Lâle's presentation showcased the bottom line for labs as it relates to the PAMA preliminary payment rates. In short, for about 75% of all codes on the Clinical Laboratory Fee Schedule (CLFS), the weighted median of the private-payer rates shows a decrease over current payment rates. Whereas, only 10% would result in an increase. Also significantly, CMS expects the proposed changes in lab pricing to save Medicare Part B $670 million in calendar year 2018 alone. There is no indication that CMS intends to delay this implementation.
A market-based reimbursement strategy is appropriate for example for the introduction of new sole-sourced assay, but it is not reflective of true market value for test pricing that has been exploited through coding and coverage sophistry and non-market-based reimbursement manipulation by both public and private payors.
Kyle's presentation titled, "MACRA for the Lab: What is it and Why it is Important?" provided key insights on the Medicare Access and CHIP Reauthorization Act (MACRA) and its impact on labs. MACRA has several facets important to lab leaders including the Quality Payment Program (QPP), as well as eligibility, reporting, and timeline requirements.
The primary focus of this legislation, passed in 2015, is on value-based payment and quality reporting and CMS estimates 90% of eligible clinicians will participate in this payment reform. At the core of the value-based payment framework is the move toward rewarding healthcare providers for giving better care not more care. The program provides both incentives and penalties for reporting quality metrics. Laboratories can benefit by actively reporting as well as participating in an additional positive payment adjustment.
Labs have a key role to play in clinical quality improvement and quality reporting from the diagnostics perspective. The CMS Quality Payment Program implements payment adjustments linked to evidence-based and practice-specific quality data. Diagnostics provide the basis for downstream quality reporting, thus laboratories become the supporting network for physician partners.
To learn more about either of these topic, please contact us.