TRICARE beneficiaries soon will have to pay out of pocket for certain diagnostic genetic tests their civilian physicians order but the Defense Health Agency doesn’t view as appropriate or medically necessary.
In January 2013, without notice to beneficiaries or to health care providers, TRICARE stopped reimbursing clinical laboratories for more than 100 different genetic or “molecular pathology” tests.
Beneficiaries haven’t complained yet because the laboratories impacted are still providing the tests that physicians order at no charge, said Julie Khani, vice president of American Clinical Laboratory Association (ACLA), which lobbies on behalf of the impacted laboratories.
To date, labs have provided about $10 million worth of free tests to TRICARE users.
“That’s obviously unsustainable,” Khani said.
Most of these tests cost about $60, but a few carry charges of several thousand dollars.
One of the more routine genetic tests that TRICARE no longer covers is used to determine if a woman who is pregnant carries a marker for cystic fibrosis, which would increase chances of the baby having the disease.
If the woman has the marker, the father usually is tested too.
With this test no longer covered, “TRICARE beneficiaries will not receive the standard of care or benefits equal to other insured patients,” Khani said.
The American Congress of Obstetricians and Gynecologists has recommended prenatal testing for CF for more than a decade, she said.
“It’s covered by Medicaid and other commercial health plans. It is also the standard of care under VA-DoD clinical practice guidelines for management of pregnancy,” Khani said.
The Defense Health Agency, in a written response to questions, dismissed the significance of the prenatal CF testing.
“Awareness that a fetus is at increased risk of having CF, in and of itself, does not usually change the management of labor, delivery and the neonatal period,” wrote DHA officials.
Also, they noted, infants at birth are tested for a host of health conditions, including CF, and those tests continue to be covered by TRICARE.
Reps. Tom Marino and James P. McGovern, co-chairs of the Congressional Cystic Fibrosis Caucus, urged Lt. Gen. Douglas J. Robb, director of DHA, in a letter signed Monday to reconsider the decision not to cover prenatal CF testing, arguing that “patient care will suffer.”
If TRICARE doesn’t begin soon to pay for these tests, doctors won’t stop ordering them but laboratories will have no choice but to charge patients for their cost, Khani said.
The Military Coalition, an umbrella group of military associations and veterans groups, recognizes that laboratory profits and complex medical questions are entwined in this debate.
But one clear concern for beneficiary advocates, said Kathy Beasley, co-chair of the coalition’s health subcommittee, is that DHA has created two standards of care regarding molecular pathology tests.
Patients who use civilian providers will have to pay for these tests, while patients at military clinics and hospitals won’t. Providers in the direct care system can continue to order such tests knowing the military will pay for them.
“TRICARE beneficiaries without access to military treatment facilities are relegated to second-class healthcare. This is troubling,” Beasley said.
DHA acknowledges this disparity and explained that a single contract is in effect that allows Army, Navy and Air Force providers to request lab services if military facilities cannot perform the tests in house.
“As this is not a DHA contract, we are in the process of gathering data regarding the tests being ordered by MTF providers and will examine any changes that need to be made to the contract,” DHA said. “Lab testing, whether ordered in the private sector or by MTF providers, needs to be safe and effective.”
But DHA said differences in lab test coverage might survive any such review because purchased care has more restrictive laws and regulations.
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