Discoveries in Health Policy

PAMA Bizarre Patterns Revisited: When Outliers Drive Margins

2026-10-27T14:04:12.647-07:00

A week ago, we used PAMA raw data to show not just the median price for codes, but the actual distribution of payments (normal vs bimoda vs skewed left or right, etc). Blog here. In a later blog, we wondered if accusations (from employers) that United Healthcare was overpaying some providres, might be related to the most extreme prices seen on the far-right column of

Employers Sue United Healthcare: Does It Overpay Providers??

2026-10-27T12:25:32.665-07:00

Header: A large group of employers sues United Healthcare, asserting it overpays providers when it is merely dolely out third-party administrator payments (the employer's money.) They say it is more careful when it is acting as an insurer and paying its own money. ?Could this show up as high-end payments for lab tests (e.g. $200 for $10 test) in PAMA data?###See

A Mouse is Not a Microscope: Digital Pathology Waiting for Quantum Leap in User Devices

2026-10-26T12:28:43.374-07:00

Header: Should digital pathology have a true revolution in the quality of input devices?###Recently, we blogged about how digital pathology advances slowly. And rather than looking to radiology for advice, we should look to...the adoption of Da Vinci robotic surgery.Robotic surgery probably took half the prostatectomy market in ten years - at huge cost in equipment and infrastructure.

Version 2: CMS, NIH, FDA Websites Switching to "SUPER INTELLIGENCE"

2026-10-25T11:46:49.447-07:00

VERSION TWO - SUPER INTELLIGENCEThe original version of this blog discussed government websites switching to "SUPER INTELLIGENCE" terminology. I included a playful, silly parody news article as well.This triggered a content warning from Google Blogger (my blog host), apparently because any kind of parody is something that is "not true" so it needs to be flagged.Here, I move the

Version One; It's Here, It's Now: CMS, NIH, FDA Websites Switching to "SUPER INTELLIGENCE"

2026-10-25T10:55:24.492-07:00

VERSION ONE (TRIGGERED GOOGLE PARODY WARNING)##You might have heard the White House use the phrase "Super Intelligence" a couple times. This stems from a September 29 Executive Order that talks about AI policy but includes an order that the government switch exclusively to the term "Super Intelligence," not artificial intelligence. That's wide-ranging - every webpage,

PAMA Unveils Bizarre Patterns for US Lab Test Pricing

2026-10-24T21:08:28.034-07:00

Here's an analysis run mostly by AI, based on my ability to "vibe code" instructions of what AI had to do with raw PAMA Excel data.Data shows the bar charts of the private payer price distribution for about 15 codes. The distributions are strange and not many are "Guassian" or "normal." While some are tightly distributed and others spread evenly around the price range. See

CMS New Voluntary Exclusion Authority: What Court Cases Have Said

2026-10-24T15:42:30.933-07:00

This month, RFK Jr gave CMS itself the elective exclusion authority long reserved only for referral to the OIG's attorneys. Blog.Here I've asked Claude to put on its virtual law school professor hat and discuss how case law may have shaped the interpretation of the statute. (The statute allows years of exclusion for violations as loosely defined as "unnecessary services" or "

Dr. Oz Videos: (#1) Hates Lab Industry, (#2) Deep Dive on Fraud, Documentary

2026-10-24T15:02:34.079-07:00

HEADERDr. Oz’s recent and biting criticism of laboratory pricing and CMS’s unusual fraud documentary reveal an increasingly aggressive agency. This review examines the alleged schemes, enforcement strategy, and implications for CRUSH and exclusion authority—with one welcome observation for laboratories: the October 21 documentary and press conference did not single them out.###Something

Speeding Up Digital Pathology: Great Lessons from Adoption of Da Vinci Robotic Surgery

2026-10-22T09:08:03.195-07:00

We often hear that adoption of digital pathology (since, for example, the $100M acquisition of Bioimagene by Roche almost twenty years ago)...is so slow due to microeconomics.Let's look at another transformation. Robotic surgery aka da Vinci blew into the markets like a tornado. There were four possible drivers -Better clinical outcomesBetter economics (faster-cheaper)Urologist

Cologuard 2.0 - Pricing on Earnings Call - Screen Shots from CMS

2026-10-21T22:42:08.839-07:00

On the October 21, 2026, Abbott earnings call, there were some remarks on the pricing of Cologuard 2.0 in 2027 and forward.I'll show the dialog, from Motley Fool transcript, and then some screen shots of the CMS pricing data and its sources.##https://www.fool.com/earnings/call-transcripts/2026/10/21/abbott-abt-q3-2026-earnings-call-transcript/....Our next question will come from Vijay Kumar

Using AI to Search PubMed: A case study on "External Control Group" literature

2026-10-21T21:40:16.254-07:00

We often hear the first step in learning to use AI, is using it as a big powerful kind of Google.I find AI can often work as a "big powerful PubMed," going beyond the use of keywords in Pubmed and using instructions that AI can interpret and understand. Also, since the domain is PubMed to start with, the risk of (hallucinations) should go from tiny to zero.Here's an example from my work

An Early View: Stakeholders Respond to FDA's Concept Paper on LLM-SAMD

2026-10-21T14:19:03.290-07:00

One brick at a time, FDA has been advancing LLM-based SAMD. See the approval of draft-report software for ultraound and see the breakthrough status for radiology CXR draft-report software and see FDA's $1.3M contract for accelerating the regulatory science for radiology diagnostic reporting with AI.There's also the "big story"- in August FDA released a major concept paper for SAMD in an

National Kidney Plan, 10/2026: Key Sightlines into CMS Innovation Frames

2026-10-20T20:53:58.008-07:00

A new national kidney care plan was a major effort in the Trump-1 administration (2019 here). One of the leaders, Abe Sutton, now heads CMMI. In October 2026, HHS announces an updated Kidney Plan. Worth tracking. It gives important sightlines into how this CMS views healthcare innovation.A Google-AI summary is here.The new Kidney Care National Plan, KCNP, home page is

Four Transcripts and a Sale: LabCorp Adopts Myriad "Prenatal Health" Assets

2026-10-20T12:43:55.221-07:00

Just days after LabCorp agrees to acquire BioReference from OPKO, LabCorp agrees to buy Myriad Prenatal Health assets for $210M.Here, we let Chat GPT write the full case, including the assets, their origins, and how Myriad's public discussion of the business evolved over four quarters.As always with these reports, they are AI generated reported and not ground truth. However they service as

Time for Pathology to Follow Radiology's Lead at FDA; Deep Dive on the FDA Radiology AI Contract

2026-10-19T23:25:12.956-07:00

Over the last several months, this blog has covered rapidly advances in AI software that will prepare radiology and pathology reports ready for human review, validation, and sign-out. Radiology at Lightning SpeedThe scale tends to be bigger in radiology, and the benchmarks further. For example, AIDOC gets Breakthrough Status for FIRST READ, meaning it's well along in the FDA

Labcorp Gets Bioreference: "Four Transcripts and a Funeral"

2026-10-18T07:23:25.112-07:00

According to plans announced, Labcorp will acquire most remaining assets of Bioreference labs from OPKO. See this new 12-page report developed entirely by AI from existing records, especially the past year of Investor Call transcripts. Find it HERE: https://drive.google.com/file/d/1e9dQl6vaZLcGq1q2561iAWz4tSCjlJoZ/view?usp=sharing ;# # # The PDF above is an AI-generated

MolDx Withdraws Proposed NonCoverage of Prelude DCISionRT (0360U)

2026-10-16T05:18:52.676-07:00

On October 15, 2026, MolDx announced it was canceling its draft non-coverage LCD for Prelude's DCISionRT. This follows recent announcements (1) first, the draft would be delayed and (2) and second, a CAC meeting 10/13 on the topic.See message from CEO here.I have updated my September 21 blog to keep the storyline in one place.https://www.discoveriesinhealthpolicy.com/2026/09/

LabCorp Gets Bioreference, References 4K Score 81539

2026-10-15T15:59:42.267-07:00

Bioreference acquisitioni by LabCorp features some carve-outs for 4Kscore behavior. Here's how it fared in recent Medicare Part B sales and in PAMA.###In 2025, Part B sales for 81539 were $12.6M for 16,500 units.In 2024, Part B sales for 81339 were $11.7M for 15,300 units.In 2023, Part B sales for 81339 were $10.4M for 13,700 units.In current PAMA price data, 81539 has a 2026

LabCorp Gets Bioreference: Two AI Viewpoints

2026-10-15T15:38:14.208-07:00

Below find a Chat GPT and a CLAUDE review of the Labcorp-Bioreference acqiusition. Each had the same prompt (350-400, use internet).This is AI writing and should not be taken as ground truth. It can be taken as an example of current AI research and writing skills.###Chat GPT###BioReference:From OPKO’s Growth Platformto Labcorp’s Consolidation OpportunityOPKO acquired

A Final Reg, A Proposed Bill: Information, Transparency, Coverage

2026-10-15T13:05:44.177-07:00

CMS has released a final regulation on (mostly PRICE) transparency in coverage. See Fed Reg, see Press Release, Fact Sheet. Here, in this blog, see an AI summary.Meanwhile, the House has posted HR 9393, a bill called Lower Costs, More Transparency Act.###AI discusses.###Transparency in Coverage:Clearer Prices, but How Much Clearer Coverage?The new Transparency in Coverage

Program Integrity - Something New Every Month - Exclusion Authority Added to CMS, Formerly Only the OIG

2026-10-15T11:07:24.402-07:00

Update; See also a review of how legal cases have shaped our view of the exclusion statute - here. ##Medicare's exclusion authorities - kicking you out of the program for 10 or 20 years - was previously handle by the legal eagles in the OIG.With a quick announcement in the Federal Register, that exclusion can now also be handled by CMS staff, in the name of the Administrator (RFK/HHS).

MEDPAC Updates its Basics of Payment series

2026-10-15T10:55:33.019-07:00

MEDPAC has a dozen short articles, usually two-pagers, on the different payment systems (one of which is Clin Lab Fee Schedule.)It's says they're updated for 2026; I suppose most had little change from the last version. Find them here:https://www.medpac.gov/document-type/payment-basic/

Oh Noooo... MACs Forbid Coverage of AI for MRI

2026-10-15T10:22:36.525-07:00

We saw this LCD topic as Final in February from CGS* and in Draft from Wellpoint Federal, here it comes from Palmetto GBA in draft in October..On October 1, Palmetto released for comment LCD DL40464, "Automated Detection and Quantification of Brain MRIs." The take-home lesson is simple:This is a non-coverage policy for artificial intelligence (AI) assistive software tools for

When Digital Pathology is as much fun as Da Vinci - Sales will Follow

2026-10-15T10:06:12.815-07:00

Could AI-drafted pathology reports become something physicians actively want to use—as some surgeons came to love da Vinci robotics? This white paper explores that possibility through surgeons’ experiences describing their enjoyment of robotic surgery.Find the 7-page cloud white paper HERE._______________I also draw two personal examples - how the technology of literature

AGILENT-Proscia. ROCHE-PathAI. Deep Dives into Business Strategy and Impact

2026-10-14T17:34:59.103-07:00

Roche acquires Path AI, Agilent acquires Proscia. Tempus acquires PAIGE. In a carefully guided Chat GPT 6 essay, we try to figure out what it means and where we're going.This is an AI generated report. It should not be taken as ground truth ,but as an example of currrent AI abilities to grasp, plan, and write multi-part essays.##Access this white paper as a 15-page