Discoveries in Health Policy

Can AI help discover new quality measures for oncology?

2026-10-07T19:48:34.799-07:00

In some circles, you hear that we need new better quality measures in oncology, but it's not always clear how to go about discovering them.In this exercise, we try to use "guided creativity" to see if AI can help (Chat GPT). Since good measures begin with the patient, we asked Chat GPT to list 15 problems that cancer patients face. THEN, list an intervention or remedy for each, if

CMS Wants Your Views on its Fraud Contractors (UPICs etc)

2026-10-07T15:09:19.985-07:00

Earlier this year, CMS posted an RFI on its "CRUSH" anti fraud scale-up. CMS has generated a proposed rule now percolating at OMB. This week, CMS pivots to its categories of fraud contractors (eg UPIC) and asks for YOUR views on them.Blog by Chat GPT.###CMS Seeks a New Fraud-Defense Contracting Model, Alongside Pending CRUSH RulemakingCMS has opened a new request for information

PAMA: What Happened to Exome, Genome, and NIPT?

2026-10-05T16:13:08.857-07:00

Under PAMA, what happens to Exome, Genome, and NIPT beginning in 2027?Here's the data, click to enlarge:click to enlargeExome 2018 In 2018 PAMA data, Exome came in at $4780, sibling exome at $12,000, and exome re-evaluation aka "dry lab" at $320. This data was based on very few claims and some thought the $12,000 number may have mistakenly been meant as the family price (

PLA Use of "100 genes or more." It's baaaack!

2026-10-05T13:05:33.091-07:00

For several years, there seemed to be a PLA moratorium on the use of "or more" so you'd see the construction "Panel of 85 genes" instead of "Panel of 85 or more genes." Use of "Panel of 85 genes" suggested you'd start over with the PLA panel if you added a gene ("Panel of 85 ^86 genes.")I discussed this in some detail today in a blog about new PLA

CMS Issues New October PLA Codes, New October Clin Lab Fee Schedule CLFS. Essay on "Or More."

2026-10-05T12:58:11.409-07:00

CMS has released the October 1, or fourth-quarter, Clin Lab Fee Schedule, CLFS. The next one, on January 1, will be based on PAMA prices. CLFS here. PLA codes (new and unpriced) run up to 0698U.AMA has issued PLA codes for the October 1 cycle. This includes "new" codes released now and effective January 1, 2027 PDF here. 0699U to 0715U are

FDA Awards $1M for Approval Methods for AI Radiology Reports. Will AI Pathology Reports be Far Behind?

2026-10-05T10:36:21.658-07:00

I've argued that the billion-dollar app in digital pathology will be an FDA-cleared app for draft report preparation. (The pathologist then supervises the slide results and confirms/edits the report). (My blog & PDF white paper.) Critical news 1: FDA has already starting approving some specific apps for draft reports in radiology.Critical news 2: FDA gave a $1M

Understanding Sparano via Understanding the "C Statistic"

2026-10-04T17:28:21.909-07:00

The adjacent blog about the Oncotype test and Sparano's new IICM+ test, pivots almost every quantitative comparison on "C-statistic.' If you're like me, you may be asking, "Whazzat!?!"Here's a Chat GPT explanation of C statistic.###The C-Statistic for the Perplexed: What Does “Better Prediction” Actually Mean?A new cancer prognostic test is reported to outperform an established test.

Is Sparano et al. Better than Oncotype DX? New Publication.

2026-10-04T16:27:02.696-07:00

From time to time a test is published as "Better than Oncotype Dx," which has been around since about 2004.Some have even been based on H&E slides, WSI, and AI.Here's a complex multi-modal tour-de-force approach to a new test. Here's some pre-publicity from 12/2025 on the project, from Caris. (See supplements at bottom of blog, for a tech critique of Sparano AI (via Dawood),

Case Study: The Border Between Wellness Devices, Medical @Home Devices, and Coding

2026-10-04T14:04:14.397-07:00

What happens when a $299 wristband challenges a medical service built around much more expensive equipment? In this fictional business school case, TrackBP has raised $75 million to bring cuffless ambulatory blood pressure monitoring to market. (One part of the large remote physiological monitoring market, RPM.) Its CEO sees a cleared FDA predicate and an existing CPT code. What

What Cancer Payment Rewards, and What Gets Left Behind: Shah 2026 in JAMA Oncol.

2026-10-02T16:08:11.400-07:00

In a new article at JAMA Oncology Shah describes two treatments - one superior - and then reveals we pay $100,000 for the less useful thing and $10,000 for the most useful thing. He also reveals that most useful thing is radiotherapy. And it is "facing drastic reimbursement cuts, leading some centers to shut down." (Shah is a radiation oncologist.) He

When AI Beats Google: Agentic AI Searchs for Media about "14 Day Rule"

2026-10-02T14:57:32.474-07:00

The "14 day rule" for CMS lab specimens is pretty obscure. I asked Chat GPT to search the internet for media, op eds, etc, on 14 day rule. Here's what it came back with...in...two minutes.###Media about the 14 Day Rule (AI agentic internet research)Please use agentic internet research to find articles or media about the 14 Day Rule.###Yes—there is meaningful public coverage,

CMS Releases Pricing Proposals for 110 New 2027 Lab Codes

2026-09-29T20:24:34.304-07:00

CMS has released its 110 proposals for new lab codes for 2027. On this web page, scroll down for Agendas and Important Materials to find the proposals. CMS takes comment until October 21.Chat GPT provides an analysis (giving me what I asked for, without my having to count row by row.)The CMS Pricing Proposals, September 2026110 codes are in play. CMS proposes crosswalking

MolDx: Final Gapfill Pricing for CY2027

2026-09-29T16:33:11.423-07:00

The gapfill year has run its course for 17 codes. We saw proposed prices in May, final pries in September. Five codes changed price (although one by only 5%). Get the spreadsheet on this page, scrolling down to "agenda & important materials."I've put a summary spreadsheet in the cloud. I've included a fact-based "Tips and Tricks" section at bottom.Chat GPT writes as

Digital Pathology Update: Signals from Leica, from CAP TODAY, from Mayo

2026-09-29T13:47:54.132-07:00

[AI generated, Chat GPT 5.6][Links at bottom]##Future of Digital Pathology: Signals from Leica, Mayo, and CAP TODAYDigital pathology’s next major commercial advance may come when software can assemble a substantially complete pathology report for a physician to review, correct, and sign. That capability could give laboratories a powerful new reason to invest in scanners, image management,

Date of Service Rule for Inpatients: Does It Conflict with Other Regulations?

2026-09-29T10:39:24.010-07:00

The Medicare Date of Service rule defines "date of specimen collection" as the "date of service" - for inpatients, unless the test is ordered over 14 days after the hospital discharge.The way it works is this: The patient is admitted July 1, has surgery July 2, is discharged July 6. A molecular test is ordered ten days later (July 16). This July 16 is less than 14 days after July 6,

The Distribution of PAMA Prices: Case Study 81455, 81456 (51 or more tumor genes)

2026-09-28T11:13:19.706-07:00

CMS has released a new clin lab fee schedule for 2027-2028-2029. Price cuts were common, based on reported private payer pricing data. (Genomeweb here, HC Dive here.)CMS released Excel files of roughly 7M claims (999,999 rows x 7 pages). Find the data on this page under the header "CY 2027 Information" which includes preliminary data aka raw data and preliminary medians

LegislationWatch: ASAP (Alzheimer Tests), MAIA, PACA, PPA (all for Medicare Advantage Claims)

2026-09-25T08:17:35.407-07:00

ALZHEIMER ON THE HILLOn September 16, 2026, the House Ways and Means committee advanced a bipartisan Alzheimer bill, "Alzheimer's Screening and Prevention Act ASAP."See a dedicated website: https://alzimpact.org/ASAP_Act ; It's numbered as, H.R. 6130 / S. 3267. ###MEDICARE ADVANTAGE CLAIMS - ON THE HILLTired of Medicare Advantage payment nightmares?

Very Brief Blog: John Warren Highlights "Genealogy of Pricing" as Key to Crosswalks

2026-09-25T07:58:23.621-07:00

In an excellent Linked In posting, CMS consultant John Warren emphasizes that you can't do crosswalks and gapfill decisions any more, without understand the genealogy of how your comparable codes were priced by CMS. Was it by gapfill? By PAMA? By a crosswalk? If a crosswalk, what's happening to the crosswalk code? Sounds like a hall of mirrors, but it's

Cheat Sheet: The Six Publications About GRAIL (Released Concurrent with FDA Ad Comm)

2026-09-24T23:43:29.003-07:00

We just had the Ad Comm for GRAIL - whose stock nearly doubled from 9/17 to 9/24. Market cap rising from $2.5B to $5.5B. You'll be excused for not keeping this week's six publications straight in your head. See an article and op ed in NEJM, plus two articles and op ed in Nature Medicine, and finally a concensus publication by Etzioni in Cancer on late-stage-cancer as a

History Corner: The Origins of the Mismatched -26 and -TC Modifiers

2026-09-24T18:48:30.875-07:00

Part 1Why Is the Professional Component “26,” but the Technical Component “TC”? A Little CPT Archaeology[Article by: Chat GPT 6][Part 1 of this article - top - on the origins of -26 and TC. Part 2 of this article - bottom - on the earliest history of two-digit modifiers.] For anyone who works regularly with pathology and laboratory billing, modifier 26 and modifier TC seem

BCBS, NYT: Hospital AI Bills Battle Payer AI Denials!

2026-09-24T11:33:57.141-07:00

The headline was inevitable. Hospital AI pumps out bigger better invoices. Health insurer AI rolls up its sleeves and pumps out denials.The story in the NYT is here. It's based on a new report issued by the BCBS Association here, here. See HC Dive here.Here's a short quote from NYT:Using codes for various medical conditions, hospitals submitted claims for tens of

GRAIL's Day at FDA: The Most Detailed Report

2026-09-24T09:05:36.434-07:00

GRAIL has its day at FDA on September 23, 2026, with panelists voting in favor of the effectiveness and safety of Galleri.The FDA website is here (see a 55p PDF from FDA and a 111-page PDF from GRAIL.) At YouTube FDA posts a 9-hour video which includes an autotranscript. Numerous concise meeting reports are available at news sites on the Internet.BUT...I gave Chat GPT

The July 2026 RFI on Modernizing CLIA: What Do Public Comments Say??

2026-09-22T21:18:53.207-07:00

CMS issued a Request for Information (RFI) on modernizing CLIA in July 2026, with comments closing September 14, 2026. See the comment search page here:https://www.regulations.gov/document/CMS-2026-2345-0001https://www.regulations.gov/document/CMS-2026-2345-0001/comment>>> Article below is written by Chat GPT.##Pathology Groups Tell CMS How CLIA Should Enter the Digital

When Does MolDx Change Its Mind? The Prelude Papers

2026-09-21T23:44:18.984-07:00

When does MolDx change a non-coverage proposed LCD into a coverage final LCD?Famously, this happened once in the last few years, regarding the PRISM-RA test, which provides some help when choosing advanced medications in arthritis. (However, MolDx remarked in the final that it still found some of the evidence marginal.) (Draft, 9/2022). (Final, 8/2023). It's an evergreen

CMS Posts Cy2025 Part B National Utilization Data

2026-09-21T17:09:30.042-07:00

CMS has posted CY 2025 National Part B utilization data as simple Excel files. Find them here:https://www.cms.gov/data-research/statistics-trends-and-reports/part-b-national-summary-data-file?For example, allowed dollars for code 81479 are up to $512M (for 205,000 services).The same data will be posted in vastly more detailed sometime around June 2027, sortable for every physician and