Rapid, accurate and convenient point-of-care lab testing for patients is one of the promises of 21st century medicine. However, reimbursement cuts enacted through the Protecting Access to Medicare Act of 2014 (PAMA) threaten access to this testing, explains Colin Edgerton, MD, FACP, RhMSUS, partner in Articularis Healthcare and chair of the ACR’s Committee on Rheumatologic Care (CORC).
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Mandated by PAMA, the CMS implemented a new payment methodology this year for clinical laboratory testing services paid under the Clinical Laboratory Fee Schedule (CLFS). This new market-based system is resulting in cuts to reimbursement for clinical testing services, including those provided at the point of care by physician office-based labs.
Although cuts in 2018 are capped at 10%, cuts over the next two years may total more than 30% of 2017 payment rates. These cuts significantly jeopardize patient access to care, particularly for those in rural and underserved areas.
Threatening Reimbursement for Laboratory Testing
Dr. Edgerton says medically fragile or compromised patients, a common demographic in the rheumatology office, will face delays in testing with potential for worse outcomes and an overall increase in program costs.
“This is indeed an example of being ‘penny wise and pound foolish’ when it comes to medical care,” Dr. Edgerton says. “Patients may face delays due to logistical difficulties traveling to multiple facilities to obtain services, reduced adherence, and potential for waiting longer for appropriate treatment to include prescription medications.”
Many fear these cuts to reimbursement could have an outsized impact on vulnerable populations, including Medicaid patients.
Vulnerable Patient Populations at Risk
As a physician with Arthritis Associates of Kingsport in Tennessee, a small private practice in the Southern Appalachian region, Christopher Morris, MD, is very concerned with how these changes are affecting small private practices.
“Our poverty rate is much higher than in the northeastern metropolitan areas, and there is a severe shortage of rheumatologists in our region,” he shares. “We care for these people because there is no one else to provide the care they need. This cut in coverage means we are, in many cases, providing the appropriate care at a loss, or on a razor-thin margin.”
Dr. Morris believes that in the big picture, these cuts have a negligible effect on CMS expenditures, while resulting in physicians having to discontinue doing the labs. “If they really want to cut costs, they need to look at the big expenditures, not punishing the physicians in the small communities who are trying to provide care and cover costs.”
ACR Actions to Address PAMA Impact
The ACR is working through the American Medical Association (AMA) and the AMA Federation to identify the best path forward for correcting the payment system to protect patient access to important lab testing services at the point of care. As part of these collaborative efforts, the ACR has joined a letter written by concerned stakeholders to CMS Administrator Seema Verma outlining these concerns.
One major concern with this new payment methodology is the data used to establish it. Medicare reimbursement for a test equals the weighted median of private payer rates, based on rates from applicable labs, which largely excluded hospital labs from reporting data, according to ACR Senior Director of Government Affairs Adam Cooper, MS.
Because of concerns about these data used by the CMS to establish the new payment methodology, Mr. Cooper says the AMA is urging the CMS to issue an interim final rule that holds current 2017 rates in place until it has performed a targeted survey of all segments of the laboratory market.
Stay tuned to the ACR’s Advocacy News for further coverage on the College’s efforts to address how the PAMA is affecting practice and patient care.
Carina Stanton is a freelance science journalist in Denver.