Historically the lab’s focus has been on the quality of analytical performance, volume of activity, and cost of delivery. If results were accurate and delivered in a timely and cost-effective manner, the lab had fulfilled its function. But it is more complicated than that in the current—and future—healthcare environment.
Laboratories must use new approaches to demonstrate value. Those approaches include collaboration with administrative, medical, and information technology leaders to help physicians quickly and accurately diagnose patients, improve patient outcomes, and reduce the cost of care.
Changing times for physician reimbursement
In October 2016, the Centers for Medicare and Medicaid Services (CMS) released the final rule for the Medicare Access and CHIP Reauthorization Act (MACRA), a landmark law that replaces the sustainable growth rate formula in determining physician payments under Medicare Part B.
In 2017, physicians begin reporting under a Quality Payment Program. This program is focused on moving the payment system to reward high-value, patient-centered care. There are two pathways for provider participation in MACRA’s Quality Payment Program: the Merit-Based Incentive Payment System, or MIPS, and the Advanced Alternative Payment Model, or Advanced APM.
The Merit-based Incentive Payment System (MIPS) is a new program for Medicare-participating clinicians that will make payment adjustments based on performance on quality, cost, and other measures, and will consolidate components of three existing programs—the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive. The results of physicians’ reporting in 2017 will affect their reimbursement in 2019.1,2 The Advanced Alternative Payment Models (APMs) are a set of risk-sharing programs, some similar to Accountable Care Organizations (ACOs), created by CMS. APMs are also measured on quality of care, patient outcomes, and cost of care.
The laboratory’s role in general
The ultimate role of the laboratory has always been to deliver results that enable clinicians to improve their diagnostic and therapeutic decisions and thus improve patients’ outcomes. In the current environment, however, labs must go beyond simply enabling clinicians. Somewhere within the healthcare organization, there should be a group or an IT system that does the analyses so that clinicians can easily, quickly, and visually identify patients who require therapeutic changes or are not following a prescribed treatment plan.
You may be thinking “but that isn’t the lab’s job.” But in healthcare today, that is everyone’s job.
A good example is chronic disease management. According to the U.S. Centers for Disease Control and Prevention (CDC), chronic diseases are responsible for seven of 10 deaths each year, and treating people with chronic diseases accounts for 86 percent of our nation’s healthcare costs.3 More than 20 percent of healthcare spending is for people with diagnosed diabetes.4
Laboratories can contribute to chronic disease management by identifying laboratory data that indicates care gaps, and monitor risk factors by analyzing and tracking laboratory results.
Under MIPS, one of the quality measures that physicians report for diabetes is “Hemoglobin A1c Poor Control.” This measurement is defined as the percentage of patients from 18 to 75 years of age with diabetes who had hemoglobin A1c > 9.0 percent during the measurement period. In a clinical setting, this measure (> 9.0 percent) would normally indicate that the patient is not adhering to the recommended therapy or needs therapy revisions.5
There are many other quality measures that rely on laboratory results. These can be found at: https://ecqi.healthit.gov/ep/ecqms-2016-reporting-period.
The lab’s role regarding information technology
Since the introduction of Meaningful Use Incentives in 2012, most physicians have acquired some type of EHR system. Unfortunately, not all EHR systems are created equal. Some are very full-functioned and provide tools to automatically identify (staying with diabetes as an example) patients that have A1cs that require attention or flag patients who have not followed treatment plans, such as having blood drawn. Some EHRs do not have these features, however, and it can be a very laborious process for a physician practice to get this information.
If data is pulled from a data base at the end of a reporting period only for the purpose of reporting QA measures to CMS, it has no effect on patient outcomes. Physicians need information in real time, or at least weekly reports.
Given that 70 percent of the data stored in the EHR is laboratory data, laboratories are well positioned to provide innovative solutions to connectivity and interoperability. If real-time reports are not possible within the physician’s existing infrastructure, the lab can generate them.
How? Start with a small pilot project of physicians who have a large number of diabetic patients, and develop an action plan.
Elements of a plan
What will such a plan consist of? Here’s a possible template for how you might proceed:
Gather data. Meet with a representative sample of your physicians to understand their level of access to information—what they currently have, and what they need. Be sure to include physicians on different EHR platforms.
If there is an unmet provider need, move on to meeting within your organization. Find out what is being done, future plans, and what is possible. Meet with IT management to make sure the needs are well understood and represented during budgeting cycles. Make sure they understand why you need it. Help with preparing the presentation, or, better yet, get invited to the meeting if possible.
Other allies and mentors within your organization could be the Chief Medical Officer, Care Coordinators, ACO Coordinator, wellness programs, community outreach initiatives, etc.
Create a management proposal. After your meetings you will have a better understanding of what is important to your clients, both internal and external, and what gaps they are
experiencing.
Deliver clear, succinct, fact-driven ideas for solutions to the problems you have identified. Focus on how those ideas can save healthcare dollars or improve patient outcomes.
Monitor and report monthly. Monitor the solutions you have in place and update results routinely. Conduct informal satisfaction surveys so you can make improvements. Advertise. Tell the physicians and your management what you are doing to help with chronic patient management and what results you have experienced to date. Throughout this process you will probably uncover opportunities for Outreach business. Outreach is a good way to add revenue and use excess capacity in the lab.
Assist with therapy compliance. If your lab has received a lab order, or the patient has a standing order but hasn’t been in for the draw, send an e-mail to remind him or her. The patient and the physician will see this as a service. If the patient utilizes a family member or caregiver, the e-mails should go to that person. (Collect this information on their first draw.) If possible, let patients make appointments for draws and send reminders one or two days prior. They are much more likely to come in if they have an appointment and have received a reminder.
Engage the patients. Laboratories can help engage patients by sharing test results directly with them. Test results should be accompanied by historical trending graphs and information that helps patients understand the implications of the results. This information can be valuable for patients as they discuss test results with treating physicians and determine if action needs to be taken.
This method of distributing lab test results is routine for national reference laboratories, but often lab results from health systems and community laboratories reside only in physician EHR patient portals. High-risk patients often have multiple physicians and therefore multiple locations for their laboratory results. This approach complicates patients’ access to their lab results and often leads to duplicate testing.
Healthcare reimbursement has been in a state of flux for many years and will continue to be for many more. Remember this quotation from Charles Darwin: “It is not the strongest or the most intelligent who will survive but those who can best manage change.”
Become part of the solution—and build value for your laboratory.
REFERENCES
- Centers for Medicare and Medicaid Services. The Quality Payment Program Overview Fact Sheet. https://qpp.cms.gov/docs/Quality_Payment_Program_Overview_Fact_Sheet.pdf.
- Ellison A. 100 things to know about Medicare reimbursement. 2017. Becker’s Hospital CFO. www.beckershospitalreview.com/finance/100-things-to-know-about-medicare-reimbursement-2017.html.
- U.S. Centers for Disease Control and Prevention. Chronic disease prevention and health promotion. https://www.cdc.gov/chronicdisease/.
- U.S, Centers for Disease Control and Prevention. Diabetes: Working to reverse the U.S. epidemic at a glance 2016. https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm.
- eCQI Resource Center. Diabetes: HbA1c poor control. https://ecqi.healthit.gov/ep/ecqms-2016-reporting-period/diabetes-hemoglobin-a1c-poor-control.
Linda Newman is the Director of Marketing and Strategic Projects for CareEvolve. Linda’s prior experience includes senior management positions in both start-ups and Fortune 100 corporations specializing in market assessment, product development, launch and support of technology products and services in the healthcare marketplace. She has also managed the chemistry laboratory of a 1200-bed hospital. She holds a BS in Medical Technology and is ASCP certified.
