Lab gets a jump on pay-for-value world

“We will send a message to the provider’s inbox in the EMR, create a special queue for patient scheduling service to contact the patient to set up a follow-up appointment, and drop the results in a special folder where follow-up can be automatically doc­umented and centrally tracked by health system quality management,” Yelen says. “This is to improve patient safety. It makes sure patients get the results and protects the clinicians.”

Yet, even when patients and physicians do see the test results, greater intervention may be needed to turn around a patient’s trajectory. That’s the basis for another ambitious project at UM that seeks to use laboratory data to help improve chronic disease care. Pathology already tracks how well UM ambulatory clinics are doing in meeting population health goals. One of these metrics is the proportion of a clinic’s type 2 diabetics whose glycated hemoglobin is below the seven percent target. Such measurements are used as part of Medicare’s Physician Quality Reporting System and the National Committee for Quality Assurance’s patient-centered medical home certification standards.

“These are quality assessment tools that will be critical for pricing and credible for quality assurance,” Dr. Cote said. “It answers the question, ‘What’s your quality?’ But we not only give a general assessment. We’re now moving to provide specific alerts on outliers for appropriate intervention, identifying those patients who need better or more specialist management.”

The first target for intervention are patients whose A1c levels are well beyond goal and have stayed that way for an extended period, says Philip Chen, MD, PhD, UM’s chief of clinical pathology and vice chair of the Department of Pathology.

“With diabetes patient management, at some point they get so complicated that they need to be handed to endocrinology specialists,” he says. “This is one approach where we said, as a laboratory: We have the data, we know what the patients look like because we’re following them. How do we use our data and informatics tools to identify these patients who have been out of control for so long with primary care physicians that it’s time to go to a specialist?”

The idea, Dr. Chen says, is to notify the outlier patient’s primary care physician about the out-of-control result, encourage a change in management, and make it easy for the doctor to set up a referral to a UM endocrinologist. Also, the plan is to automatically generate a note to patients urging them to make a physician appointment regarding their A1c results. There are still technical hurdles to be overcome to put the plan into place, but UM leaders say they hope to have it up and running soon.

“We did this in collaboration with the endocrinologists at the University of Miami,” Dr. Cote said, noting that an algorithm-based protocol was developed to identify the outlier patients based on their lab results and medical histories.

While some primary care doctors may not like pathology suggesting they send their patients with diabetes elsewhere, Dr. Cote tells CAP TODAY that this is simply another step UM pathology leaders are taking to help ensure better care.

“It’s just that closing of the loop,” he says. “Let’s not miss these patients and let them fall through the cracks. If we were practicing medicine in a perfect world, and we as individuals never missed anybody, and we always saw that bad lab result and acted on it, then we wouldn’t need this. But that’s not how it works. Often, the patient comes in, then the lab results come in, and you see them back in six months and that’s when the doctor sees the lab results. Using informatics tools can help us, the pathologist-clinician partnership, deliver best practices consistently all the time.”

Another big plan in the works would help spot patients whom Dr. Cote, in his War College talk, dubbed “time bombs” in terms of their potential for needing costly care. He said it is generally understood that 20 percent of patients account for 80 percent of health care costs, while five percent tally 50 percent of medical expenses. Of that five percent, two-thirds of patients go from being low-cost patients to high-cost patients year over year.

Dr. Chen explains the point further. “The year before, essentially most of these patients were spending no money on health care,” he says. “These people don’t see the doctor and are deteriorating without anyone knowing it. And then, all of a sudden, they show up in the emergency department with an acute MI that costs $65,000 to treat.”

But how can a health system such as UM identify these patients before that call to 911 is made? That is where a predictive modeling questionnaire that asks just a few questions about a patient’s age, sex, weight, and basic medical history comes into play.

“We have about 3 million patients in our EMR database,” Dr. Chen says. “With almost every clinical visit, whether you have a little cut on the finger or a little cough and go to the clinic, we collect this kind of data. . . . Using a scoring system, we can identify the people at high risk and, looking to the EMR to see if they have existing diagnoses of diabetes along with laboratory markers, we can really narrow down the list to those people who are at high risk but don’t know about it.”

The plan is to intervene by having UM’s care coordination group reach out to these patients to encourage them to see a physician to be evaluated for diabetes or heart diseases and to help avoid a complication down the road. While the initiative makes sense from a population-health-management perspective and aligns well with the idea of accountable care, UM officials note that it also makes short-term sense under the predominant fee-for-service pay model. These are patients who, after all, might have otherwise gone untreated at UM, or might seek emergency care elsewhere.

Indeed, as is the norm for the South Florida market, UM does not participate in any Medicare or Medicaid accountable care programs. The health system does take part in Medicare and Medicaid managed care programs. Though UM has been slow to enter the brave new world beyond fee-for-service, this has not stopped Dr. Cote and his colleagues from following the Boy Scout’s motto, “Be prepared.”

“The Department of Pathology must continue to assert ownership of the entire laboratory test process and actively participate in and lead campuswide initiatives aimed at improving the quality, timeliness, cost-effectiveness, and safety of laboratory testing and patient care,” Dr. Zeitouni says.

Dr. Cote believes the steps that UM’s pathologists are taking are worthwhile regardless of the payment picture.

“Decreasing costs, controlling utilization, performing evidence-based medicine—these all are good things to do, even in the absence of being in an at-risk reimbursement model,” he says.

As scary as the move toward pay for value may be, it also presents an opportunity for pathology and laboratory medicine, Dr. Cote said.

“We know that fee-for-service is being challenged. We know those fee-for-service arrangements will go away, and when we do have fee-for-service we know those rates are only going to get lower. There is no upside in the fee-for-service rates,” he told the War College crowd. “But we do have some advantages we can bring. We have some values we can add, and we can make the laboratory important. . . . We must not be a commodity, and we have to deliver values outside what we’ve traditionally perceived as the value proposition in pathology. We have to reassess what laboratory services are and how we provide them.”

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Kevin B. O’Reilly is CAP TODAY senior editor.