TMA: Medicaid Patients Could Lose Access to Clinical Tests
By David Doolittle

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Medicaid patients in several states, including Texas, might not receive needed clinical tests because of new payment rates mandated by a federal law named, ironically, the Protecting Access to Medicare Act (PAMA).

PAMA directs the Centers for Medicare & Medicaid Services (CMS) to base Medicare payments for tests on the Clinical Laboratory Fee Schedule (CLFS) on rates paid by private payers. Laboratories are required to report to CMS accurate private-payer rates or face a $10,000 penalty per day past the annual March 31 reporting deadline.

Under Medicare, the new payment rates, which took effect Jan. 1, have been cut by as much as 10 percent – and further reductions are expected in 2019 and 2020, according to a letter that the American Medical Association, Texas Medical Association, and numerous state and specialty medical societies sent to CMS. If payments continue to decline, the societies are concerned physician offices will no longer be able to offer testing services at the point of care.

The societies’ letter urges CMS Administrator Seema Verma to push state Medicaid directors to set payment rates sufficient enough to ensure Medicaid beneficiaries maintain equal access to laboratory services. In Texas, payments for clinical laboratory services cannot exceed Medicare rates, so any decrease in the Medicare allowable could translate into Medicaid cuts, too. 

“PAMA rates are widely expected to reverse the positive trend of providing rapid, accurate clinical testing during a patient’s medical appointment — one of the key promises of 21st Century medicine,” the letter said. “The loss of equal access to rapid, point-of-care testing will result in delayed diagnosis and treatment, increased acuity, the use of higher cost care delivery sites such as emergency departments, higher care coordination costs, and limitations on the ability of physicians in communities across the nation to triage when there is an infectious disease outbreak.”

Last Updated On

May 09, 2018

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David Doolittle


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Dave Doolittle is editor of Texas Medicine and Texas Medicine Today. Dave grew up in Austin, where he attended culinary school as well as the University of Texas. He spent years covering Central Texas for the Austin American-Statesman newspaper. He is the father of two girls, a proud Longhorn, and an avid motorsports fan.

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