Unsustainable Physician Reimbursement Rates

Comparing Medicare Fee Schedule Updates to Inflation Rates
The United States has the highest per capita healthcare spending in the world. U.S. healthcare costs have outpaced inflation for several years. Over the past 20 years, the federal government has attempted to control costs—specifically Medicare costs.

Cost reduction strategies often focus on specific segments of the healthcare market. These segments include hospitals, outpatient facilities, labs, drugs, physicians, rehabilitation, durable medical equipment, etc. Medicare has unique fee schedules for the various segments of the healthcare economy. The annual changes to these various fee schedules have not been uniform.

The most striking finding among various provider fee schedule changes was the Medicare Physician Fee Schedule (MPFS), which controls how physicians are paid by Medicare. MPFS rates have remained relatively flat over the past decade. With annual rate changes between 0 percent and 1 percent, the average increase in the MPFS since 2007 was 0.24 percent. The average annual rate of inflation during the same period was 1.88 percent. It does not appear that Medicare will increase the MPFS in the near term. This occurs at a time when inflation is 2.5 percent and seems to be increasing. By failing to keep pace with inflation, this relative reduction of revenue and subsequent practice margin is disruptive for physicians and may challenge traditional practice models. Furthermore, other Medicare fee schedules have had more favorable annual changes, such as the hospital Inpatient Prospective Payment System (IPPS) and hospital Outpatient Prospective Payment System (OPPS).

Historical overview and background of Physician Fee Schedule
Healthcare costs in the United States continue to outpace inflation. According to the Advisory Board Company, healthcare spending was 17.8 percent of the total U.S. gross domestic product (GDP) in 2015, and the Centers for Medicare and Medicaid Services (CMS) estimates healthcare spending could reach close to 20 percent by 2020.

These spiraling healthcare costs are a significant concern to the government, which is responsible for funding the Medicare and Medicaid programs. Several pieces of federal legislation have attempted to control healthcare spending.

In 1997, President Bill Clinton signed into law the Balanced Budget Act (BBA), which established the Medicare Sustainable Growth Rate (SGR) methodology for physician payment. The BBA was designed to increase physician reimbursement when healthcare spending growth was below that of the GDP and decrease physician reimbursement if healthcare spending outpaced the GDP.

A cut to Medicare reimbursement by nearly 5 percent in 2002 caused the SGR to call for deep cuts to physician payment. The flawed SGR methodology was mitigated by Congress’ yearly stopgaps, which avoided cuts to physician reimbursement.

In 2015, the SGR was replaced when the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law by President Barack Obama. This legislation subsequently led to the Quality Payment Program (QPP), which mandates annual physician payment increases of 0.5 percent in 2016, 2017, and 2018 (compared to the current rate of inflation over the past 12 months of 2.5 percent).

Beginning in 2019, most physicians will be reimbursed under the Merit-Based Incentive Payment System (MIPS) program, which is budget neutral. The MIPS program has an adjustment payment that is based on a composite score of quality indicators, resource use, clinical practice improvement activities, and meaningful use of electronic health records. The payment to physicians can initially change as much as +/–4 percent in 2019 and will increase to +/–9 percent in 2022, depending on performance.

Fee schedules in the current environment
Medicare has several different fee schedules for various healthcare providers. Each schedule is typically adjusted annually.

We examined the five major Medicare fee schedules, including:

  1. inpatient prospective payment system (IPPS)
  2. outpatient prospective payment system (OPPS)
  3. ambulatory surgical center (ASC)
  4. clinical laboratory fee schedule (CLFS)
  5. MPFS

The most readily accessible CMS data regarding annual Medicare fee changes date back to 2007. Annual updates to the MPFS lagged behind the updates to the other four fee schedules studied as well as inflation from 2007 to present (see Fig. 1).

In the last 11 years, the MPFS rates increased an average of 0.24 percent annually while inflation increased an average of 1.88 percent annually—an average difference of 1.64 percent. Annual changes to the IPPS, OPPS, ASC, and CLFS largely kept pace or exceeded the rate of inflation (see Table 1).

The MPFS rates may be further compromised in the future with MIPS adjustments beginning in 2019. MIPS has the potential to markedly reduce the margins of physician enterprises—such as orthopaedic surgeons—that treat Medicare patients. These changes may further decrease physician financial performance and financial resources for future investment.

Reduction in purchasing power (what can be purchased when adjusted for inflation) caused by flat MPFS reimbursement for physicians and their practices may create a cycle that further reduces payment from MIPS because of less capital to invest in practice infrastructure. Reduction in MIPS payments is particularly important for orthopaedic surgeons who had relatively low participation in earlier CMS pay-for-performance reporting programs. An inability to invest in practice infrastructure to participate in QPP may result in further reduction in physician payment. Medicare payment reductions combined with increased overhead demands required to optimize performance in QPP programs may continue to drive physician practice consolidation, hospital employment, and physicians exiting the market via retirement or career changes.

Conclusion
Controlling healthcare costs is a vital societal issue. For more than a decade, physicians unilaterally absorbed more negative payment pressure than any other provider stakeholder studied with the lowest annual Medicare fee schedule updates. The physician fee schedule updates were less than inflation for every year we studied. Although these annual shortfalls were relatively small, the cumulative effect was profound. The inflation adjusted decrease in the MPFS was more than 20 percent from 2007 to 2017 (2.68 percent versus 22.76 percent), as seen in Fig 2.


Fig. 2 Inadequate increases in the Medicare Physician Fee Schedule has resulted in more than 20 percent reduction in real (inflation adjusted) compensation since 2007.
CMS, 2017: OrthoIndex Analysis, 2017

It is unclear why CMS singled out physicians for asymmetrical negative annual fee schedule adjustments. The other four provider stakeholders studied—hospital inpatient and outpatient, ambulatory surgical centers, and clinical laboratories—all had fee schedule adjustments that were nearly equal to and typically greater than inflation for the period studied.

This outcome is troublesome for physicians. The impact of this disparity is compounded when considering that most commercial payers benchmark their physician fee schedules off the MPFS. As legislators look to solutions to control healthcare costs in the future, they must consider the economic burden they have already placed on physicians. The adverse impacts of inadequate annual MPFS increases are additionally troubling as CMS adds costly physician compliance and reporting obligations as required in the MIPS and Alternative Payment Model payment tracks of the QPP.

John Cherf, MD, MPH, MBA, is the practice and payment section leader of the Health Care Systems Committee, a member of the Council on Education, and a member of the AAOS Now Editorial Board. 
Alex Paul is an administrative intern at Advocate Health Care and currently is enrolled at the University of Illinois at Chicago Master of Hospital Administration program.

References

  1. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “FY 2017 Final Rule and Correction Notice Tables.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page-Items/FY2017-IPPS-Final-Rule-Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
  2. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “FY 2016 Final Rule and Correction Notice Tables.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2016-IPPS-Final-Rule-Home-Page-Items/FY2016-IPPS-Final-Rule-Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
  3. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “FY 2015 Final Rule Table.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2015-IPPS-Final-Rule-Home-Page-Items/FY2015-Final-Rule-Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
  4. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “FY 2014 Final Rule Tables.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2014-IPPS-Final-Rule-Home-Page-Items/FY-2014-IPPS-Final-Rule-CMS-1599-F-Tables.html
  5. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “FY 2013 Final Rule Tables.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/fy-2013-ipps-final-rule-home-page-items/fy2013-final-rule-tables.html
  6. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “FY 2012 Final Rule, Correction Notice and 1442-N (508 Wage Index) Tables.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2012-IPPS-Final-Rule-Home-Page-Items/CMS1250520.html
  7. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “FY 2011 Final Rule Tables.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2011-IPPS-Final-Rule-Home-Page-Items/CMS1237948.html
  8. Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “Table 1A-1E Final Rates for FY 2010; First and Second Half Rates for FY 2010.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2010-Final-Rule-Home-Page-Items/CMS1227440.html?DLPage=1&DLEntries=50&DLSort=0&DLSortDir=ascending
  9. Centers for Medicare and Medicaid Services, FY 2009 IPPS Final Rule, “Table 1A-1D Final Rate for FY 2009.” Table 1A-1B. Access August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2009-IPPS-Final-Rule-Home-Page-Items/CMS1221341.html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=ascending
  10.  Centers for Medicare and Medicaid Services, Acute Inpatient PPS, “Files for FY 2008 Final Rule and Correction Notice.” Table 1A-1B. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Acute-Inpatient-Files-for-Download-Items/CMS1247844.html
  11. Department of Health and Human Services, Centers for Medicare and Medicaid Services, “Medicare Program; Hospital Inpatient Prospective Payment Systems and Fiscal Year 2007 Rates: Final Fiscal Year 2007 Wage Indices and Payment Rates After Application of Revised Occupational Mix Adjustment to Wage Index.” Page 59. October 2006. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/downloads/CMS-1488-N.pdf
  12. Centers for Medicare and Medicaid Services, Fact Sheet, “CMS Finalizes Hospital Outpatient Prospective Payment Changes for 2017.” November 2016. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-01-3.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending
  13. Centers for Medicare and Medicaid Services, Fact Sheet, “CMS Finalizes Hospital Outpatient Ambulatory Surgical Center Policy and Payment Changes Including Changes to the Two-Midnight Rule and Quality Reporting for 2016.” October 2015. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-3.html
  14. McCurdy, Debra, Reed Smith: “CMS Finalizes CY 2015 Medicare OPPS/ASC Rates & Policies.” November 2014. Accessed August 31, 2017 Online: https://www.healthindustrywashingtonwatch.com/2014/11/articles/regulatory-developments/medicare-medicaid-services-regulations/cms-finalizes-cy-2015-medicare-oppsasc-rates-policies/
  15. Centers for Medicare and Medicaid Services, Newsroom, “CMS Issues Hospital Outpatient Department and Ambulatory Surgical Center Policy and Payment Changes for 2014.” November 2013. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2013-Fact-sheets-items/2013-11-27-3.html
  16. Centers for Medicare and Medicaid Services, Fact Sheet, “Proposed 2013 Policy, Payment Changes for Hospital Outpatient Departments, Ambulatory Surgical Centers, Inpatient Rehabilitat.” July 2012. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2012-Fact-sheets-items/2012-07-06.html
  17. Centers for Medicare and Medicaid Services, Fact Sheet, “Final 2012 Policy, Payment Changes for Hospital Outpatient Departments.” November 2011. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2011-Fact-sheets-items/2011-11-01.html
  18. Centers for Medicare and Medicaid Services, Fact Sheet, “Final 2011 Hospital Outpatient, Ambulatory Surgical Center Payment Rule.” November 2010. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2010-Fact-sheets-items/2010-11-022.html
  19. American Hospital Association, Regulatory Advisory, “Medicare Outpatient PPS and ASC Proposed Rule for CY 2010.” Page 2. July 2009. Accessed August 31, 2017 Online: http://www.aha.org/advocacy-issues/tools-resources/advisory/2009/090724-regulatory-adv.pdf
  20. Centers for Medicare and Medicaid Services, Fact Sheet, “CMS Proposes Quality Improvements and Other Changes for Hospital Outpatient.” July 2008. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2008-Fact-sheets-items/2008-07-03.html
  21. Arkansas Hospital Association, The Notebook, “Medicare 2008 OPPS Final Rule.” Volume 14, Number 42 Page 1. November 2007. Accessed August 31, 2017 Online: http://www.arkhospitals.org/notebookpdf/Notebook_11-05-07.pdf
  22. Centers for Medicare and Medicaid Services, Press Release, “CMS Proposes Changes to Policies and Payment for Outpatient Services.” August 2006. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2006-Press-releases-items/2006-08-082.html
  23. Centers for Medicare and Medicaid Services, Fact Sheet, “CMS Finalizes Hospital Outpatient Prospective Payment Changes for 2017.” November 2016. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-11-01-3.html
  24. Centers for Medicare and Medicaid Services, Fact Sheet, “CMS Finalizes Hospital Outpatient and Ambulatory Surgical Center Policy and Payment Changes, Including Changes to the Two-Midnight Rule and Quality Reporting for 2016.” October 2015. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-3.html
  25. Centers for Medicare and Medicaid Services, Fact Sheet, “CMS Finalizes Hospital Outpatient and Ambulatory Surgical Centers Policy and Payment Changes for 2015.” October 2014. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-31.html
  26. Centers for Medicare and Medicaid Services, Fact Sheet, CMS Issues Hospital Outpatient Department and Ambulatory Surgical Center Policy and Payment Changes for 2014.” November 2013. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2013-Fact-sheets-items/2013-11-27-3.html
  27. Centers for Medicare and Medicaid Services, Fact Sheet, “CMS Issues Outpatient Policy and Payment Changes.” November 2012. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2012-Fact-sheets-items/2012-11-012.html
  28. Centers for Medicare and Medicaid Services, Fact Sheet, “Final 2012 Policy, Payment Changes for Hospital Outpatient Departments.” November 2011. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2011-Fact-sheets-items/2011-11-01.html
  29. Centers for Medicare and Medicaid Services, Fact Sheet, “Final 2011 Hospital Outpatient, Ambulatory Surgical Center Payment Rule.” November 2010. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2010-Fact-sheets-items/2010-11-022.html
  30. Centers for Medicare and Medicaid Services, Fact Sheet, “Final 2010 Policy, Payment Changes for Hospital Outpatient Departments and Ambulatory Surgical Centers.” October 2009. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2009-Fact-Sheets-Items/2009-10-302.html
  31. American Hospital Association, AHA News, “CMS Releases Final 2009 Outpatient/ASC Rule.” October 2008. Accessed August 31, 2017 Online: http://news.aha.org/article/cms-releases-final-2009-outpatientasc-rule
  32. OR Manager, “CMS Sets Final 2008 ASC Payment Rates.’ Et. Al. Volume 23 Number 12. December 2007. Accessed August 31, 2017 Online: http://www.ormanager.com/wp-content/uploads/2012/06/ORMVol23No12ASCcmsPaymentRates.pdf
  33. Centers for Medicare and Medicaid Services, Questions and Answers, “Calendar Year (CY) 2008 Revised Ambulatory Surgical Center (ASC) Payment System.” Et. Al. Accessed August 31, 2017 Online: https://www.cms.gov/medicare/medicare-fee-for-service-payment/ascpayment/downloads/asc_qas_03072008.pdf
  34. Centers for Medicare and Medicaid Services, Press Release, “CMS Proposes Changes to Policies and Payment for Outpatient Services.” August 2006. Accessed August 31, 2017 Online: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2006-Press-releases-items/2006-08-082.html
  35. Centers for Medicare and Medicaid Services, Fact Sheet, “Final Policy, Payment, and Quality Provision in the Medicare Physician Fee Schedule for Calendar Year (CY) 2017.” November 2016. Accessed August 31, 2017 Online: https://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2016-fact-sheets-items/2016-11-02.html
  36. Association of American Medical Colleges, Washington Highlights, “CMS Releases Final Rule for the CY 2016 Physician Fee Schedule.” November 2015. Accessed August 31, 2017 Online: https://www.aamc.org/advocacy/washhigh/highlights2015/448254/110515cmsreleasesfinalruleforthecy2016.html
  37. American Society of Cataract and Refractive Surgery, News Room, “2015 Medicare Physician Fee Schedule (MPFS) Final Rule Released.” Accessed August 31, 2017 Online: http://www.ascrs.org/node/20577
  38. Washington State Medical Oncology Society, Medicare Updates January 2014, “Physician Payment Cut Averted for 3 Months.” January 2014. Accessed August 31, 2017 Online: http://www.wsmos.org/news/view/medicare-updates-january-2014
  39. Hahn, Jim; Mulvey Janemarie, Congressional Research Service, “Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System.” Page 2, 6-7. August 2012. Accessed August 31, 2017 Online: https://thornberry.house.gov/uploadedfiles/r40907.pdf
  40. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule, “Clinical Laboratory Fee Schedule.” December 2016. Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-fee-for-service-Payment/clinicallabfeesched/index.html
  41. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “17CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/17CLAB.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
  42. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “16CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/16CLAB.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
  43. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “15CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/15CLAB.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
  44. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “14CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/14CLAB.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
  45. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “13CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/13CLAB.html?DLPage=1&DLEntries=50&DLSort=2&DLSortDir=descending
  46. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “12CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/12CLAB.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
  47. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “11CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/11CLAB.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
  48. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “10CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/10CLAB.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
  49. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “09CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/09CLAB.html?DLPage=2&DLEntries=10&DLSort=2&DLSortDir=descending
  50. Centers for Medicare and Medicaid Services, Clinical Laboratory Fee Schedule File Items, “08CLAB.” Accessed August 31, 2017 Online: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files-Items/08CLAB-b.html?DLPage=1&DLEntries=25&DLSort=2&DLSortDir=descending
  51. Centers for Medicare and Medicaid, Medicare Learning Network, “2007 Annual Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment.” Et. Al. December 2006. Accessed August 31, 2017 Online: http://wayback.archive-it.org/2744/20110902034156/http://www.cms.gov/MLNMattersArticles/downloads/MM5362.pdf
  52. United States Department of Labor, Bureau of Labor Statistics, “Databases, Tables & Calculators.” Accessed August 31, 2017 Online: https://data.bls.gov/pdq/SurveyOutputServlet