Lower laboratory testing fees are driving out competition and potentially limiting care for seniors who live in nursing homes, warns a coalition of providers fighting to replace the law that mandates rate cuts.
The Protecting Access to Medicare Act, PAMA, was meant to bring lab fees in various settings within standard market rates. But a flaw in early rate setting has led to $4 billion in cuts in nine years. The Congressional Budget Office had projected only $2.5 in cuts over 10 years.
The last three rounds of cuts shaved 10% of the reimbursement for many common tests; the next round, slated for January, threatens a 15% reduction to as many as 800 different tests. Nearly three-quarters of tests on the clinical fee schedule have already been affected by PAMA cuts.
That could jeopardize access to many of the clinical laboratory tests that are used to diagnose, monitor and manage diseases, especially among nursing home residents. That’s according to the American Clinical Laboratory Association, which is rallying behind new legislation that would stop the PAMA cuts for good.
ADVION, which represents laboratories as well as a variety of other ancillary service providers in the skilled nursing field, is also backing the effort to stop lab cuts.
The group said that the most frequent lab tests ordered for nursing facility residents are:
- Prothrombin time (PT/INR). Measures how quickly the blood forms a clot and is monitored for patients taking a blood thinner.
- CBC with differential. Used to help diagnose and monitor many different conditions, including anemia and infection.
- Comprehensive metabolic panel. Measures 14 different substances in the blood. It provides important information about the body’s chemical balance and metabolism. Liver and kidney health, blood sugar levels, blood protein levels, acid and base balance, fluid and electrolyte balance and metabolism.
“The cuts apply to all the tests that nursing facility patients need and significantly reduce our ability to continue providing these tests,” said ADVION Executive Vice President Cynthia Morton in an email to McKnight’s Thursday.
Most skilled nursing facilities are served six days per week by clinical laboratories, which often provide same-day results that inform patient care. Prior to PAMA’s adoption in 2014, there were 25 clinical laboratories that specialized in skilled nursing. Today, the ACLA reports there are just six.
“Without congressional action, the most frail, and vulnerable patients in skilled nursing facilities may experience compromised access to timely and comprehensive clinical laboratory testing essential to treating medically complex conditions,” the ACLA said in materials that support its new campaign.
Service providers, including associations representing labs, want Congress to adopt
HR 2377 / S1000, the Saving Access to Laboratory Services Act.
SALSA would simplify the data reporting process by providing the Centers for Medicare & Medicaid Services with the authority to collect data from a statistical sampling of all major lab types that provide services to seniors, including independent, hospital, and physician office laboratories.
Those new samples would be used to set “accurate and sustainable” Medicare rates for laboratory services.
ACLA says the fatal flaw of the PAMA approach was its first-round market data, which was collected from less than 1% of the nation’s laboratories. Because it wasn’t truly representative national data, later payment reviews led to lower-than-realistic rate setting.
In related news Thursday, the Health and Human Services Office of Inspector General announced it would add an assessment of Medicare payments for clinical diagnostic lab tests to its 2024 work plan.
Medicare is the largest payer of clinical laboratory services in the United States.
PAMA requires the OIG to publicly release an annual analysis of the top 25 tests based on Medicare Part B spending and that it conduct analyses that OIG determines appropriate. OIG will analyze and report on the top 25 laboratory tests by expenditure for 2022.