Wednesday, October 7, 2020

Brief Blog: Comparing Medicare Molecular Pathology Spending in the Non-MOLDX States

As recently as CY2017, Medicare Part B spending on molecular pathology told a fairly simple story: Most of it was in the MolDx states.  

  • As recently as CY2017, about 70% of MoPath spending was in MolDx states, rising closer to 90% if one excluded one line item, the spending for Cologuard (in Wisconsin, a non-MolDx state).

By CY2019, the picture had changed drastically.   MolDx states garnered only 35% of MoPath spending, the 70% of spending going to NGS MAC, Novitas, and FCSO MAC.   

However, it quickly becomes evident that Novitas/FCSO spending is highly anomalous, with very suspicious (?fraudulent) spending becoming dominant - here.

Spending in Non-MolDx MACs

There are three non-MolDx MACs, NGS MAC, Novitas, FCSO.   NGS MAC has Jurisdictions J6, JK, with 7,047,841 beneficiaries in 2019 per CMS dataNovitas has JH and JL jurisdictions, with 9,188,988 beneficiaries.  FCSO has 2,604,216 beneficiaries in Florida (JN).


NGS MAC spending on MoPath codes in CY2019 was $349,404,055, or $49.58 per beneficiary.  However, this includes $79.5M on FMI F1 CDx test, governed by an NCD, and $243M for Cologuard test, governed by an NCD.  If you leave out just those two line items, NGS MAC spending on MoPath drops to $27.0M, or $3.83 per beneficiary.

Novitas, FCSO MACs

Spending on MoPath in CY2019 at Novitas was $528,842,240, or $57.55 per beneficiary.  Spending at FCSO MAC in CY2019 was $123,653,432, or $47.48 per beneficiary.   I noted previously that spending year-on-year in some Novitas/FCSO states like Florida and Oklahoma rose as much as 7X.


We can do the same data analysis for 28 states in the MolDx consortium (WPS, Noridian, CGS, Palmetto), although the data is harder to interpret since so many national labs bill in MolDx states, especially California.  (You can't really segregate local vs national lab spending in MolDx, but in NGS MAC, you can segregate local and national spending by just removing FMI and Cologuard).  

Birds-eye view, there are 19.1M beneficiaries in MolDx states, and CY2019 MoPath spending of about $570M, or about $29.80 per beneficiary.  That's about half of the per-beneficiary spending (even including MolDx's national labs) as FCSO and Novitas.


National spending on Part B beneficiaries was about $1.7B in CY2019, as I've reported in the past couple weeks, although that's misleading because there are hundreds of millions of dollars of fraudulent spending mixed up in it (see DOJ program "Operation Double Helix" in 2018/2019).   There are about 40M FFS beneficiaries, so the average spend per bene was $40.