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The Defense Health Agency is moving ahead with plans to cover the costs of some laboratory tests that Tricare, by law, cannot.
A panel of medical experts is meeting this week in Falls Church, Va., to review more than 100 laboratory developed tests, or LDTs, to decide which should qualify for coverage under a Tricare demonstration project that already includes a handful of genetic tests.
Tricare is restricted from paying for tests or medicines not approved by the Food and Drug Administration. LDTs fall into that category, but only because the FDA has concluded the tests don’t warrant tight regulation, since they are simple and pose little risk to patients.
Tricare stopped covering many LDTs in January 2013 after the American Medical Association expanded its medical codes to better define each laboratory test, making it easier for the Defense Department to determine what it was paying for.
But the Pentagon recognizes that some of the tests have medical utility. The demonstration project seeks to make sure a small number of frequently ordered tests are available to all Tricare beneficiaries.
“The first priority is ‘do no harm,’ ” said Army Maj. Gen. Richard Thomas, DHA healthcare operations director. “We have to make sure there are processes in place to assure that new technologies don’t have the potential to cause harm by redirecting treatment or misguiding doctors.”
According to Thomas, the Joint Lab Working Group will be examining the tests for effectiveness, accuracy and medical need. He did not say how many may make the final cut, but he expects those that have become standard medical practice likely would be included.
“We want to give our patients the access, value and quality of health care they have come to expect and certainly what they deserve,” Thomas said.
Concerns over nonpayment for laboratory fees have been circulating since the beginning of the year, when lab advocacy groups, including the American Clinical Laboratory Association, began campaigning for reimbursement of more than $10 million it believes Tricare owes some labs.
Retired Air Force Lt. Col. Bob Prouhet is among the beneficiaries who received a bill for $1,148 for a blood test he receives every 110 days to monitor remission of acute promyelocytic leukemia. After Tricare refused to pay, the lab passed the expense to Prouhet.
Without the test, Prouhet would require painful and costly bone marrow biopsies to learn the same results.
While Prouhet’s bill eventually was forgiven by the lab, Colorado Laboratory Services, he believes the Pentagon should pay.
He now receives the test at Peterson Air Force Base, Colo., where physicians there order it for his oncologist.
“I’m fortunate in that I live near Peterson. Not everyone is as geographically as lucky as I am. It’s just not right,” Prouhet said.
Thomas said DHA is in discussions with affected labs to determine which tests fall under the billing problem and whether they can be reimbursed.
During its annual meeting in March, ACLA President Alan Mertz said the challenges the labs face in reimbursement — not just from Tricare but also from Medicare and private insurance companies — have brought the industry together.
Mertz said ACLA will continue to fight for recognition of LDTs and reimbursement.
“As an industry, clinical labs provide the most critical information needed for 70 percent of physician decisions,” Mertz said. “Our industry is poised at the forefront of scientific advances in personalized medicine.”
But as Thomas pointed out, just because a test is possible doesn’t mean it’s beneficial for patients. And that’s a criterion the Joint Lab Working Group will consider.
For example, a new LDT that measures lipid levels as a predictor for developing Alzheimer’s disease may do more harm than good because treatments for Alzheimer’s are scarce, Thomas said.
“Is it medically necessary and is it going to change treatment? With this LDT ... are we helping them or are we not? It comes back to ‘do no harm,’ ” Thomas said.
LDTs approved by the defense panel likely will be added to the demonstration project by summer. Thomas did not provide a cost estimate for the initiative.