CMS Posts State Level Payment Data for Part B for CY2016: MoPath

CMS annually posts both national payment data by CPT code (here) and by state (here). 

Specific to genomics, I've done an initial analysis of 2016 national payment data here.

It's difficult to analyze the state payment data since there are over 50 files.   However, I've pulled the MoPath code series for Northern California, Southern California, and Utah into one spreadsheet, because these three areas total the lion's share of US MoPath payments.   In the cloud, here.

2016 Data by State: BRCA as a Case Study

       Update:  I've published expanded data and charts in March 2018, as a survey that reviews 2014 2015 2016 together,  here.

While it would take a long time to assess all the MoPath codes by all the states, I've pulled just the BRCA related codes, here, as a case study:

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Let's analyze as BRCA1/BRCA2 testing, with or without a larger panel of genes.   In Northern California, CMS paid 2,963 claims for 81432 (zero claims for sister code 81433) totaling $2.7M, at an average price per claim circa $1000.    In Southern California, in contrast, almost all claims came in as code 81162 (the consolidated BRCA1-2 sequencing and DupDel code), with payments of about $18M for only twice as many patients.

Turning to Utah, claims came in variably under code 81162 and 81211 at about a 2:1 ratio.   It's not possible to know how many patients are represented by the code pairs 81211+81213;  for this table, I assume there were 3,613 unique patients.  With that assumption, there were about 12,000 patients getting BRCA sequencing in Utah with payments of $31M and the average price just a little higher than in Southern California. 

In round numbers -- with some assumptions -- if all the patients getting BRCA1-2 sequencing (with or without a larger panel)  had been paid at the average Northern California rate, total CMS payments would be around $23M.  If all the patients had been paid at the Southern California or Utah rates, total payments would have been closer to $58M. 

Medicare has published provider specific payment data for up to CY2015 (here).  As of CY2015, there was only one 81211 provider in Utah, although that may not be the case in 2016.  As for SoCal, that's a puzzle.  There were only a few dozen payments for 81211 in SoCal in CY2015, but over 7,000 payments for 81211 in SoCal in CY2016.   At the same time, payments for unlisted code 81479 in SoCal dropped from $62M in CY2015 (of which $31M to Ambry Genetics) to $51M in CY2016.

Can CMS Do Anything?

CMS has long applied a panel pricing rule in lab medicine, so that components of a panel can never get paid more than the total panel.  CMS could apply that to BRCA testing.   If it was a leg fix, it looks like it would score $35M savings per year or (as a first guess) $350M savings over 10 years. 

Bonus: Pie Chart

As best as I can reconstruct, this is a pie chart of the five different ways to code BRCA testing at five different net prices, using CMS 2016 data.  2016 was the first year that comprehensive code 81162 was available, as well as gene panel codes 81432, 81433.   I've shown earlier, in PAMA data for commercial payers in 1H2016, the use of 81162 was around 1%.   The "blue slice," 81162, paid about $2500; the "orange slice," 81213+81211, paid about $2700 but required not employing a published CMS CCI edit against code stacking 81213+81211.   The yellow slice (81432+81433) pays about $1500 but not in California, where a MolDX edit classifes 81433 as an "excluded" code (here) and payment is for 81432 alone at $932 (blue slice).

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