Saturday, September 22, 2018

The Boom/Bust in Medicare Part B Pharmacogenetic Spending: 2013-2017

In 2014, spending on just three pharmacogenetic codes was over $300 million dollars, about 55% of Medicare's MoPath spending for the year.   By 2016, spending was down to $18M, about 3% Medicare's MoPath spending (which was lower in total in 2016 than 2014). 

In the interim, there was rapid production of Medicare LCDs which markedly limited payments for pharmacogenetic testing.  OIG/DOJ had concerns about overuse, Genomeweb here.

I pulled some data together in preparation for an October slide presentation, and I've posted some key screenshots below.

click to enlarge

click to enlarge

click to enlarge

For a broader view of CY2017 mopath codes and spending at CMS, here.


Data Sources

You can access and download CMS data for all Part B CPT Codes by year, here.   Every year 2000-2017.

I've also put the CLFS codes (80,000 series) in the cloud in one zip file, for the five years 2013-2017, here.  2013 was the first year of the current MoPath codes.

Extra Credit

Let's say you are a lab CFO or lab industry financial analyst.

In 2014, you projected that CYP revenues would be level in 2015, 2016, and 2017 (at $315M per year, the same as CY2014).   In fact, revenues would prove to be only ($108M, $18M, $17M) in those years, creating a gap of ($206M + $296M + $297M).  The total gap between your projection of steady 2014 revenue and actual revenue over three years would be negative $800M.

OIG Interests

A sampling of news articles imaged below.  The drop in molecular spending 2014 -> 2015 was noted in a 2016 OIG report here.