Wednesday, November 6, 2024

Caris MI Test Gets FDA Approval; Should Lock-In CMS NCD Coverage

Header:  The Caris MI Cancer Seek test garners FDA approval as a comprehensive genomic profiling test plus several companion diagnostic claims.

Being an NGS test including CDx claims, it should have automatic on-label coverage under the CMS NCD for NGS tests in cancer.   The policy, in use since 2018, is designed to be an incentive for seeking FDA approval.  Other CGP tests getting FDA approval this year include tests from Tempus (lab-based) and TSO from Illumina (kit-based).

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See the extensive press release here:

https://www.carislifesciences.com/about/news-and-media/caris-life-sciences-receives-fda-approval-for-mi-cancer-seek/

According to the AAPC website, the code for Caris MI Cancer Seek is 0211U, which is priced on the clinical laboratory fee schedule at $8455.  (The CMS price was set by the additive crosswalk method several years ago).   The test includes DNA exome and RNA transcriptome.

In the next couple weeks, FDA will post online the test's safety & effectiveness validation.  Caris has posted a 64-page validation document:

https://www.carislifesciences.com/wp-content/uploads/2024/11/MICancerSeek_TechnicalLabel.pdf

Caris writes in part, "MI Cancer Seek is the first and only simultaneous Whole Exome Sequencing (WES) and Whole Transcriptome Sequencing (WTS)-based assay with FDA-approved CDx indications for molecular profiling of solid tumors."   The test tracks single variants and indels in 228 genes.  The test has 7 indications, including breast cancer, colon cancer, melanoma, lung cancer, and "solid tumors" for MSI (microsatellite instability for Keytruda).



Exact Sciences -- Earnings Call a Tutorial in Crosswalk and ADLT pricing.

On November 5, 2024, Exact Sciences held its 3rd quarter earnings call.  This generated news because of a downgrade in expected revenue, at one point, share price was down 30%.  E.g. here.

The earnings call (9300 words long) also includes multiple snapshots that are like a class in CMS lab test pricing.   In the transcript, Exact discusses CLDT (crosswalk) pricing, ADLT pricing, and the lower cost of goods for Cologuard Plus.

(Transcript here at NASDAQ).

Crosswalk Process

Exact Sciences very recently got FDA approval for Cologuard Plus, a new version of its stool test incorporating nucleic acid analysis.  In the summer public comment meeting for new codes, Exact asked that it be priced at 1.25X the current price (that is, a crosswalk of 1.25X).   In its September proposed prices for comment, CMS offered a 1.0X crosswalk.   

(There was a public comment period from September 25 - October 25.)  

(CMS offers fractional crosswalks, like 1.25, quite rarely.  One code got the fraction 0.5, in Fall 2023.)

The transcript mentions Medicare about 12 times.  Exact notes, "Next, we plan to establish a higher price through an available Medicare pathway before launching the test with Medicare coverage and guideline inclusion."   

Pivot to ADLT Discussion

There was a question regarding pricing:  "Can you just kind of remind us of the pricing strategy for 2.0, sounds like ADLT will be the focus, given the clinical at schedule, I think the interim update didn't go your way. So can you let us know kind of what price you look to seek with ADLT status? You talked about it, it will apply to Medicare?"

The response includes:

In terms of how we intend to price that, we are still before Medicare with a clinical lab fee schedule process that plays out before the end of the year. And we remain -- we continue to engage with CMS on getting a clinical -- the CDLT process to seek a price increase.

But if not, then we will go the ADLT path, and the ADLT path is just a slightly longer path. We get there's a benefit that you probably start with the higher price than the CDLT path. The process then takes a couple of years to transition from Cologuard to Cologuard Plus. The patients who have access to Cologuard Plus will get Cologuard Plus.

And over time, we will start with the Medicare patients and then move into the commercial and then Medicaid patients. That process probably takes 12 to 24 months to play out. Obviously, there are a lot of benefits for payers and their members to have access to Cologuard Plus, including the performance. And also the price -- the cost makeup of Cologuard Plus is lower.

In response to a follow up question about ADLT, Exact notes,

In terms of the mechanics, yeah, you have that essentially right that you have a list price, you pick that list price. You get paid, find [by?] Medicare for that list price.  [ADLT] And then at the end of a period, it reverts to the median of the commercial rate if there's commercial rates that are -- where there are claims that have been processed. And you can dig into how the mechanics of the ADLT process works.

That's the essence of it. And then you get that price for 2 years, and then it readjusts and every year after that. So you do have the ability to control that price, and you get paid on the Medicare claims. Initially be the Medicare fee-for-service claims over time as you get commercial contracts or your commercial contracts that exist, cover Cologuard Plus.

In another section, Exact discusses overall gross margin, and remarks, "That should flip to a tailwind for us in 2025 with the launch of Cologuard Plus, which will give us added ASP as well as lower cost of goods. "

A Few Links: Trump Administration and Health Policy

 Here are few links on Trump Administration and health policy:

  • Fierce Healthcare:  Where do Harris and Trump stand on health policy?
  • STAT:  Donald Trump returns with big ambitions to shake up health care.
    • Here, November 6.
    • See also their November 4 article, here.
  • NPR on Trump health policy, November 6.
  • HealthCareDive - How health industry reacts, November 7.
  • Healthcare Finance - What election means; November 7.
  • BioPharma Dive - Biotech, Trump, FTC may relax on mergers, etc.
  • NYTimes - What could Trump do to Obamacare?
    • Here.
    • Speaker Mike Johnson, who would likely continue in his role in a Republican majority, said that his caucus would seek “massive reform”[of ACA].
  • The Guardian [UK]:  Trump's queasy prescription to 'make America health again' takes shape.  
  • WSJ reviews Trump economics more generally - e.g. the balance of pro's and con's re tariffs, tax cuts, potential inflation, etc. 

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Court Postures

One topic not mentioned above that could affect a few issues is how the Trump administration fights, or doesn't fight, the government side of some legal battles.  For example, from the Obama to Trump to Biden administration, there were several 180 degree flip flops on whether to include "transgender" under the heading of "sex discrimination."    ANother grand flip flop was from MCIT (Medicare Coverage for Innovative Technology) to TCET (Transitional Coverage for Emerging Technology) between Trump 2020 and Biden 2021.

Current legal cases include Braidwood v Becerra, where the moving party would like to eliminate USPTF recommendations as requirements for preventive services, an issue it is up to the government to defend in the way it chooses.  Similarly the government could opt to take one of various responses to the FDA LDT litigation being pushed forward by ACLA.

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Leadership Nominations

Leadership of HHS, CMS, FDA, etc., will be up for grabs, and we may not know more until mid-spring.  

My blog of January 25, 2017, just after the inauguration, contained several then-contemporary links to news report about Dr. Shiong-Soon (a biotech billionaire who owns the LA Times) and potential positions in the administration.

Returns?

One senior health policy executive in the Trump administration is Joe Grogan, who has remained active and public on health policy topics.  E.g., he was interviewed at length on a second Trump administration in Stat Plus on October 16.  He was one of just three Trump administration interviewed in a panel at the IOP (Institute of Politics) on October 15.  See also his 30-minute interview on health policy at Andreessen-Horowitz (January 2024).   He's also been outspoken on drug pricing policy and innovation (here).   Another active figure in the Trump HHS was Eric Hargan, deputy secretary and acting secretary.  See Hargan Group / Hargan Strategies.

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The Guardian article cites some "Project 2025" policies that the Trump campaign disavowed.

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AI Corner

This is a Chat GPT summary of recent health policy news.   There are many different ways to summarize this news, and I only offer this as "if of interest" or "FYI."

Chat GPT 4o:

The recent election of Donald Trump for a second presidential term is anticipated to impact U.S. healthcare policy, with significant shifts in areas like Medicaid, telehealth, and Medicare Advantage. Industry experts foresee a continuation of Trump's earlier priorities, focusing on healthcare cost reduction, deregulation, and possibly more market-driven reforms.

Healthcare Legislation and Data Privacy: Trump's administration, supported by a Republican-majority Senate, is likely to fast-track changes in AI and cybersecurity regulations within healthcare. HIMSS, a major health information group, anticipates new policies aimed at interoperability and data-sharing, which were pivotal in the previous administration. Telehealth, expanded during the COVID-19 pandemic, could see a legislative push to make its benefits permanent, while maintaining remote patient monitoring services.

Medicare Advantage and Pharma: Stocks in Medicare Advantage insurers surged post-election, as expectations rise for a friendlier regulatory environment. Pharma representatives, like PhRMA’s Stephen J. Ubl, are optimistic about partnering with the administration to reduce regulatory constraints on drug innovation. Trump’s previous policies included initiatives aimed at lowering drug costs by tackling pharmacy benefit manager (PBM) practices, which could continue in his new term.

Medicaid and the ACA: Medicaid could face restrictions, with possible reintroductions of work requirements and spending caps through block grants, potentially limiting coverage. The ACA may remain, but Trump’s administration could scale back financial supports, such as enhanced subsidies, which were recently extended. Experts predict this would likely result in premium increases and a potential rise in uninsured rates.

Public Health and Health Agencies: Trump’s focus on lowering healthcare costs may extend to public health reforms, with Robert F. Kennedy Jr., a known vaccine skeptic, positioned to influence regulatory approaches. This could potentially shift long-standing public health policies and introduce more scrutiny on vaccine mandates.

Overall, Trump’s healthcare agenda seems aimed at reducing federal spending and emphasizing free-market principles, with potential effects across Medicare, Medicaid, and public health sectors. Industry stakeholders, including hospital and pharmaceutical groups, have expressed both optimism and caution as they prepare for possible regulatory changes that could reshape healthcare delivery and access in the coming years.  [END CHAT GPT]

Tuesday, November 5, 2024

Tempus to Acquire Ambry Genetics for $600M

Tempus will acquire Ambry Genetics for about $600M, it was announced yesterday.

See the TEMPUS press release here:

https://www.tempus.com/news/pr/tempus-reports-third-quarter-2024-results-and-agreement-to-acquire-ambry-genetics/

Tempus writes,

Tempus today announced that it has entered into an agreement to acquire Ambry Genetics, a leader in genetic testing. Under the terms of the agreement, Tempus will pay $375 million in cash and $225 million in shares at closing, of which $100 million will be subject to a lock-up agreement until one year post-transaction close. The deal is expected to be financed in part through a $300 million increase in short and long term debt provided by Ares, Tempus’ current lender. Ambry expects to generate >$300 million in revenue in calendar year 2024 and EBITDA of >$40 million. 

For more information on Ambry and its impact, see Tempus’ latest investor deck.

Tempus also announced quarterly financials, with $116M in 3Q revenue, gross margin of about 50%, and net loss of about $75M. 

Tempus has a market cap of about $7B.   Stock price was bouncy as the market absorbed the news.



DNA plus RNA

Separately, TEMPUS authors on a publication of the importance of dual DNA and RNA sequencing to identify actionable variants (RNA NGS).  See Owen et al. in JAMA Open Network on November 4.

Monday, November 4, 2024

CMS Creates Special Add-on Payment for Inpatient Infectious Disease Care

Header: For physicians managing inpatient care, CMS and AMA’s CPT system offer a range of codes covering initial, mid-stay, and discharge day encounters, each with multiple levels of time and intensity to capture the scope of patient care. Now, CMS has introduced an add-on code specifically aimed at compensating the added complexity of treating infectious disease patients in these settings.

For more information and links, click here:

https://www.discoveriesinhealthpolicy.com/2024/11/cms-releases-final-pfs-and-opps-rules.html

For the CY2025 PFS rule see here.  In the inspection copy version, see pp. 301-316.

IDSA flags the new code as a big win - here. See also their 2024 comment letter.  And see the Congressional letter of support, which notes that 80% of US counties lack even one ID specialist and last year, only half of infectious disease fellowship slots were filled.



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In final rulemaking for CY2025, CMS creates a new G-code code, valued at about 1 RVU (circa $30), that reflects the adding complexity of managing an infectious disease patient.   The code is G0454 and defined as follows:

  • G0545
  • Visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases consultant, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment. (add-on code, list separately in addition to hospital inpatient or observation evaluation and management visit, initial, same day discharge, or subsequent).
  • This is an add-on code, billed together with the underlying encounter code the provider would otherwise bill (and still bills).   

    The code seems to be triggered if the patient (1) is an inpatient (or inpatient observation), (2) the patient has confirmed or suspected infectous disease, and (3) the billing provider is "an infectious disease consultant."  This includes infectious disease specialty physcians, but also e.g. a nurse practitioner with infectious disease specialization.

    If the consultation is made remotely, bill the appropriate electronic records review consultation code, but do NOT add G0545.

    Justification for the novel code includes special public health concerns (including data research and time) related to being an infectious disease physician caring for an infectious disease patient: 

    1. Disease transmission rusk assessment and mitigation
      1. Such as consulting with infectoius prevention staff and managing prevention protocols;
    2. Public health investigation and analysis
      1. Such as in-depth chart review farther back in time communicating with microbiology lab, state health, CDC;
    3. Complex antimicrobial therapy counseling and treatment
      1. Such as counseling regarding antimicrobial stewardship, resistance, emergence of variants, new strains, public health concerns, etc.
    ##

    CMS received a few complaints that creating a specialty-specific inpatient payment was contrary to long-established policy norms.   CMS offers to replace the G-code with an AMA CPT code if one is created.   

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    The wheels of the gods turn slowly; CMS notes it began considering this policy change in 2021 (for CY2022).

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    AI Corner

    Here is a Chat GPT generated news article.

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    CMS Finalizes New Add-On Code for 

    Infectious Disease Hospital Visits: HCPCS Code G0545

    The Centers for Medicare & Medicaid Services (CMS) recently announced a significant policy update impacting hospital inpatient and observation care for infectious diseases. Under the new rule finalized for Calendar Year (CY) 2025, CMS introduced HCPCS code G0545—a complexity add-on code to enhance payments for infectious disease specialists providing complex care during hospital stays.

    Addressing Complexity in Infectious Disease Care

    The decision to create HCPCS code G0545 acknowledges the unique challenges posed by infectious disease cases in hospital settings. Infectious disease cases often involve intricate decision-making and risk management, including infection control, collaboration with public health agencies, and personalized antimicrobial therapy management. According to CMS, infectious diseases require extensive medical review because resistance patterns and public health risks continually evolve, posing unique challenges for patient management and community safety.

    Key Components of HCPCS Code G0545

    HCPCS code G0545 allows infectious disease specialists to report additional complexity beyond standard Evaluation and Management (E/M) hospital codes. This add-on code covers three main areas:

    1. Disease Transmission Risk Assessment and Mitigation – Includes specialized infection control measures, counseling for patients and caregivers, and care coordination to reduce transmission risks.
    2. Public Health Investigation, Analysis, and Testing – Encompasses thorough patient history reviews, specialized diagnostic evaluations, and coordination with public health authorities for contact tracing and diagnostic testing.
    3. Complex Antimicrobial Therapy Counseling and Treatment – Involves advising patients and families on antimicrobial stewardship, managing resistance concerns, and selecting appropriate therapies based on population health considerations.

    Implications for Infectious Disease Specialists and the Healthcare System

    The final rule emphasizes that G0545 may be billed only by infectious disease professionals trained to manage the unique challenges inherent in infectious disease cases. CMS has set a work Relative Value Unit (RVU) of 0.89 for G0545, reflecting the time and decision-making intensity involved, estimated at 30 minutes per encounter, though not time-based for billing. This new code is seen as a response to growing concerns that current E/M codes fail to account for the expertise required in managing infectious diseases, particularly in light of increased vigilance following the COVID-19 pandemic​.

    Responses to Public Comments and Future Directions

    The proposal for HCPCS code G0545 received broad support, with many stakeholders welcoming its focus on complexity. Some commenters requested it be converted to a standalone code for use without a face-to-face visit, but CMS decided to keep it as an add-on code. Additionally, CMS clarified that practitioners, including nurse practitioners and physician assistants with infectious disease expertise, can bill for G0545 under the appropriate conditions. CMS also affirmed that no new documentation requirements would accompany this add-on code, maintaining that the medical record should reflect the complexity inherent in infectious disease cases.

    The implementation of HCPCS code G0545 marks a key step toward improving reimbursement for specialized care in infectious disease cases and reflects CMS’s ongoing efforts to adapt Medicare payment policies to the complexities of modern medical practice.


    ##

    I understand there was a complaint from someone that CMS violates longstanding policy by creating a specialty specific code (re read the PDF if needed).

    ##

    Yes, there was indeed a complaint from several commenters regarding CMS’s decision to create a specialty-specific code for infectious disease care, specifically HCPCS code G0545. These commenters argued that CMS's approach departs from longstanding policy, as CPT codes have traditionally been non-specialty-specific to ensure fairness across medical disciplines. The concern is that such specialty-focused codes, like G0545, may inadvertently favor one specialty’s expertise over others, potentially creating imbalances in physician payment.

    The commenters suggested that instead of focusing solely on infectious disease specialists, CMS should consider a more generalized code for complex inpatient care that any specialty could use. They pointed out that many specialties also provide critical, complex E/M services in inpatient settings, and these services are similarly undervalued under the current Physician Fee Schedule (PFS). The commenters also expressed willingness to collaborate with CMS and other stakeholders to address broader issues with the undervaluation of E/M services across specialties.

    In response, CMS maintained that infectious diseases require unique attention due to their inherent risks and public health implications. CMS argued that infectious disease cases, by nature, demand specialized infection control, complex diagnostic coordination, and nuanced antimicrobial stewardship, which are not fully accounted for in general E/M codes. Thus, CMS finalized HCPCS code G0545, reaffirming its belief that the complexities of infectious disease care justify a distinct coding approach.


    Friends of Cancer Research: Variability of HRD Testing; Dx Meeting on 2/5/2025

    Friends of Cancer Research (FoCR) has sponsored a new publication on variability among different tests to measure HRD - homologous recombination deficiency.  This tumor tests helps select PARP inhibitors in ovarian cancer.

    Find the press release here

       Find the article, Andrews et al., here.   

           Register for a half-day meeting in DC or online, on February 5, 2025 - here.

    The paper focuses on variability per se.  There wasn't a comparison of accuracy against a gold standard, because, there wasn't an agreed-upon gold standard.




    Benchmark Prices at MolDx (A Few Examples)

     In its October 25, 2024, comments to CMS on recent gapfill pricing for molecular diagnostics, the Association for Molecular Pathology raised some concerns about transparency of pricing at MolDx under its proprietary (and non-public) Equitable Pricing Model (EPM).

    https://amp.org/AMP/assets/File/advocacy/AMPComments-MACFINALGAPFILLdeterminationsFINAL.pdf?pass=12

    While the internal rules are not known, the recent final gapfill prices show that in some cases, EPM results in a crosswalk to a CLFS fee schedule price, and in other case, it results in a de novo MolDx price. 

    You can find some of the pricing examples either in the public record or by searching the MolDx public database, DEX.   DEX lists all services for which there are Z codes (over 15,000).   In the test is coded by a CLFS CPT code, with a CLFS price, the DEX directory says "see CPT code" (it doesn't tell you which it is).    If the test is coded with an unlisted code (81479) the DEX directory lists the price.

    Paraffin versus Liquid Biopsy - $2916, $3649

    For example, you can find examples in DEX of differential pricing of paraffin (FFPE) and liquid biopsy testing.  The CARIS ASSURE test is MolDx-priced at $3649.   This is a circulating tumor DNA test for single nucleotide variants and indels.   (See a press release from 2022 here.)   On the other hand, DEX lists the Caris CGP (comprehensive genomic profiling test) at $2916, which is a locally assigned code and price (81479 other molecualr test) that also matches the price of 81455 (CPT code for tumors, >50 genes).   While the two tests are not identical, you can see the bonus for LBx methods (about +$740).

    Minimal Residual Disease: Exome versus Periodic Test - $3878, $794

    One common approach to minimal residual disease testing is an exome test followed by a bespoke (custom) patient test for recurrence of cancer.   Invitae (now part of LabCorp) got codes for the exome (0306U) and each subsequent test (0307U).   MolDx priced these by gapfill a year or two ago, at $3878 for the exome test and $794 for the recurring bespoke test.   Since these codes are specific codes found on a fee schedule, MolDx DEX would just refer readers to "see fee schedule" to find the prices (leaving it to the reader to puzzle out that the coding is 0306U, 0307U).   But the two prices provide relatively recent benchmarks on how MolDx values the up-front exome test versus the serial single tests.

    Your Results May Vary -

    If you were submitting similar tests for MolDx pricing today, you wouldn't necessarily get the same prices.  However, examples like the above do give some approximate benchmarks for planning purpose.  

    Dizzyingly Complex

    The examples above are pretty simple comparisons.  If you get into some areas like MolDx coding for minimal residual disease testing, you'll need either a master's degree or three years of experience to figure it out.  A teaching example I've used, there are well over 20 codes in the online DEX for Natera-related tests, including many variants for its MRD testing, with various prices.   

    Sunday, November 3, 2024

    CMS Releases Final PFS and OPPS Rules for CY2025

    Header: Every year, from July to October, CMS conducts policymaking for physician and hospital outpatient policies.  The 2025 final rules came out on November 1, 2024.

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    PHYSICIAN FEE SCHEDULE FINAL RULE

    Fact sheet here.
    Federal Register here.

    The typescript "inspection copy" talies 3088 pages; look for the final typeset publication December 9.

    HOSPITAL OUTPATIENT POLICY FINAL RULE

    Fact sheet here.
    Federal Register here.

    The typescript "inspection copy" tallies 1734 pages; look for the final typeset publication November 27.

    ##

    Below, I highlight some changes that might have particular policy interest (or curiousity).

    BRIEF NOTES

    PFS

    • The RVU conversion factor drops by $1 (3%) unless stopped by Congress.
    • Many Congressional benefits for Medicare telehealth will expire on January 1, 2025, unless modified by Congress.
    • CMS finalizes a benefit for mental health apps, FDA approved, with a complex system of G-codes (opposed by AMA). 
      • Inspection copy, p 587ff (587-601).
      • New term, DMHT digital mental health treatment. [Which abbreviation appears 87 times.]
      • There were concerns that CMS did not define "mental health condition" clearly enough, p. 591.
      • On page 593, they note that "one commenter remarked about our inconistent language using the phrase "incident to or integral to."  (Statute specifically calls out services "incident to" a physician, and "integral to" seemed vague.)  I think that writer was me.
        • CMS writes, "First, we acknowledge the inconsistent use of the term “incident to or integral to professional behavioral health services.” (593).  
      • Payment as a supply is available only when the practitioner billing the G code incurred a cost (for monthly use of the software).
      • Invoice prices vary considerably so CMS is leaving the G code G0552 "contractor priced." (601).
      • See a separate section on requested public input, in general, on RVU cost methodology for software as a medical device and AI (page 71-78, esp 77).
    • CMS finalizes a special add-on for hopsital inpatient (or observation) care releated to infectious diseases, WHEN, performed by a practitioner in that field.
    • There have been numerous articles on difficulties with "single dose vials" and discarded amounts  CMS modifies some rules in keeping with Section 90004 of the "Infrastructure Investment and Jobs Act."
    • In another tweak to drug rulemaking, CMS will treat as "not available" ASP drug prices that are negative.
    • A physician's order will not be required for the preventive service, hepatitis B vaccine.
    • Last year, CMS allowed stool-based colorectal screening tests to trigger a copay-free service for colonoscopy.  Now, CMS allows blood-based CRC tests to trigger the copay-free service, as well.

    OPPS

    • CMS finalizes a proposal to now pay separately for costly nuclear medicine tracers (e.g. for Alzheimer's disease) in the hospital outpatient setting.  These had previously been bundled to one price (including the scan).  That price had previously by set primarily by inexpensive FDG that dominates the service. Tracers over $630 will be paid separately.
      • This proposal had been sought by industry and hospitals for at least 15 years.
      • Coverage at Genomeweb.

    • CMS continues to implement Section 4135 of the Consolidated Appropriates Act of 2023, which provides "temporary additional payments" for non-opioid treatments for pain relief, which might otherwise be bundled in the OPPS setting.

    • CMS will make a "blended payment" for certain devices under CED, so that patients who have been randomized, will not receive different bills based on their position in a control or treatment group.
    ###
    AI Corner

    Here's an AI reading from the PFS rule, regarding RVU criteria in general, and regarding mental health apps.

    ##
    • For years and years, like in the 2000-2010 period, there was some factor for the Medicare Physician Fee schedule that would result in major price reductions that were perennially delayed by Congress.  (They may have ultimately reached 20% or more.) What was the CMS budget principle called?

    The budget principle you're referring to is the Sustainable Growth Rate (SGR) formula. Implemented in 1997, the SGR was designed to control the growth of Medicare spending on physician services by setting annual targets. If spending exceeded these targets, the SGR would trigger automatic cuts to the Medicare Physician Fee Schedule. Over time, these cuts grew significantly, reaching over 20% by the early 2010s.

    However, the looming cuts created a situation known as the "doc fix," where Congress would repeatedly step in to delay or override the cuts. This pattern of delays continued until 2015, when the Medicare Access and CHIP Reauthorization Act (MACRA) permanently repealed the SGR, replacing it with a new payment system that incentivizes quality and value.

    • Interestly as in this weekend's PFS final rule, there will seems to be a 3% or more annual cut that is deferred again and again by Congress, much like the "old days" of SGR!

    You're correct in observing parallels between the current Medicare Physician Fee Schedule (PFS) adjustments and the former Sustainable Growth Rate (SGR) system. The SGR, established in 1997, aimed to control Medicare spending by linking physician payment updates to economic growth. However, it often mandated significant payment cuts, leading Congress to enact annual "doc fixes" to prevent these reductions.

    In recent years, the Centers for Medicare & Medicaid Services (CMS) have proposed reductions in the PFS conversion factor, which determines physician reimbursement rates. For instance, the 2024 PFS final rule included a 3.37% decrease in the conversion factor. In response, Congress intervened to mitigate the impact. The Consolidated Appropriations Act of 2024, signed on March 9, 2024, provided a 2.93% update to the CY 2024 PFS conversion factor for services rendered from March 9 through December 31, 2024, effectively reducing the cut to approximately 1.8% for that period. 

    This pattern of proposed cuts followed by legislative intervention mirrors the SGR era's cycle of scheduled reductions and subsequent congressional "fixes." The recurring need for such interventions highlights ongoing challenges in establishing a sustainable and predictable physician payment system within Medicare.
    • Could you clarify that the current annual cuts (which remind readers of SGR) come out of some principle in MACRA, if so.
    Yes, the current recurring Medicare Physician Fee Schedule (PFS) cuts have their roots in the Medicare Access and CHIP Reauthorization Act (MACRA), even though MACRA itself replaced the Sustainable Growth Rate (SGR). While MACRA eliminated the SGR's automatic cuts, it established new mechanisms and requirements that indirectly impact reimbursement rates.

    MACRA introduced the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) as part of the Quality Payment Program (QPP). These programs aimed to shift the focus from volume-based to value-based care, incentivizing quality and outcomes. However, MACRA also created budget neutrality requirements and conversion factor adjustments:

    1. Budget Neutrality Adjustments: MACRA requires the PFS to remain budget-neutral, meaning increases in payment for certain services or providers must be offset by reductions elsewhere. This contributes to periodic updates that may decrease the conversion factor.

    2. Sequestration and PAYGO: Broader federal budget policies, including sequestration and statutory "Pay-As-You-Go" (PAYGO) rules, have also imposed additional cuts on Medicare payments, leading to cumulative reductions similar to those once seen under the SGR.

    3. Expiration of Temporary Increases: In recent years, Congress has intervened to provide temporary relief from these scheduled cuts (like the Consolidated Appropriations Act provisions). However, as these increases expire, the base payment rates reset to lower levels, necessitating further interventions to prevent steep declines in reimbursement.

    Though MACRA intended to create stability post-SGR, these combined factors have led to a scenario where Congress frequently steps in to prevent reductions, reminiscent of the annual "doc fixes" under SGR.




    Friday, November 1, 2024

    Brief Blog: Texas Doctor, Ten-Year Sentence, $34M Fraud; $30 per scrip

    According to the US Department of Justice, a Texas doctor was sentenced in October 2024 to 10 years in prison with regards to $34M in "a scheme to defraud Medicare."   Claims involved genetic testing as well as DME.

    See the DOJ press release here:

    https://www.justice.gov/opa/pr/doctor-sentenced-54m-medicare-fraud-scheme

    To quote the DOJ,

    From August 2018 through April 2019 [9 months], Canchola received approximately $30 in exchange for each doctor’s order he signed authorizing DME and cancer genetic test orders that were not legitimately prescribed, not needed, or not used — totaling more than $466,000 in kickbacks. The doctor’s orders Canchola signed were used to submit more than $54 million in false and fraudulent claims to Medicare.

    The press release indicates a period of two years from pleading guilty (October 2022) to sentencing (October 2024).


    What's HTAN? 12 Papers in Nature, "Human Tumor Atlas Network"

     What's HTAN?   For one thing, it's a new package of 12 papers on tumor genomics (including at the single cell level) in Nature.

    See the news article here:

    https://www.nature.com/articles/d41586-024-03539-3

    See the project home page here:

    https://www.nature.com/immersive/d42859-024-00059-y/index.html

    See one-stop shopping for every title in the series:

    https://www.nature.com/collections/fihchcjehc



    November 12, 2024: Friends of Cancer Research Annual Meeting; Also Streaming

    On Tuesday, November 12, 2024, the Friends of Cancer Research annual meeting will be held in Washington (and streaming as well) from 10-3 ET (7-12 PT).

    See registration and agenda below:

    https://friendsofcancerresearch.org/event/friends-of-cancer-research-annual-meeting-2024/



    Alzheimer Biomarkers vs Early Diagnosis: Tempest in a Teapot

    Header: How to handle people who are positive for Alzheimer biomarkers, but negative for symptoms?

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    In June 2024, a big spash in publishing Alzheimer's Association Workgroup criteria for the diagnosis and staging of Alzheimer's disease.   See Jack et al., in the journal Alzheimer's and Dementia.  This concensus article prioritized the rapid increase in precision and publications for Alzheimer proteomics, especially plasma biomarkers which had been a "Holy Grail" in this field for thirty years.

    But November 2024, see another big splash from the "International Working Group" and published in JAMA Neurology.   This one is Dubois et al., which opens by acknowledging the status of the "Alzheimer's Association Workgroup" by highlights some disagreements coming from these authors, the "International Working Group." 

    The IWG recommends a category of "at risk for Alzheimer's" for the earliest phases where only 1 biomarker is positive and the evolution is still uncertain (at least, within a reasonable clinical forecast).  The IWG still maintains a diagnosis of "presymptomatic Alzheimer's disease" but requires an escalation in biomarkers past the minimum.

    See the new consensus article from IWG as Dubois et al. in JAMA Neurology here.   See an Op Ed by Peterson et al. here.    See coverage at Precision Medicine Online here.

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    For those who'd like to read more, here, this is an extended quotation from Peterson et al.

    [IWG] contend that persons who possess varying degrees of biomarker positivity but are clinically unimpaired do not warrant a label of AD. They emphasize that specific risks factors (eg, age, ApoEe4 genotype) and biomarkers (ie, degree of positivity) will alter age of onset and lifetime risk. Therefore, the IWG specifically recommends the nomenclature of at risk for AD for those with AD biomarkers but low lifetime risk and presymptomatic AD for those with AD biomarkers with a very high lifetime risk of progression.

    A major issue of contention between the 2 groups pertains to the issue of the basic definition of AD. The AA group states that because most people who have positive core 1 biomarkers, such as a positive amyloid PET scan, also have intermediate to high AD neuropathological changes in the brain, the core 1 biomarkers represent both plaques and tangles. The IWG group does not accept this rationale, suggesting the core 1 biomarkers may only represent amyloid positivity, and many asymptomatic persons who are positive for amyloid (A+) will never develop clinical symptoms.

    The IWG provides important considerations in an era of early detection and increasing knowledge of lifetime risk of symptoms. Nonetheless, a key element in the 2 positions pertains to the semantics of the term AD, ie, is AD a biologic entity or a clinical-biologic entity?

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    AI Corner

    In addition to the long quote above, and the original sources, here is an AI summary of Dubois and Peterson.

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    The new Dubois consensus article from the International Working Group (IWG) advocates for a nuanced, clinical-biological framework for Alzheimer’s disease (AD) that avoids premature diagnosis in asymptomatic individuals. The IWG’s new criteria emphasize a separation between “asymptomatic at risk” (one biomarker, no cognitive symptoms) and “presymptomatic Alzheimer’s disease” (more biomarkers with a higher risk of progression to AD symptoms). They argue that the earlier Alzheimer Association (AA) approach, which allowed for a biological diagnosis based on a single biomarker, risks overdiagnosing cognitively normal individuals who may never progress to symptomatic AD. By setting a higher biomarker threshold for "presymptatomic" AD diagnosis, IWG aims to prevent the potential psychological and societal impacts of labeling individuals with AD before clear clinical signs appear​ and in whom disease evolution is uncertain, e.g. at risk.

    The Peterson op-ed works to balance the AA and the IWG perspectives, acknowledging the benefits of early biomarker use in AD research while critiquing the risks highlighted by the IWG. Peterson acknowledges IWG’s concerns over labeling asymptomatic individuals as having AD but also underscores the need for accessible biomarker data in research. The op-ed raises the question of whether AD should be treated purely as a biological condition or as a clinical-biological syndrome, stressing that clearer guidelines for clinical application are necessary to bridge biological frameworks with real-world practice. Both articles agree on the potential of biomarkers in establishing the disease’s pathology and recognize a need for caution in applying these biomarkers clinically, but they differ on how liberally biomarkers should be used to label asymptomatic individuals​

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    Finally, I next asked Chat GPT for a more nuanced and academic review of the articles.

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    Title

    Revisiting Alzheimer’s Diagnostic Criteria: Perspectives from the Dubois IWG Framework and the Peterson Op-Ed

    Abstract

    The recent recommendations by the International Working Group (IWG), led by Bruno Dubois, challenge the Alzheimer Association’s (AA) approach to the presymptomatic diagnosis of Alzheimer’s disease (AD), advocating for a revised clinical-biological framework. While the AA criteria emphasize a more biologically grounded diagnosis, the IWG framework stresses a cautious approach to applying diagnostic labels in asymptomatic individuals. This article explores the nuanced differences between these perspectives, drawing on the Dubois et al. paper and the Peterson et al. editorial commentary to outline implications for clinical practice and future AD research.

    Introduction

    Alzheimer’s disease (AD) diagnosis has evolved significantly with the advent of sensitive biomarkers, creating the potential to identify pathology years before clinical symptoms arise. Historically, AD diagnosis has been reserved for those presenting with cognitive impairment and neuropathological findings. However, with increasing reliance on biomarkers, earlier identification in asymptomatic individuals is now possible, prompting a debate within the research and clinical communities. The IWG, in its recent Dubois-led recommendations, argues for a stringent bifurcation in diagnostic categories, emphasizing risk assessment rather than direct labeling of AD in asymptomatic individuals. In response, the Peterson et al. editorial provides critical insights into the advantages and challenges of the IWG’s clinical-biological stance.

    Methodological Foundations and Perspectives of Dubois et al.

    In their recommendations, Dubois and colleagues advocate a clinical-biological construct for diagnosing AD, distinguishing between asymptomatic individuals at risk and presymptomatic AD based on specific biomarker thresholds. This new framework reflects an increased caution in directly labeling cognitively unimpaired, biomarker-positive individuals as having AD. The IWG defines:

    1. Asymptomatic at Risk for Alzheimer’s Disease: This category includes cognitively normal individuals who display only one AD biomarker, typically indicating amyloidosis. Dubois et al. argue that while amyloid positivity may elevate lifetime AD risk, it does not justify an AD diagnosis in the absence of symptoms.

    2. Presymptomatic Alzheimer’s Disease: This category applies to cognitively normal individuals with a higher combination of AD biomarkers, which, the IWG posits, confers a near-deterministic risk of symptomatic progression. This group often includes individuals with biomarker profiles showing both amyloid and tau positivity across cortical and medial temporal regions or those carrying high-risk genetic mutations, such as autosomal-dominant AD variants.

    The IWG justifies this approach by reviewing longitudinal studies and biomarker validation efforts, suggesting that the lifetime risk in biomarker-positive, asymptomatic individuals is heterogeneous. The IWG also considers factors like comorbid neuropathologies (e.g., Lewy bodies, TDP-43), resilience mechanisms, and other patient-specific variables that may influence disease progression. These complexities, they argue, necessitate a conservative approach to presymptomatic AD diagnosis to avoid mislabeling individuals with indeterminate risk profiles.

    Peterson et al. Op-Ed: A Response to the IWG Framework

    In their editorial, Peterson and colleagues address key elements of the IWG's recommendations, framing the AD diagnostic debate within the context of evolving medical nomenclature and societal considerations. Peterson et al. appreciate the IWG's emphasis on maintaining a clinical-biological basis for AD but argue that the cautionary stance on labeling cognitively normal, biomarker-positive individuals may lean overly conservative.

    Peterson critiques the IWG’s concerns on two primary grounds:

    1. Semantics and the Definition of Disease: Peterson questions the IWG's restrictive interpretation of AD, noting that the AA’s biological framework aligns with evolving definitions in other medical fields, such as oncology, where presymptomatic stages (e.g., in situ cancers) are routinely identified. They suggest that the IWG’s clinical-biological model may conflate risk status with disease status, arguing that the term "Alzheimer’s disease" could encompass those with high biomarker positivity even in asymptomatic stages, potentially benefiting from early intervention and lifestyle modifications.

    2. Risk and Benefit of Early Diagnosis: While the IWG emphasizes the potential psychological harm of labeling asymptomatic individuals with AD, Peterson calls for a more evidence-based assessment of this impact. The editorial suggests that knowledge of AD biomarker status could empower individuals to make proactive lifestyle changes, citing analogies from cardiovascular and oncological care. However, Peterson et al. support the IWG’s reservations regarding direct-to-consumer testing and emphasize the need for rigorous guidance in clinical application to mitigate misuse or misinterpretation of biomarker data.

    Implications for Clinical Practice

    The distinctions between these perspectives underscore a significant shift in AD diagnostic frameworks and their applications. The IWG’s model emphasizes differential risk stratification, proposing that biomarkers in cognitively normal individuals be used primarily for risk assessment rather than definitive AD diagnosis. This model posits that asymptomatic amyloid- or tau-positive individuals be categorized as “at risk” rather than diagnosed with AD, unless multiple biomarkers confirm a high, near-deterministic risk.

    Peterson et al., however, support a more integrative approach to AD pathology, suggesting that high biomarker positivity alone may sufficiently justify an AD diagnosis in asymptomatic individuals, provided there are clinical protocols to safeguard patient welfare and interpret biomarker status within a probabilistic framework. They propose that the field may be better served by embracing a flexible model that encompasses both biological and clinical entities of AD, potentially allowing for earlier pharmacologic and non-pharmacologic interventions under monitored conditions.

    Research Implications and Future Directions

    The IWG's recommendations, if adopted, may influence future research by shifting focus from early diagnosis in asymptomatic individuals toward risk assessment studies in genetically or biomarker-predisposed populations. These studies could clarify the impact of amyloid and tau burden in predicting clinical outcomes and identify secondary risk factors modulating AD progression. Moreover, population-based cohort studies and trials may need to adapt to incorporate broader definitions of AD risk, including lifestyle, genetic, and resilience factors, to refine individual patient profiles and therapeutic targets.

    Conversely, Peterson’s stance implies that research should not exclude biomarker-positive individuals from AD diagnostic categorization but rather adapt clinical criteria to accommodate evolving evidence about biomarker impact. This stance suggests a need for appropriate-use criteria for biomarkers, potentially establishing a consensus on which asymptomatic biomarker profiles warrant closer clinical monitoring and preventive intervention trials.

    Conclusion

    Both the IWG and Peterson et al. converge on the necessity for biomarker integration in AD diagnosis but diverge on the semantics and clinical application of AD labels in cognitively normal individuals. The IWG’s clinical-biological construct provides a conservative, risk-focused approach, reserving AD diagnosis for individuals with tangible clinical symptoms or robust, near-deterministic biomarker evidence. Peterson et al., however, argue for a more inclusive diagnostic model, emphasizing that early biomarker identification could offer preventive insights and treatment benefits.

    The ongoing debate highlights a critical need for appropriate-use frameworks and consensus definitions in AD diagnosis, where both risk stratification and early intervention paradigms must be balanced. As biomarker technologies advance, a unified, patient-centered approach that addresses both scientific rigor and clinical pragmatism will be essential in shaping the future of AD diagnosis and care.


    This synthesis draws from the detailed perspectives of both papers, translating their recommendations into actionable insights for AD diagnostic criteria. By framing AD as both a clinical and biological entity, these articles invite further exploration into how best to integrate biomarkers into nuanced, real-world applications.