Discoveries in Health Policy

tag:blogger.com,1999:blog-83343212718272177592026-04-15T20:14:14.122-07:00Discoveries in Health PolicyIdeas for or from an evolving healthcare systemBrucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comBlogger3305125tag:blogger.com,1999:blog-8334321271827217759.post-22993674926669443922026-04-15T13:18:00.000-07:002026-04-15T20:14:14.078-07:00CMS Inpatient Proposed Rule: Canning Fast Track to NTAP (!)

In 2020, the first Trump adminstrationi proposed fast track routes to Inpatient NTAP (new technology add on payment) and fast track to coverage for breakthrough devices (under MCIT).   MCIT was replaced, under Biden, with TCET, an inferior plan.Now, the Trump administration itself threatens to nix the fast track methods to NTAP.  See AI discussion below.Find the CMS source material

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-59691906459144493922026-04-14T15:31:00.000-07:002026-04-15T13:18:18.712-07:00CMS Releases Inpatient Proposed Rule

 CMS has released the Inpatient Proposed Rule.   Find it here:https://www.federalregister.gov/documents/2026/04/14/2026-07203/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-ipps-andIt's in Fed Reg, April 14, 2026, 91:19312 (576pp).  16 mb.Note: This downloads for me in a locked copy I can't annotate.  However, you can "extract all

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-88258121305186974592026-04-14T11:34:00.000-07:002026-04-14T11:34:35.988-07:00AMA Releases the Biggest Batch of PLA Applicants Ever

Just two weeks ago, AMA released 29 new and finalized PLA codes, April 1 (here).Here's the PLA home page:https://www.ama-assn.org/practice-management/cpt/cpt-pla-codesAccording to the calendar there, AMA releases draft codes April 14, wants feedback by April 21, and will finalize by April 21.  The codes are then voted on by the Editorial Panel regular spring meeting (April 30-May 1).Here is

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-50644228387493766792026-04-13T08:49:00.000-07:002026-04-13T12:51:23.915-07:00Friends of Cancer Research: 3-Hr Webinar on "External Control Arms"

 When you have a one-arm trial, you need a comparison group - the general problem presented by "External Control Arms."Catch up with the newest thinking via a 3-arm webinar hosted by Friends of Cancer Research (streamed live on April 7, 2026).Find it on YouTube here:https://www.youtube.com/watch?v=fh7y3J2xyYYFind the project home page at FoCR here:https://friendsofcancerresearch.org/eca/

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-44453983297291364362026-04-12T17:19:00.000-07:002026-04-12T17:19:00.794-07:00House Hearing on Medicare Fraud: Comparison to CMS CRUSH Proposal

CMS released its CRUSH anti-fraud proposals around February 26.   At the beginning of the month, February 3, the House Energy & Commerce Committee held a 3 hour hearing on healthcare fraud.  Find it here:https://energycommerce.house.gov/events/oversight-and-investigations-common-schemes-real-harm-examining-fraud-in-medicare-and-medicaidI asked Chat GPT to compare the contents

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-75642736318619655792026-04-12T16:59:00.000-07:002026-04-12T17:09:29.447-07:00College of American Pathologists, CRUSH & Genomics Fraud; Doesn't Like National MolDx

Since comments closed on March 31, I've highlighted several groups that commented, such as ACLA and the BCBS Association.  Both supported "nationalization" of MolDx, a topic on which HHS was seeking input.   (ACLA had some guardrails, though).College of American Pathologists (CAP) posted its comments, 7 pages long.  A substantial proportion of the comment recounts problems

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-3853604335217217282026-04-09T17:42:00.000-07:002026-04-09T17:42:44.745-07:00Tamara Syrek Jensen - The Medtech Strategist Interview

Medtech Strategist has released an interesting podcast interview.   Learn about Tamara Syrek Jensen's career at CMS, much of it in the Coverage Group, and the insights she brings to clients today as a Principal of Rubrum Advising.(Note, she seems to say a couple times, CMS is where I am; but it's clear she was out-of-government at this interview and working with Lee Fleisher at Rubrum

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-46183495189780735142026-04-09T13:47:00.000-07:002026-04-14T14:39:07.897-07:00CMS Webinar on PAMA Lab Data Submissions: Video April 16,

Here's new from CMS about PAMA sales price reporting, due at CMS in May-June-July 2026.The live webinar is sold out, but hopefully they will post archive video.It was sold out but they opened a larger channel.###CMS press release:Clinical Diagnostic Laboratories: Get Ready to Report Starting May 1Are you an independent laboratory, physician office laboratory, or hospital outreach laboratory that

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-29658284738990036132026-04-09T12:59:00.000-07:002026-04-13T09:31:54.674-07:00Phillips et al in SCIENCE: Diagnostics and Policies for Value

In the April 9, 2026, issue of SCIENCE, see an article by Phillips, Horn, & Califf on the value of diagnostics and good diagnostics policy.   It's titled:Diagnostics investments and disease burdenRegulatory and payment policies could facilitate investment and innovation in diagnosticsFind it here - (firewalled).Find a detailed UCSF press release here.Here's the abstract:Screening

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-21828371405513625272026-04-07T16:46:00.000-07:002026-04-08T09:07:40.957-07:00CMS "CRUSH" Comments Website is Flaky

Update - The website is still flaky, but a bit more on that.  If you search for ACLA, you will in fact pull up 1 thing, the ACLA comment.  This has many mentions of "MolDx" but if you search "MolDx" you will not get ACLA.  Also, when I searched on "Blue Cross Blue Shield" I got a comment about MolDx being related to BCBS South Carolina, but I didn't get the big 54 page BCBS

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-50653360667275134742026-04-07T13:27:00.000-07:002026-04-07T13:27:14.358-07:00Released:; Chaihorsky et al., A New White Paper on the "Laboratory 2.0" Vision

 At Linked In, see a new 16-page paper about the vision for "Clinical Laboratory 2.0," by Chaihorsky, Van Ness, Cooper, and Shotorbani.  Authors are from the consultancy Alva10, Wuscott LLC, and the Project Santa Fe Foundation.Link here.Abstract,Clinical laboratories are facing significant economic pressure as the Protecting Access to Medicare Act (PAMA) driven reimbursement cuts erode

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-72520530567472322292026-04-07T12:35:00.000-07:002026-04-07T12:49:15.214-07:00Chat GPT Can Now Write 20-page Reports with 30 Citations ("Deep Research")

My subscription version of Chat GPT ($20/mo) recently got a new function called "Deep Research" (an option on the left-hand menu.)This week, I asked it to write a report on value-based cancer care, what has held back the field, and whether new kinds of metrics (maybe using AI) could have a big impact.Chat GPT thought for 45 minutes, and wrote a report (17-page PDF) with some 30 specific footnotes

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-89868880105699362342026-04-07T12:20:00.000-07:002026-04-07T13:20:00.203-07:00Blue Cross to CMS: Nationalize MolDx Now!

This winter, CMS proposed a wide anti-fraud initiative called CRUSH, taking comments until March 30.  Two targets were (1) genomics fraud and (2) DME fraud.   In an earlier blog, I covered the ACLA comment, includings their remarks on MolDx.At least 17 of the public comments involved MolDx.   This includes the 50-page BCBS comment, which supports the proposed

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-36497633886922697922026-04-01T10:56:00.000-07:002026-04-01T10:56:24.184-07:00Quick Access to Top Providers of any "Popular" Part B CPT Code. OpenMedicare.US

 CMS group "Data.CMS.Gov" has an elaborate website for payments to providers by CPT code.  It's a little tricky to use but powerful.  Find it here:https://data.cms.gov/provider-summary-by-type-of-service/medicare-physician-other-practitioners/medicare-physician-other-practitioners-by-provider-and-serviceThere's a nonprofit website OpenMedicare.US, that lets you look up the

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-27259411916710748942026-04-01T10:44:00.000-07:002026-04-01T10:44:35.125-07:00AMA CPT Publishes Latest Batch of Quarterly PLA Codes

 On April 1, 2027, AMA CPT released the results on the latest batch of quarterly PLA codes.  These codes were applied for around December 10, published today, and active July 1AMA summarizes there were 2 revisions, 4 deletions, and 29 new codes 0631-659U.https://www.ama-assn.org/system/files/cpt-pla-codes-long.pdfNote that AMA includes a number of important instructions for acceptable

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-65081307691963257542026-04-01T10:26:00.000-07:002026-04-06T17:49:36.029-07:00Will CMS Nationalize MOLDX? Coverage at 360DX

A month ago, CMS announced a major new anti-fraud initiative, called CRUSH.  It had two main targets: DME fraud and genomics fraud.  The comment period closed on March 30, and journalists are sorting through the comments received.See coverage by Adam Bonislawski here (subscription).   (See my CMS comment here).I see a Regulations.gov posting that 768 comments were

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-34749304625320119912026-03-31T10:41:00.000-07:002026-03-31T12:30:40.954-07:00New to Me: AMA Comment Deadlines are NOON CENTRAL on the Day

 New to me, so I'm just flagging this.The last few weeks, comments have been accepted for the April 30 - May 1 AMA CPT meeting.  One important topic is revisions to Appendix S, a major ongoing issue that affects AMA CPT policy for software-intensive services (e.g. AI).The comment deadline is March 31 2026, I had that right.I for one, had not noticed the specific deadline is 11:59 am

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-38574490710322654632026-03-30T11:17:00.000-07:002026-04-02T11:40:42.752-07:00Horizons in Diagnostics Value: Case Study: Rethinking Value for Infection Diagnostics

Here's a paper that is worth discussion, and potentially applicable to many areas of diagnostics, not just infection.In a 2025 paper at Open Forum Infectious Diseases, some excellent thought capital is created by Claeys, Prinzi, and Timbrook.  Here.It's also a great example of a good abstract - I can't do better than quoting it.Evaluating the clinical impact of in vitro diagnostic tests (

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-78417754522054150502026-03-28T09:56:00.000-07:002026-03-28T09:58:49.420-07:00Chris Klomp, Health Policy Expert for CMS and HHS - Some Notes on His Experience

Over the last few weeks, shake-ups at HHS have brought Chris Klomp to the #2 position next to Secretary Kennedy.  See news reports here; see an annotated one-hour interview with Klomp here.I asked Chat GPT to discuss his educational background and professional experience through the lens of his current top-level health policy roles.Endpoints discusses Klomp on AI, Klomp on biotech/China,

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-5586272879389694742026-03-27T11:15:00.000-07:002026-03-28T09:59:34.529-07:00Korie et al. 2026: What Drives Next Gen Sequencing Denials at Yale Pathology?

Header:  A Yale pathology study presented at USCAP 2026 shows that NGS reimbursement denials are less about overuse and more about administrative failure—especially ICD-10 miscoding. Only 20% of cases were denied (275/1392), and most denials occurred despite guideline-concordant testing. The authors conclude, the fix is operational, not clinical.Reimbursement Denials for NGS: A Systems

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-1672625159139679292026-03-27T09:49:00.000-07:002026-03-28T09:59:47.000-07:00Register for AMA Meeting on Coding & AI: "Appendix S Revisions" - April 16

 AMA has big, big plans for changing how it handles AI services (potentially affecting digital pathology and genomics) in terms of policy and coding, possibly even with whole new classes of codes.  These come under the headline of "Revising Appendix S," which has been a topic for several AMA CPT meetings in a row.   You can register with AMA to view and comment on

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-6356649292040620252026-03-26T10:04:00.000-07:002026-03-26T10:08:41.504-07:00AI, Advanced Software, and AMA CPT Policy: Deadline March 31: Appendix S for Upcoming CPT Meeting

 For several quarters, AMA CPT has been debating major amendments to the AMA CPT "Appendix S," which may have enormous implications for how AI- or software-dominant healthcare services are reimbursed.At the upcoming AMA CPT meeting in Chicago [virtual registration still available], a new round of revisions to Appendix S will be debated.  You can sign up now to read the current revisions

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-50763595908063455592026-03-26T09:42:00.000-07:002026-03-26T09:42:13.093-07:00Comment on CRUSH, CMS Policy, Genomic Testing: Due Monday, March 30

On February 27, 2026, CMS announced a vigorous plan for anti-waste, anti-fraud measures in Medicare, with strong highlighting given to two areas: (1) durable medical equipment DME, and (2) genomic testing.   The initiative, abbreviated CRUSH ("crush fraud") is open for public comment until Monday, March 30, 2026.See my blog and links here:https://www.discoveriesinhealthpolicy.com/2026/

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-11310041967740767392026-03-24T10:03:00.000-07:002026-04-02T11:41:30.427-07:00Nerd Note: 2017 PAMA Raw Data File is Still Posted

Header:  CMS still stores publicly available cloud data on lab test pricing surveyed in 2017 and representing CY2016.### Congress and CMS are re-activating the PAMA reporting process.  For reporting laboratories who had >$12500 in Medicare payments in 1H 2025, they will report data on all claims paid by commercial payors in 1H2025, and they will report in May-June-July 2025.&

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.comtag:blogger.com,1999:blog-8334321271827217759.post-44562845199862797332026-03-23T09:42:00.000-07:002026-03-23T09:45:08.161-07:00AI Experiment: How Alex Dickinson Describes the CARIS MCED ACHEIVE Report

In March, Caris released top-line results of its ACHIEVE study, testing its MCED test in real cases.  Press release here.  Active Linked In author Alex Dickinson wrote a set of 5 articles about the results.  One, two, three, four, five.Out of curiousity, I asked what Chat GPT could make out of the six documents.AI CORNER###OverviewCaris reports striking interim performance for its

Brucehttp://www.blogger.com/profile/05149672650241065616noreply@blogger.com