genes panels$602.10$597.91
CPT 81432 (Invitae hereditary cancer panel)Invitae$931$838
CPT 81528  (Cologuard colon cancer screen)Exact Sciences$512$509
CPT 81420  (prenatal testing)Illumina, Natera, et al.$802$759
CPT 81435     (Lynch syndrome test)$802$38

Advanced Diagnostic Laboratory Tests (ADLTs)

Another category of tests to dodge the axe are the newfangled ADLTs, i.e., tests developed and offered by a single lab that use a unique algorithm to analyze multiple DNA, RNA or protein markers, and which provide new clinical diagnostic information that cannot be obtained by any other test. Two key ADLT test codes to get increases included:

  • CareDx’s AlloMap for cardiac transplant rejection risk (CPT 81595): from $2,841 to $3,240; and
  • Veracyte’s Affirma Gene Expression Classifier for classifying thyroid nodules (CPT 81545): from $3,222 to $3,600.

Crosswalk Codes

CMS also issued crosswalk- and gapfilling-based preliminary rates for 58 HCPCS codes for which it received no private payor data. (See related item on page y).

Takeaway: CMS is taking public comments on the proposed rates through October 23 with the expectation of issuing final rates in November. In the meantime, the lab industry has not given up on its efforts to persuade the agency to change the pricing formula to include hospital labs or at least delay the new PAMA rates from taking effect on Jan. 1.

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