Medical tests seek delicate balance between cost and results

By Roger Morris

Medical lab testing continues to provide a mixture of good news/bad news headlines as more diseases and conditions are being detected earlier and more precisely, saving or extending the lives of patients, while at the same time dramatically adding to the costs of health care for governments, businesses and patients.

Last year, lab testing and X-rays alone cost the state of Delaware $26.5 million, mainly in Medicaid payments, according to Jill Fredel, communications director for the Department of Health & Social Services. Altogether, the state’s Medicaid spending amounted to 19.2 percent of Delaware’s total budget, according to Ballotpedia, a nonprofit and nonpartisan research organization.

At the same time, the Centers of Medicare & Medicaid Services (CMS) approved in March of last year a new genetic test, F1CDx, which it called “the first breakthrough-designated, Next Generation Sequencing-based in vitro diagnostic test that is a companion diagnostic for 15 targeted therapies as well as can detect genetic mutations in 324 genes and two genomic signatures in any solid tumor.”

A companion treatment was approved later in the year that cost about $32,000 a month per patient wholesale.

“The significance is that old testing might target one mutation of a gene, while Next Generation Sequencing or NGS testing might query the whole genome,” explains Dr. Russel Kaufman, chief medical office for Delaware-based Kentmere Healthcare Consulting, which advises health-care insurers, including Blue Cross/Blue Shield’s Highmark Delaware, on medical testing benefits, costs and protocols.

But, at the same time, Kaufman says, “When a physician has the opportunity to get more data, they will ask for more data.”

Kaufman and others attempting to control costs argue that a distinction should be made when ordering expensive tests between what is nice to know and what is medically relevant. As he describes it, “Not all mutations are equal – there are ‘drivers’ and there are ‘passengers,’ and passengers are of little consequence. There is a gap between what we can learn and what we can target,” he says, and that gap may represent thousands of dollars in testing costs per patient.

In order to try to contain medical costs at the state level for Medicaid and for employee and retiree medical benefits spending, Gov. Carney last November ordered a controversial health-care benchmarking program overseen by the Delaware Health Care Commission and the Delaware Economic and Financial Advisory Council. While not specifically targeting medical lab testing, the benchmarking study illustrates the divide between those who provide medical services, such as physicians and hospitals, and those who pay for them.

Susan Conaty-Buck, a member of the University of Delaware School of Nursing faculty and president of the Delaware Coalition of Nurse Practitioners, advocates for a patient-centered approach to better treatment and cost savings.

“We may warn patients that the cost of the test may not be reimbursed, and that they might have to pay for it out of pocket,” she says, noting that doctors and nurses usually have no knowledge of how much a test will cost or whether there will be a copay.

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