Some relief from surprise lab fees vowed

Army Maj. Gen. Richard W. Thomas, newly assigned as chief medical officer and director of health care operations for the new Defense Health Agency, acknowledges that some Tricare patients and their civilian physicians face lab fee challenges that the DHA needs to address.

A year ago Tricare, the military’s health insurance program, quietly stopped reimbursing civilian laboratories for more than 100 genetic or laboratory-developed tests. Some of the tests are critical for patient care and, in fact, routinely are still ordered by military physicians.

Among patients frustrated by disparity of coverage is retired Air Force Lt. Col. Robert Prouhet, who is fighting a blood cell cancer called acute promyelocytic leukemia. His civilian oncologist in Colorado orders a special blood test for him every 110 days. The PML/RAR Alpha Translocation Analysis Monitoring Test is the most sensitive available to track this type of leukemia for patients in remission. The alternative is a bone marrow biopsy, which is more expensive and invasive and therefore more risky, Prouhet said.

His oncologist, Prouhet said, told him he would consider “it malpractice if he did not use this test to monitor and treat my cancer.”

Prouhet felt the financial string of lost Tricare coverage last summer when the laboratory sent him a bill for $1,148 for the blood test his oncologist ordered in May. While appealing the charge to Tricare, Prouhet learned he could avoid additional out-of-pockets costs by asking the hospital at nearby Peterson Air Force base to request the lab test for his oncologist. That’s because military treatment facilities don’t face the same restriction on LDTs.

“We’re got a situation where we are doing some of these in some of the MTFs and (yet) won’t pay for them in the (purchased care) network. That is a disparity (and) we don’t want to be there,” Maj. Gen. Thomas explained in a phone interview.

It’s also true, he said, that some of the LDTs that Tricare no longer covers represent “standard of care in medication.”

The DHA, he said, is working on solutions.

As reported here a month ago, Tricare stop reimbursing for many of these tests a year after the American Medical Association revised Current Procedural Terminology codes for genetic tests. The new codes gave greater transparency on the kinds of testing Tricare was paying for.

With hundreds of genetic tests developed every year, Defense health officials decided to use an existing regulation to tighten coverage and force labs to have tests screened for safety and effectiveness through the Food and Drug Administration.

Absent FDA approval, Thomas affirmed, “by law … we can’t pay for these tests” even if they’ve become a standard for care and despite military physicians still being allowed to order tests “not fully FDA approved.”

“The good news is this change in the law has helped us to identify that there is a lag in FDA approval for some of these more commonly used tests in many cases,” Thomas said.

In rejecting Prouhet’s final appeal for payment Dec. 24, a lawyer for the Department of Defense cited not a law but a Tricare regulation that bans coverage of “unproven” medical devices and procedures. LDTs are deemed unproven now by Tricare because they cannot be lawfully marketed across state lines without approval of the FDA.

Laboratories that developed the tests haven’t sought FDA approval in part because they haven’t had to do so. Civilian insurance companies, Medicaid and even, for some tests, Medicare haven’t required it.

Thomas, an ear, nose and throat surgeon who served for a time as surgeon general for U.S. forces in Afghanistan, said he wants to close the gap between LDTs military physicians can order and Tricare coverage.

The new Defense Health Agency, an operational level command with greater authority than the Tricare Management Activity it replaced, is “perfectly designed to address some of these issues, including these disparities,” Thomas said.

Step one, already begun, is to gather information on each LDT not covered by Tricare including frequency of use, how much Tricare previously paid for it and military physicians ordered it. That will allow DHA, he said, “to identify the nifty 50 or top couple of dozen, understanding that many of these things have become the standard of practice on medications.”

For those tests DHA will seek expedited review by FDA.

Tricare did set up a limited demonstration project on LDTs in 2011, inviting manufacturers of certain tests not approved by FDA, but covered by Medicare or Medicaid, to submit them for special review. Two were found significant for clinical decision-making on cancer treatments and were approved quickly by FDA to allow continued Tricare coverage.

DHA wants something like that process revived and expanded, Thomas said, to expedite FDA approval of LDTs that are beneficial to care management, while protecting beneficiaries from tests that lack sufficient evidence of clinical validity and usefulness.

The American Clinical Laboratory Association, which lobbies on behalf of laboratories being affected by tightened Tricare coverage, has opposed subjecting genetic testing to new hurdles of review.

“We are … concerned that Tricare is imposing standards that are outside of industry norms,” said Karen Ruedisueli, a health care advocate for National Military Family Association. She called Tricare worries over the safety of these tests “a red herring” given that FDA has not moved to strengthen its oversight and commercial insurers and Medicaid cover them.

But giving all LDTs “a free wave is not the answer,” Thomas said. “What we have to do is just push (the best of) them to the front …”

Send comments to Military Update, P.O. Box 231111, Centreville, VA, 20120, email milupdate@aol.com or twitter: Tom Philpott @Military_Update

Talk to us

More in Local News

Everett Police Chief Dan Templeman announces his retirement after 31 years of service at the Everett City Council meeting on Wednesday, Sept. 27, 2023 in Everett, Washington. (Olivia Vanni / The Herald)
Everett police chief to retire at the end of October

Chief Dan Templeman announced his retirement at Wednesday’s City Council meeting. He has been chief for nine years.

Boeing employees watch the KC-46 Pegasus delivery event  from the air stairs at Boeing on Thursday, Jan. 24, 2019 in Everett, Wa. (Andy Bronson / The Herald)
Boeing’s iconic Everett factory tour to resume in October

After a three-year hiatus, tours of the Boeing Company’s enormous jet assembly plant are back at Paine Field.

A memorial for a 15-year-old shot and killed last week is set up at a bus stop along Harrison Road on Wednesday, Sept. 13, 2023, in Everett, Washington. (Ryan Berry / The Herald)
Teen boy identified in fatal shooting at Everett bus stop

Bryan Tamayo-Franco, 15, was shot at a Hardeson Road bus stop earlier this month. Police arrested two suspects.

Mike Bredstrand, who is trying to get back his job with Lake Stevens Public Works, stands in front of the department’s building on Wednesday, Sept. 27, 2023, in Lake Stevens, Washington. Bredstrand believes his firing in July was an unwarranted act of revenge by the city. (Ryan Berry / The Herald)
Lake Stevens worker was fired after getting court order against boss

The city has reportedly spent nearly $60,000 on attorney and arbitration fees related to Mike Bredstrand, who wants his job back.

Chap Grubb, founder and CEO of second-hand outdoor gear store Rerouted, stands inside his new storefront on Thursday, Sept. 21, 2023, in Gold Bar, Washington. Rerouted began as an entirely online shop that connected buyers and sellers of used gear.  (Ryan Berry / The Herald)
Used outdoor gear shop Rerouted finds a niche in Gold Bar

Seeking to keep good outdoor gear out of landfills, an online reselling business has put down roots in Gold Bar.

Naval Station Everett. (Chuck Taylor / Herald file)
Everett man sentenced to 6 years for cyberstalking ex-wife

Christopher Crawford, 42, was found guilty of sending intimate photos of his ex-wife to adult websites and to colleagues in the Navy.

Snohomish County Executive Dave Somers speaks to the crowd during an opening ceremony at the new PAE2 Amazon Fulfillment Center on Thursday, Sept. 14, 2023, in Arlington, Washington. (Ryan Berry / The Herald)
Snohomish County executive pitches $1.66B budget

Snohomish County Executive Dave Somers announced his proposed budget Tuesday afternoon. Public comment is slated to begin Oct. 10.

Lars Kundu wipes away tears during his sentencing Thursday, Sept. 28, 2023, at Snohomish County Superior Court in Everett, Washington. (Ryan Berry / The Herald)
5 years after fatal hit and run, Lake Stevens man sentenced to prison

Lars Kundu, 28, pleaded guilty in May for the 2018 death of Chad Keeler. He was handed more than 6 years in prison Thursday.

Jamel Alexander, center, listens as a Snohomish County jury records their verdict of guilty, in the murder of Shawna Brune, on Tuesday, May 18, 2021 in Everett, Washington.  Alexander was convicted in the first degree murder of Brune. (Andy Bronson / The Herald)
Appeals court orders new trial in Everett woman’s stomping death

Appellate judges ruled that additional evidence should have been admitted in Jamel Alexander’s trial for the murder of Shawna Brune.

Most Read