Jun 9, 2017 | Compliance, Legal, and Malpractice, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology, Uncategorized
New studies show number of Americans who are unwilling to reveal private health information is growing, hindering medical technology developers
Healthcare consumers appear not only to be raising their expectations of the quality of care they receive, but also in the privacy and security of their protected health information (PHI) as well. This is an important development for clinical laboratories and pathology groups, since they hold large quantities of patient test data.
News reports indicate that, due to the increase in patient distrust about privacy and security, developers of health information technology (HIT) products that collect and transmit patient data are struggling to insert their products into the broader healthcare market.
However, there is a positive side to this trend for medical laboratory professionals. Patients’ interest in tighter security and privacy protections provides pathology groups and clinical laboratory leaders with an invaluable opportunity to inform patients on their lab’s use of cybersecurity measures and to reiterate their commitment to protecting their patients’ data.
Clinical Laboratories Can Ease Patient Fears
It’s not enough that medical laboratories promote their services and efficiencies. They also must tout the capability of their laboratory information management systems (LIMS) to protect a patient’s PHI. That’s critical because recent studies indicate high proportions of healthcare consumers are becoming increasingly wary of how their healthcare data are protected.
The graphic above taken from a 2017 Accenture survey may indicate why healthcare consumer trust in an organization’s ability to secure protected health data (PHI) has eroded so deeply. (Graphic copyright: Accenture.)
Numerous reports of data hacking and security breaches have eroded healthcare consumers’ trust. Patients are more skeptical than ever about the benefits of HIT, such as:
That’s according to a national poll conducted by Black Book Market Research of more than 12,000 consumers in the fourth quarter of 2016.
The poll aimed at exploring consumers’ adoption and acceptance of HIT. It found:
- 87% of consumers are unwilling to divulge all their medical information (up from 66% in 2013);
- 70% of Americans distrust health technology (a significant increase from 10% in 2014);
- And 57% of people who underwent actual encounters with providers’ technology (including ancillary providers, such as clinical laboratories) remain skeptical of HIT.
Even with all the bells and whistles, HIT cannot penetrate the healthcare system if people don’t adopt it, a Black Book news release pointed out.
89% of Patients Withhold Information During Office Visits
Respondents to Black Book’s poll reported being especially alarmed by their data being shared (without their acknowledgement or consent) beyond their hospital and physician. This includes:
- Pharmacy prescriptions (90%);
- Mental health notes (99%); and
- Chronic conditions (81%).
Other key findings from the Black Book poll include the fact that:
- 89% of consumers withheld health information during their 2016 provider visits;
- 93% are concerned about security of their personal financial information;
- 69% say their primary care doctor does not have the technological expertise necessary for them to feel safe divulging extensive personal information.
Missing Data Compromises Care, Analytics
An article in Healthcare IT News reported that fear of breaches is translating to consumers’ reticence to share information. And, the Black Book survey states that data analytics and population health efforts by healthcare providers could be compromised due to consumer distrust, according to a FierceHealthcare article.
“Incomplete medical histories and undisclosed conditions, treatment, or medications raises obvious concerns on the reliability and usefulness of patient health data in application of risk-based analytics, care plans, modeling, payment reforms, and population health programming,” stated Doug Brown, President, Black Book, in the news release.
“This revelation should force cybersecurity solutions to the top of the technology priorities in 2017 to achieve tangible trust in big data dependability,” he concluded.
Patients/Doctors at Odds Over Use of Patient Data
According to the Black Book poll, 91% of people surveyed who use wearable medical tracking devices believe their physician’s EHR should be able to store any health-related data they wish. However, physicians responding to the provider section of the survey stated they have all the information they need. In fact, 94% of the doctors stated patient-generated data (generated by wearables) are “overwhelming, redundant, and unlikely to make a clinical difference.”
The disconnect has led to miscommunication and frustration in the doctor/patient relationship, noted a HealthITSecurity article.
Low Health Literacy Linked to Distrust of HIT
A study published in the Journal of Medical Internet Research by the University of Texas at Austin (UT) linked skepticism of HIT with low health literacy.
People who struggle to find and understand medical information tend to also be wary of health technologies, such as wearables, patient portals, and mobile apps, noted a UT news release.
Conversely, Americans with a high degree of health literacy are more likely to use fitness trackers and online portals and view them as useful and trustworthy, UT researchers stated.
This study of nearly 5,000 Americans also explored patients’ perceptions of privacy and trust in institutions. Researchers found lower health literacy was associated with more distrust and less adoption of HIT tools.
“There is a pressing need to further the understanding of how health literacy is related to HIT app adoption and usage. This will ensure that all users receive the full health benefits from these technologies in a manner that protects health information privacy, and that users engage with organizations and providers they trust,” the researchers wrote.
Cybersecurity a Priority for Labs
Cybersecurity and wearable technologies were identified as among the three primary trends (along with Social Media) facing clinical laboratories and in vitro diagnostics (IVD) manufacturers in 2017, according to insights shared by the Diagnostics Marketing Association in a recent Dark Daily e-briefing.
Another Dark Daily e-briefing summarized accounts of ransomware and cyberattacks on hospitals and medical labs in 2016. Clinical laboratory leaders are reminded to work with provider teams and appropriate experts to determine the lab’s ability to prevent and withstand cyberattacks.
Labs may glean some ideas from these cybersecurity “2017 must-haves” shared (along with others) in a Healthcare IT News article:
- Invest in a risk assessment that makes clear exactly what needs to be protected;
- Recognize that beyond medical and billing information, high tech equipment (such as lab analyzers) need to be addressed in planning.
Medical laboratory leaders should not be shy about communicating their lab’s cybersecurity priority, investment, and actions taken to keep their patient’s PHI private and secure. That message could be just what skeptical consumers need to hear and could be well received by the lab’s patients.
—Donna Marie Pocius
Related Information:
Healthcare’s Digital Divide Widens, Black Book Consumer Survey
Healthcare Digital Divide Getting Bigger and Other Bad News from Black Book
Patients Don’t Trust Health Information Technology Effects of Patient Distrust on health Data Exchange Security
Effects of Patient Distrust on health Data Exchange Security
One in Four US Consumers Have Had Their Healthcare Data Breached, Accenture Survey Reveals
New Health Literacy Digital Divide: Low Health Literacy Connected to Distrust of Health Technologies
Health Literacy and Health Technology Adoption: The Potential for a New Digital Divide
Top 10 Cybersecurity Must-Haves in 2017
Diagnostic Marketing Association’s Global Marketing Summit Will Convene in New Orleans Just Prior to the Executive War College to Discuss Primary Trends Facing IVD
MedStar Health Latest Victim in String of Ransomware Attacks on Hospitals and Medical Laboratories that Reveal the Vulnerability of Healthcare IT
Jun 7, 2017 | Instruments & Equipment, Laboratory Instruments & Laboratory Equipment, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology, Laboratory Sales and Marketing, Management & Operations
Aging populations and increase in chronic disease fuel worldwide growth in tele-ICU care models that improve patient outcomes, reduce length of ICU stays, and save hospitals money, according to a study
There’s an interesting trend in healthcare that may prove beneficial to clinical pathologists and medical laboratory scientists. It is increased use by hospitals of remotely-monitored intensive care units (ICUs), which creates the opportunity for clinical laboratory specialists to remotely collaborate with their colleagues in real time.
This new approach in how hospitals alter how they monitor their patients’ care and organize their intensive care units is dubbed Tele-ICU. The technology uses “an off-site command center in which a critical care team [made up of intensivists and critical care nurses] is connected with patients in distant ICUs to exchange health information through real-time audio, visual, and electronic means,” according to a study published by AHIMA (American Health Information Management Association) that sought to identify the “possible barriers to broader adoption.”
This approach to emergency care from a distance employs telemedicine technology and has the potential to impact how in-house medical laboratories provide clinical testing services to hospital physicians.
Tele-ICU Gaining Foothold in Healthcare
Tele-ICUs are making speedy inroads into hospitals and healthcare systems. According to a statistic provided to Healthcare Dive by Advanced ICU Care, a provider of remote ICU monitoring services, an estimated 15% to 20% of hospitals currently use tele-ICU programs.
The use of this “second set of eyes” in ICUs is expected to grow. It is encouraged by an increasing number of studies showing:
- Improved patient outcomes;
- Reduced length of ICU stays; and
- Cost savings.
A Global Market Insights report predicts the tele-ICU market will reach $5 billion in 2023. That’s more than four times 2015’s $1.2 billion level. The rise, the report states, will be fueled by an increase in aging populations and chronic conditions such as cancer, neurological disorders, and other chronic diseases.
The graphic above illustrates the wide range of telehealth services available to hospitals for remote critical and in-home ambulatory care. To remain competitive, medical laboratories not yet engaged in providing testing services to remote care programs will need to adopt the technology. (Image copyright: Philips.)
Intermountain Healthcare’s TeleCritical Care program has paid dividends for the not-for-profit health system. Since 2014, Intermountain has introduced tele-ICUs in 12 of its 22 hospitals that have ICUs, and in five non-system hospitals. A pilot project has expanded the program to two rural critical access hospitals that do not have ICUs. Five more rural hospitals are also expected to join Intermountain Healthcare’s tele-ICU program.
“There’s a tremendous amount we can do from this location without being literally present,” William Beninati, MD, Medical Director for TeleCritical Care at Intermountain Healthcare, stated in a Healthcare Dive article.
Intermountain Healthcare’s analysis of 6,500 of its patients indicates tele-ICU implementation has enabled its community hospitals to treat patients with more complex cases and reduce mortality by 33%. An initial cost analysis was equally favorable, with a $4.4 million decrease in the cost of care provided and a $3.3 million decrease in reimbursement amounts.
“We’re seeing a rapid return on investment on a roughly one-year timeframe,” Beninati told Healthcare Dive.
Helping Hospitals Thrive in Value-based Environments
A study published in CHEST Journal in February 2017 by UMass Memorial Medical Center supports the argument for tele-ICU’s financial benefits. According to a Philips press release announcing the UMass Memorial study results, the researchers found the Philips telehealth eICU Program with centralized bed management control increased case volume by up to 44% and improved contribution margins by up to 665%, or $52.7 million.
Philips’ eICU telehealth technology (above) combines A/V technology, predictive analytics, data visualization, and advanced reporting capabilities to deliver critical information to caregivers at remote locations. (Photo copyright: Philips.)
Other investigations have recognized the value intensivist-centric models can play in improved patient outcomes, such as this 2014 HIMSS study, which compared ICU length-of-stay findings among three primary studies of tele-ICU use that were published from 2009 to 2014. The analysis found tele-ICU programs improved patient outcomes, particularly length of stays (from 6.9 days pre-intervention to 4.2 days post-intervention). And there was “strong evidence” that secondary outcomes such as ICU mortality and hospital mortality also decreased as a result of tele-ICU use.
“An ICU bed costs approximately $2 million to build, and this study demonstrates a significant increase in case volume by better utilizing existing resources,” said Tom Zajac, Chief Executive Officer and Business Leader, Population Health Management, Philips, in the Philips press release. “This shift enables care for expanding populations without having to build and staff additional ICU beds, thus helping hospitals thrive in a value-based care environment.”
Alignment of Attitudes Key to Tele-ICU Success
In a Healthcare Dive article, Lou Silverman, CEO of Advanced ICU Care, a provider of tele-ICU services, said the role of a tele-ICU differs based on a hospital’s staffing.
“If intensivists are internally staffed by the hospital, tele-ICU provides a second set of eyes—an additional layer of patient safety in partnership with the bedside team,” Silverman noted. “When intensivists are not readily present, tele-intensivists take a more active role directing patient care, including intervening in urgent situations.”
However, the physician who led the UMass study argues that successful tele-ICU programs requires an alignment of attitudes as well as technology. Craig M. Lilly, MD, Director of the eICU program at UMass Memorial Medical Center, says healthcare providers at the bedside, and those overseeing the ICU from a distance, must communicate well and collaborate on both ends of the telemedicine platform.
“If you apply the technology the way it was designed [to be applied], it can make a difference,” Lilly told mHealthIntelligence. “But if you don’t have collaboration, it’s not going to work. Then you have … relative antagonism.”
As Dark Daily has previously noted, anatomic pathology laboratories were among the first to adopt remote telemedicine models though the use of whole-slide imaging and digital pathology services. As tele-ICU becomes more prevalent, medical laboratories will have the opportunity to use their access to real-time patient lab test data to help the clinicians in tele-ICU centers better manage patient care. This would also be an opportunity for pro-active clinical pathologists to step up with consultative services that contribute to improving patient outcomes.
—Andrea Downing Peck
Related Information:
How Tele-ICUs are Giving Hospitals a Boost
Reducing ICU Length of Stay: The Effect of Tele-ICU Market Size
Tele-Intensive Care
ICU Telemedicine Program Financial Outcomes
Telemedicine Success Requires an Alignment of Incentives (and Attitudes)
New Study Demonstrates Improved Patient Flow and Financial Benefits of Philips eICU Program for Managing Critical Care Populations
Study: Tele-ICU Programs Improve Care While Providing Cost Savings
Survey Reveals US Consumers Choosing PCPs Based on Access to Telehealth Services; Clinical Laboratories Can Capitalize on This Trend
From Micro-hospitals to Mobile ERs: New Models of Healthcare Create Challenges and Opportunities for Pathologists and Medical Laboratories
Wal-Mart Developing Telemedicine Clinics in Selected Stores
Growing Cost of Telemedicine, Telepathology, and Medical Data Transmissions Is a Budget-Buster in Oklahoma
International Telemedicine Gains Momentum, Opening New Markets for Pathologists and Other Specialists
Jun 5, 2017 | Instruments & Equipment, Laboratory Instruments & Laboratory Equipment, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology, Laboratory Testing, Management & Operations
While many of the major gains promised by electronic health records (EHRs) and big data remain elusive, Geisinger Health’s Unified Data Architecture demonstrates how big data might help healthcare providers and clinical laboratories optimize care, improve outcomes, and control costs as the technology evolves
Use of big data in healthcare gets plenty of hoopla these days. Many experts predict great things as clinical laboratory test data is pooled with other patient information and demographic data. But there are many technical problems to be overcome before the full potential of healthcare big data can be translated into ways that improve the health of individuals.
Big data in healthcare is essential to the success of both precision medicine and population health management. However, without the ability to consolidate other data sources and provide intuitive ways for healthcare providers to access, analyze, and utilize the data coming from the various sources, such as clinical laboratory and anatomic pathology test results, much of the data can be underutilized or overlooked.
Medical laboratories continue to generate increased amounts of data, much of which often finds its way into electronic health record (EHR) systems and other data silos. A Harvard Business Review (HBR) report from doctors at Geisinger Health in Pennsylvania shows how this data might be used.
Consolidating Data to Create Cohesive Snapshots of Patient Health
The HBR report attributes Geisinger’s ability to utilize big healthcare data to its Unified Data Architecture (UDA). According to a Healthcare Informatics article, Geisinger’s UDA was based on Hadoop and other open source software. According to the doctors who wrote the HBR report, “… pulling meaningful data aggregated from many sources back out of EHRs has historically been vexingly complex. The potential insight from these data are limited in practice by the shortcomings of traditional data repositories.”
Geisinger’s UDA addresses two key issues the Healthcare Informatics authors see as obstacles to the expanded, easier use of big healthcare data:
- Lack of ways to deal with unstructured patient notes that do not adhere to traditional database organizational structures; and
- Data silos created when multiple departments collect data but use separate storage systems.
Using natural language processing (NLP), the UDA system can pull critical information from long-form written reports or analyses.
Big data graphic above from Nuance, developer of intelligent systems for healthcare and other industries, illustrates the challenges involved in acquiring, sifting, managing, and utilizing big data in healthcare. (Graphic copyright: Nuance.)
Geisinger’s system connects nurses on the floor, medical technologists in the clinical laboratory, and surgeons in operating rooms to the same pools of data. However, it also pulls in data from external sources, such as pathology groups, other reference or medical laboratories, and even patient-worn mobile medical devices. The HBR report states, “The integration of data from Health Information Exchanges, clinical departmental systems (such as radiology and cardiology), patient satisfaction surveys, and health and wellness apps provides us with a detailed, longitudinal view of the patient.”
Big Data Helps Healthcare Professionals Spot Future Worries
Geisinger’s Abdominal Aortic Aneurysm (AAA) Close the Loop Program—named semi-finalists in Healthcare Informatics’ 2016 Innovator Awards Program—is an example of how NLP and data collation offers benefits often overlooked with traditional approaches.
Geisinger doctors found that AAAs typically are discovered during care for another condition. Often, the conditions for which the patient seeks care are more serious than the small AAA and it isn’t mentioned. While AAAs might be noted in patient records, healthcare providers typically do not look for the data. Thus, left untreated, a AAA can develop into a serious condition that could have been prevented.
NLP enables Geisinger doctors to analyze UDA data for warning signs of AAA and create follow-up and treatment plans that might otherwise remain overlooked. According to the HBR report, this program has led to 12 lifesaving operations to date that might otherwise have been missed.
Real-Time, Comprehensive Updates Offer Big Gains in Combating Sepsis
Big healthcare data shows potential for treating many life-threatening conditions, such as sepsis. Prompt treatment is essential to positive outcomes in sepsis cases. Physicians at Geisinger use the company’s UDA data to both pinpoint when sepsis indicators appeared, as well as to consolidate data from across a patient’s care continuum to optimize treatment.
Instead of sorting through disparate streams of data from various operational areas and reports, data is combined into a consolidated dashboard featuring real-time physiologic metrics, such as:
- Blood pressure measurements;
- Blood culture results; and
- Antibiotic administration.
The HBR report notes, “By tracking, aggregating, and synthesizing all sepsis-patient data, we expect we will be able to both reduce the incidence of hospital-acquired sepsis and improve its management.”
Using Big Data to Track Surgical Supply Chains and Waste
With the unique cost and outcome aspects of each surgical case, and the differences in payouts from payers, creating big data for tracking the efficiency and waste of surgeries is difficult without a big picture view of the factors. Using their UDA, Geisinger can track the exact supplies used in an operation along with the outcome, recovery, cost, and follow-up data related to the procedure.
“This gives surgeons and administrators an important new view of how they perform comparatively from both a cost and outcome perspective,” noted the HBR report’s authors.
Big data is still a developing technology. Nevertheless, programs such as at Geisinger Health offer useful lessons into how data streaming from clinical laboratories, pathology assays, operating rooms, intensive care units, and even personal health-tracking devices might be combined to provide a unified patient record. That would make it possible for caregivers to use analytical tools to tailor each patient’s care and treatment to his or her specific conditions and physiology.
—Jon Stone
Related Information:
How Geisinger Health System Uses Big Data to save Lives
How Unleashing Trapped Clinical Data Has Saved Lives at Geisinger Health System
The 2016 Healthcare Informatics Innovator Awards Program: Semifinalists
Unified Data Architecture Allows Patient Insights
At Geisinger Health System, Advanced Analytics Pave the Way to Better Outcomes
New Geisinger Initiative Digs Deep into the Wild, Unstructured World of Big Data
Geisinger Reaps System-wide Benefits with Big Data Approach
Jun 2, 2017 | Coding, Billing, and Collections, Laboratory Operations, Laboratory Pathology, Laboratory Testing, Management & Operations
Aetna expects 75% to 80% of its medical spending will be value-based by 2020
Many pathologists and medical laboratory executives may be surprised to learn how quickly private health insurers are moving away from fee-for-service payment arrangements. According to Forbes, the nation’s largest health insurance companies now associate nearly 50% of reimbursements they make to value-based insurance initiatives.
This is a sign that value-based managed care contracting continues to gain momentum. And that interest remains strong in this form of reimbursement, which associates payment-for-care to quality and rewards efficient providers.
UnitedHealth Group (NYSE:UNH) and Aetna (NYSE:AET) are the fastest adopters of value-based payment models, with Anthem (NYSE:ANTM) close behind, the Forbes article noted.
Moreover, UnitedHealth and Aetna intend to increase their percentage of value-based contracts. For example, Aetna, which now ties 45% of its reimbursements to value, says its goal is to have 75% to 80% of its medical spending in value-based relationships by 2020, Healthcare Finance News pointed out.
These compelling data should motivate pathology groups and medical laboratory leaders to adopt strategies for value-based contracting. That’s because payment schemes based on clinical laboratory performance will likely grow quickly, as compared to traditional fee-for-service reimbursement models, which are being phased out.
Aetna: Lowering Acute Admits
Aetna and other insurance companies are rewarding in-network hospitals, medical laboratories, and physicians who help them keep their customers healthy.
“One way we measure our success is by how well we are able to keep our members out of the hospital and in their homes and communities,” stated Mark Bertolini, Aetna’s Chairman and Chief Executive Officer, in the Healthcare Finance News article.
“I think value-based contracting is going to continue to be encouraged by even the current [federal] administration as a way of getting a handle on healthcare costs,” he continued. In fact, Aetna lowered acute admissions by 4% in 2016 and reduced readmission rates by 27%, reported Healthcare Finance News.
UnitedHealth: Outpatient Care a Focal Point
Meanwhile, UnitedHealth Group spends $52 billion (or about 45%) of a $115 billion annual budget on value-based initiatives, Forbes noted.
In March, UnitedHealth Group joined Optum, its health services company, to Surgical Care Associates, an ambulatory (outpatient) surgery provider with 205 sites nationwide.
As surgical cases (such as total joint replacements) continue their migration to ambulatory surgery center sites, UnitedHealth Group expects this merger to offer value to patients, payers, and physicians, a statement pointed out.
“We’ve been able to drive down on a per capita basis inpatient, and inside that we’ve focused a lot in those early years around the conversion of inpatient to outpatient. And I think this is sort of the continued evolution as we focus more on the side of service to how do we get that outpatient into the ambulatory setting,” said Dan Schumacher, UnitedHealthcare Chief Financial Officer, in the Healthcare Finance News story.
The graphic above is from a slide presentation given by Eleanor Herriman, MD, MBA, Chief Medical Informatics Officer with Viewics, a provider of big-data management solutions for hospitals and clinical laboratories. Because of healthcare’s drive toward value-based payment models, clinical labs must focus on “operational efficiencies” and “testing utilization management,” and be prepared to “demonstrate value of testing to payers and health organizations,” Herriman’s presentation notes. (Image copyright: Viewics, Inc.)
Also, in 2016, OptumRx (pharmacy benefit management) announced partnerships with Walgreens and CVS Pharmacy. The joint pharmacy care agreements are intended to improve patient outcomes, connect platforms for health data leverage, and address costs of care, UnitedHealth Group stated in dual press releases (Walgreens and CVS) announcing the strategic partnerships.
Anthem: Planning for 50% Value-Based Care by Next Year
For its part, Anthem now has 43% of its operating budget focused on shared savings programs. Furthermore, the company reportedly has a plan to associate at least 50% of its budget with value-based care by 2018.
“When you combine this with our pay for performance programs, we will have well over half our spend in collaborative arrangements over the next five years,” Jill Becher, Anthem Staff Vice President of Communications, told Forbes.
Clinical Laboratories Need Value-Based Strategy
The rise of value-based care should motivate clinical laboratory leaders to create and implement novel and responsive strategies as soon as possible. Without a focus on value, labs could be denied entry into provider networks.
In a Clinical Laboratory Daily News article, Danielle Freedman, MD, noted that value-based clinical laboratory strategies could entail the following:
- Working with physicians on appropriate retesting intervals;
- Adding clinical decision support tools; and
- Vetting testing requests.
Freedman is Director of Pathology at Luton and Dunstable University Hospital NHS Foundation Trust in the United Kingdom (UK).
Clinical laboratory executives and pathology practice administrators should take note of the fact that some large healthcare insurers already have nearly half of their reimbursement under value-based contracts, with plans to grow their investment in value-based relationships in the future.
Already facing the challenges of narrowing healthcare networks, it is imperative that lab leaders also get their lab team to focus on value (and not just volume). It can be expected that, as health insurers look to partner with labs in different regions and communities, they will want medical laboratories that are creative in developing high-value diagnostic testing services.
—Donna Marie Pocius
Related Information:
United Health, Aetna, Anthem Near 50% of Value-Based Care Spending
Aetna, UnitedHealth Show Increasing Appetite for Value-Based Care Contracts
Aetna Premier Care Network Plus Helps Reduce Costs for National Employers and Members Through Simple Access to Value-Based Care
Surgical Care Associates/OptumCare to Combine
OptumRx and Walgreens to Expand Consumer Choice, Reduce Costs, and Improve Health Outcomes
OptumRx and CVS Pharmacy to Expand Consumer Choice, Reduce Costs, and Improve Health Outcomes
“V” is for Value, Not Volume
Advanced Laboratory Analytics—A Disruptive Solution for Health Systems
May 31, 2017 | Coding, Billing, and Collections, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology, Laboratory Testing
As the latest attempts to replace the Affordable Care Act (ACA) generate increased debate over protections for pre-existing conditions, Kaiser Family Foundation highlights that using pre-ACA underwriting guidelines would result in an estimated 52-million Americans unable to obtain coverage
With the American Health Care Act (AHCA) clearing the House on the way to the Senate, the public and media are scrutinizing key points. One highly-contested topic is insurance availability for people with pre-existing conditions.
Unfortunately, as most pathologists and medical laboratory managers know, media coverage—whether from the left or the right—tends to play up points that are sensational and resonate with their core audiences, but often fail to provide a full and accurate picture of the subject being covered. Thus, it is refreshing when useful information and insights about aspects of healthcare in America are presented in a fair and measured way.
Biased media coverage is certainly true on the issue of health insurance coverage for individuals who are considered to have pre-existing conditions. However, as a December 2016 Kaiser Family Foundation (KFF) study highlights, protections for pre-existing conditions were not always guaranteed. In fact, if insurers currently used the medical underwriting practices in place prior to implementation of the Patient Protection and Affordable Care Act or ACA (also known as Obamacare), the study estimates that 52-million adults under the age of 65 would likely be denied coverage on the individual market.
According to US Census Bureau figures, at the start of 2017 there were 324-million Americans. Using KFF’s figures, this means that 16% of the population are considered to have pre-existing conditions.
Who is Impacted by the Individual Market?
KFF was quick to point out that many of the 52-million people with pre-existing conditions have always qualified for insurance through their employer or a public program such as Medicaid. The foundation’s estimates show that in 2015, only 8% of the non-elderly population relied on individual market insurance plans, such as those plans offered on the ACA healthcare exchange.
The graph above shows the percentage of American’s with pre-existing conditions who “most likely” would have been denied insurance in the Individual Marketplace prior to the Affordable Care Act (ACA). According to the Kaiser Family Foundation (KFF), while the proposed American Health Care Act (AHCA) does not enable insurance companies to deny coverage for these conditions, coverage premiums could increase if a state seeks a community rating waiver. (Image copyright: Kaiser Family Foundation.)
For many patients, obtaining health insurance through individual plans is often temporary and driven by a life event, such as job loss, divorce, marriage, or reaching the threshold of an age bracket for coverage through other programs. However, for some individuals—such as the self-employed, low wage earners, or early retirees—the individual market is the only option for obtaining health insurance. For this population, pre-ACA underwriting made coverage difficult to obtain and more expensive for patients with pre-existing conditions.
Pre-Existing Conditions Cover More than Just Conditions
Study authors also note that the estimate of 52-million individuals considered to have pre-existing conditions is conservative due to other factors considered in the underwriting process. Insurance companies also based denial and uprating on a range of other factors—such as:
- Prescription medication;
- Doctor visits or procedures;
- Mental health conditions; and
- Family history.
They list a table of 30 conditions, including pregnancy and eating disorders, that might qualify as a pre-existing condition along with a list of 40 medications that might also result in a denial of coverage.
Despite the already growing list of reasons for insurance denials, there’s yet another list with job occupations that might result in ineligibility. This means that even healthy individuals could find themselves without coverage due to how they earn their income.
Neither medications nor professions were considered in KFF’s estimates due to a lack of data.
Uncertainty and Instability in Individual Market Pricing
A 2001 KFF report showed yet another hurdle faced by enrollees in the individual market.
In this KFF study, researchers created seven hypothetical applicants and compared their conditions to the underwriting practices at major insurance companies. Even if applicants cleared the underwriting process, the premiums offered by the various insurance companies differed greatly. Prices for each applicant fluctuated between hundreds and thousands of dollars per month when coverage was available. Benefits changed between plans as well, with many plans exempting coverage for pre-existing conditions.
Even with insurance, coverage for maternity care, prescriptions, or mental health fell behind the options available through most group plans. Yet, these conditions are some that might facilitate the events mentioned in the 2016 study for entering the individual market.
In the study’s conclusion, the authors found, “Insurance carriers seek to avoid covering people who have pre-existing medical conditions, and when they offer coverage, often impose limitations on the coverage they sell. This can price insurance out of the reach of many consumers in poor health or create significant gaps in coverage that could result in being underinsured.”
Decreased Demand for Clinical Laboratory Tests
Both studies show similarities to many of the concerns cited for the new AHCA. Time Magazine recently published a list of pre-existing conditions under the new proposal. The list bears striking similarity to the list offered in the 2016 KFF study. Speaking with Time, Cynthia Cox, Associate Director at KFF said, “There are plenty of other conditions, even acne or high blood pressure, that could have gotten people denied from some insurers, but accepted and charged a higher premium by other insurers.”
If fewer people can access affordable preventative care, prescriptions, and medical laboratory services, disease diagnosis is delayed. In a 2013 KFF study into the impact a lack of insurance has on healthcare, study authors noted, “Consequently, uninsured patients have increased risk being diagnosed in later stages of diseases, including cancer, and have higher mortality rates than those with insurance.”
Supporters of the proposed AHCA legislation are quick to point out that it does not eliminate protections for people with pre-existing conditions. It simply provides a process for state governments to provide an alternative solution to the federal framework and regulations.
Regardless of the outcome, KFF’s studies make it clear that a decrease in access to insurance means patients skip medical procedures they do not see as essential or cannot afford. This could result in decreased demand for screening and prevention diagnostics, such as those offered by pathology groups and clinical laboratories.
—Jon Stone
Related Information:
An Estimated 52 Million Adults Have Pre-existing Conditions That Would Make Them Uninsurable Pre-Obamacare
50 Health Issues That Count as a Pre-existing Condition
The Uninsured a Primer 2013 – 4: How Does Lack of Insurance Affect Access to Health Care?
How Accessible Is Individual Health Insurance for Consumers in Less-Than-Perfect Health?
GOP Health Bill Leaves Many ‘Pre-existing Condition’ Protections Up to States
Key Facts About the Uninsured Population
Gaps in Coverage Among People with Pre-Existing Conditions
May 24, 2017 | Compliance, Legal, and Malpractice, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology
All medical laboratory companies and hospitals following GAAP must comply as early as 2018 and 2019; revenue and profit impact can be either beneficial or negative
There is a big change coming to clinical laboratory companies, hospitals, and other providers that report their organization’s financial performance under Generally Accepted Accounting Principles (GAAP). Such organizations will need to assess their contracts in a different way to comply with the upcoming implementation of the Financial Accounting Standards Board (FASB) ASC 606: Revenue Recognition Standard.
Simply said, ASC 606 makes fundamental changes in the way all contracts must be analyzed and reported each quarter. Every lab company and organization that follows GAAP in their financial rules, and which is audited by an outside CPA firm, must comply with ASC 606. Moreover, when your lab company undergoes an outside audit, the auditor will verify that all contracts are being handled according to the requirements of the FASB ASC 606. (more…)
