Popularity of Medicare Advantage Plans fuels influx of new companies into the marketplace with anticipated enrollment of more than 22.6 million beneficiaries, or more than one-third of Medicare-eligible consumers
Provide care or pursue payment. Until recently those two common healthcare activities were mutually exclusive. But not anymore. Thanks to high-deductible health plans (HDHPs), healthcare providers today—including clinical laboratories and anatomic pathology groups—increasingly must collect full payments rather than deductibles, and directly from patients rather than from insurance companies.
This
trend is forcing doctors to become bill collectors and they’re not happy about
it. Splitting focus between caring for patients and pursuing payments is
causing stress and frustration for those in the medical community.
Collecting Full
Payments from the Insured
Physicians
and hospitals have long had processes for collecting payments from the uninsured.
However, providers must now be prepared to pursue payment from insured patients as well. This includes
clinical laboratories and pathology groups.
“Even
large medical companies with national operations are facing the problem,” Bloomberg notes. “Quest Diagnostics
Inc., the lab-testing giant, said 20% of services billed to patients in the
third quarter of this year went unpaid, costing the company about $80 million
in lost revenue.”
Helping Patients Pay
“It’s harder to collect from the patient than it is from the insurance,” Amy Derick, MD, a dermatologist who owns Derick Dermatology in the Chicago area, told Bloomberg. “If the plans change to a higher deductible, it’s harder to get the patients to pay.”
To assist her patients, Derick has implemented a procedure that
enables them to review cost estimates from their insurance providers in advance.
She finds, though, that collection rates are still slow, especially at the
beginning of the year when health plans renew and deductibles are at their
highest.
Tarek Fakhouri, MD, a Texas surgeon specializing in skin cancer, said about 10% of his patients request payment plans, delay necessary surgeries until they’ve met their deductibles, or choose alternative treatments. He had to hire an additional staff member to work with patients and their insurers for reimbursement of services.
“It’s
an unnecessary added cost to the healthcare system to have to hire staff just
to sit there on hold with insurance companies to find out what a patient’s
deductible status
is,” he told Bloomberg.
Clinical Laboratories
Also Struggle to Get Paid
It’s not only independent physicians who are
dealing with the consequences of high-deductible health plans. Medical
laboratory companies have been impacted as well.
A 2017 Kaiser Health Tracking Poll found that 43% of insured adults said they have difficulty affording their deductibles, and 29% reported having problems paying their medical bills.
Even more alarming was the number of people who said they
delayed or skipped medical care altogether due to financial concerns. The KFF
poll reported that 27% of surveyed adults admitted they had postponed getting
healthcare due to costs, while 23% said they skipped a recommended medical test
or treatment altogether. Additionally, 21% said they did not fill a
prescription due to the expense. This would apply to blood draws and other
medical laboratory visits as well.
“We certainly have a high bad-debt rate for the uninsured,” Mark Guinan, Chief
Financial Officer at Quest, told Bloomberg.
“But really the biggest driver is people with insurance. It’s their coinsurance
and their high deductibles, and they don’t always pay their bills.”
The rising costs of healthcare and health insurance in the
US continues to be a burden for everyone involved. When people allocate money
for their monthly expenses, it is clear that many are postponing making payments
for medical services.
As more Americans opt for high-deductible health plans,
healthcare professionals, as well as clinical laboratories and anatomic
pathology groups, will need new strategies for receiving payment for their
services.
The paper’s authors stand by their research and claim “requested corrections” were to protect reputations and not correct inaccuracies
Private equity companies have invested in and acquired clinical laboratories and anatomic pathology groups for the past 25 years. It’s not unusual to find private equity firms buying other medical specialty practices as well. But questioning the reasons behind such acquisitions by private corporations, or physicians’ participation in such practices is, apparently, a no go.
At least that’s what the Journal of the American Academy of Dermatology (JAAD) experienced when it published a peer-reviewed article authored by four dermatologists who wrote, “…junior dermatologists are increasingly seeking employment without ownership in private equity-backed corporate groups whose primary fiscal responsibility lies with their investors.” The authors further suggested that, “Dermatologists should be aware of this history, given the ability of corporations and private equity groups to shape the present and future of our field.”
The paper has since been restored and is available for
download from multiple scientific publication sites, as well as the JAAD site.
It should be noted that Hruza was not the only person who
expressed concerns over the voracity of the claims made by the paper’s authors.
Conversely, some dermatologists openly supported the authors’ claims on
Facebook and condemned the JAAD’s
removal of the paper, the NYT
reported.
The NYT described
outlier practices as “those that perform an unusually high number of often
rare, well-reimbursed medical procedures, and bill high amounts to Medicare.” NYT also noted that “many practices
backed by private equity firms have opened or acquired labs to process
pathology specimens, potentially another source of profit.”
The paper hypothesized that the increasing number of
equity-owned businesses in the field of dermatology is disruptive to that
profession. The authors provided evidence that the trend has emerged due to the
availability of equity funds, high student debt, and the desire for work/life
balance in younger dermatologists.
“It was interesting when we ran the numbers and we were counting how many practices with billing outliers were being acquired by private equity,” co-author Joseph Francis, MD, a dermatologist and Adjunct Clinical Professor of Dermatology, Department of Dermatology, University of Florida College of Medicine, told the NYT. “With every revision of the paper, that number kept increasing. So, it didn’t seem like an anomaly.
“It
wasn’t clear whether these investors realized that the high billing might point
to anything irregular,” Francis added. “They might have just seen that this was
a practice with booming business.”
Sailesh Konda, MD, co-author of the paper, a board-certified dermatologist and Assistant Clinical Professor of Dermatology in the Department of Dermatology, University of Florida College of Medicine, stated that he and his co-authors spent a year researching and writing the paper. After the article was submitted for review, they received constructive feedback, mostly suggesting they maintain a neutral tone.
“We strived to not use any polemic words, which could be
interpreted as bias,” Konda told the NYT.
“We decided to just deal with the facts, which would speak for themselves.”
The Complainers
The complaints, which primarily came from private equity
executives and dermatologists associated with private equity firms, included
legal threats, the NYT noted. Hruza,
MD, was among those individuals who had reservations about the article. He
specifically objected to the conclusion that “influential dermatology leaders
are being recruited to work for and promote dermatology practices backed by
private-equity firms” and stressed that “implying motivation is a stretch,” the
NYT reported.
Hruza also felt that, even though he was not specifically
named in the paper, he was easily identifiable by references made by the
authors within the article. One of the revisions requested by the journal
editor was to remove any indirect references to influential dermatologists,
including Hruza.
Research Continues
Konda said he intends to continue his research into private
equity and how it is affecting the field of dermatology. “I am passionate about
this topic,” he stated. “I realize we live in a capitalist society and money is
a driving force behind many decisions regardless of the industry. However, I
believe there has to be a balance between profit and patient care.”
The fact that the paper was removed from the journal’s
website is a notable development in the field of peer-reviewed medical
journals. Such journals are widely considered to be an important tool for
researchers and scientists to receive feedback regarding their work. In this
case, an article that was unflattering to private equity and dermatology was
removed from public view and access.
The
experience of the dermatology profession with private equity is compelling; one
those in pathology and clinical laboratory medicine should study. Private
equity companies have been investing in and acquiring clinical laboratory
companies and anatomic pathology groups for decades and will likely continue to
do so.
As hospitals and health networks struggle to implement EHRs and comply with federal regulations, medical laboratories have their own struggles fulfilling orders while dealing with physician burnout
Ever since 2009, when the federal government’s electronic health record (EHR) adoption initiatives first became law, hospital medical laboratory managers have watched their parent healthcare organizations struggle to implement behemoth information systems and comply with new federal adoption and data reporting regulations. In most instances, not entirely successfully.
Ten years and billions of dollars in incentives later, not much has improved. EHRs still lack a common interoperability protocol. And health networks still struggle to comply with federal information exchange requirements, while simultaneously engaging with Medicare data reporting schemes that treat patient data as a form of currency.
However, during that same ten years, clinical
laboratories and anatomic
pathology groups have been successful in implementing interfaces with
physicians’ EHRs to support lab test orders and results reporting.
EHR Costs and
Physician Burnout Increasing
In the current climate of acquisitions and mergers in the
healthcare industry, health networks often find themselves patching together a
mix of disparate, incompatible EHRs. All while the cost of implementing EHR
systems is increasing.
And medical laboratories that must maintain APIs
(application programming interfaces) for data exchange with these changing
systems are finding themselves between two front lines: hospitals and EHR
developers.
Tragically, there’s also growing evidence that EHRs
contribute to physician burnout, a well-known industry problem that Dark Daily reported on in multiple
e-briefings.
For example, a 2017 study published in the Annals of Family Medicine (AFM) found that primary care
physicians spend more than 50% of their time working on tasks associated with EHRs
instead of caring directly for patients.
A similar 2016 study published in the Annals of Internal Medicine (AIM)
found that “For every hour physicians provide direct clinical face time to
patients, nearly two additional hours are spent on EHR and desk work within the
clinic day. Outside office hours, physicians spend another one to two hours of
personal time each night doing additional computer and other clerical work.”
“In addition to the cost of procurement and deployment,
we’re also seeing subsequent increases in higher IT operating costs, higher
departmental operating costs. We’re also seeing lower productivity and lower
employee satisfaction,” Scott
Kolesar, Americas Health Technology
Innovation and Digital Leader for multinational professional services firm Ernst and Young, told Modern Healthcare.
This may be an understatement.
Massive Amounts of
Money
The news, however, isn’t all negative. Some health systems
are reporting efficiency gains—particularly in areas of billing—and perhaps
surprisingly, in faster clinical laboratory test turnaround times.
A recent report from Allied Market Research (AMR) seems to predict future growth in the EHR industry. “The global EHR market was valued at $23.6 billion in 2016, and is expected to reach $33.3 billion by 2023, growing at a CAGR of 5.0% from 2017 to 2023,” noted an AMR press release.
Nevertheless, the lack of true interoperability could be
responsible for a possible reduction in EHR sales as well.
“However, high cost of EHR and increase in concerns
regarding the patient data safety and security are expected to impede market
growth,” the press release also stated.
So, that’s confusing. One thing is certain, EHRs are not
going away.
Indeed, some experts suggest health networks and hospitals
view EHR implementation, maintenance, and upgrades as they would any other
investment. “If you think of EHRs like any other capital system—a phone system,
for instance—they are indispensable, so you have to just put them in your
capital plan,” Jon
Ivins, Vice President, Partner, and attorney at Hirschler Fleischer who specializes in
healthcare disputes, litigation, and regulation, told Modern Healthcare.
For better or for worse, EHRs are here to stay. Hospital and
independent clinical laboratory managers and stakeholders will want to note
this fact and become even better prepared as the EHR industry continues to
develop.
By collecting data on MS patients’ activities and abilities, parent company Roche Group hopes to create new drugs and diagnostics to combat this deadly disease
Biotechnology company Genentech, a subsidiary of multinational pharmaceutical/diagnostics company Roche Holdings AG, has developed a smartphone application (app) that enables patients with Multiple Sclerosis (MS) to monitor and track their illness in real-time and provide data and insight to their doctors.
Clinical laboratories may be able to help in the collection, storing, analysis, and reporting of the data obtained by the app. Dark Daily has reported on many mobile health apps that provided medical laboratories with similar opportunities going back to 2010.
Till now, those innovations mostly came from healthcare developers and providers looking to leverage big data for precision medicine and telemedicine. However, big pharmaceutical companies also are developing ways customers can use smartphones to track their chronic conditions and medication usage.
Seeing the ‘Big
Picture’ in Chronic Disease
Smartphone applications (AKA, mobile apps) continue to find their way into the hands of healthcare providers, patients with chronic diseases, and active people who want to monitor their health goals. Clinical laboratories have many opportunities to provide services to physicians and health networks leveraging mHealth at the point-of-care and in rural or resource-strapped regions.
Genentech’s “Floodlight” mobile app, which can be downloaded for free from Apple’s iTunes app store, is part of Floodlight Open, a global MS study that hopes to “understand the effects of MS on mental and physical functioning in a real-world setting.”
The data collected enables researchers to “see ‘big picture’ trends in the data that could help improve understanding of the disease and how it may lead to disability over time,” notes Genentech’s website.
Floodlight enables MS patients with smartphones to monitor
the progression of their illness by measuring mobility, hand motor function,
and cognition. Its passive self-monitoring also helps patients understand
fluctuations in their condition.
People using the app can choose to automatically share their
personal information with their physicians via a private ID number.
The tasks MS patients are asked to perform via the app
include:
Matching
symbols to measure how quickly the patient processes information;
Squeezing
a tomato on the screen to measure motor skills and any changes in hand-eye
coordination;
Drawing
shapes to measure speed and accuracy of hand and finger movements;
Performing
a U-turn while walking to discern ability to change direction;
Completing
a two-minute walk to measure stamina and mobility; and,
Standing
still for 30 seconds to measure posture, balance, and stability.
There are currently more than 400 MS patients using the
Floodlight app. Genentech hopes to enroll 10,000 patients in the program within
the next five years. Among the current Floodlight users, there is a 76.5%
adherence to the active tests and an 83.2% adherence to passive monitoring,
such as walking and mobility throughout the day.
When questioned about their satisfaction with the app, study
participants gave it a good to excellent rating of a 73.3 average out of 100
possible points.
Other mHealth Apps
Mobile health applications are becoming a preferred way for
diagnostics developers to gather data for their research. Many apps similar to
Floodlight are currently in development or available for free download.
One such example is FocalView by Novartis. It enables ophthalmological patients to remotely participate in clinical trials, track data about their ocular diseases, and share that information with their physicians. The app was designed to assess visual function, visual acuity, and contrast sensitivity in patients.
Another is Quitter’s Circle, a mobile app developed by Pfizer and the American Lung Association to help individuals quit smoking. The online support community currently has over 165,000 members and offers tips, information, resources, and live conversations for those interested in smoking cessation.
Applications for mHealth are gaining in popularity with both patients and healthcare providers. As the medical community strives to provide more personalized medicine and improve patient outcomes, the data obtained through real-time monitoring can assist doctors and medical laboratory professionals work together to determine the best treatment options for individual patients with chronic diseases.
SMARTChip biosensor undergoing clinical trials in England could pave way for clinical laboratories to provide additional diagnostic tests for monitoring patient progress
Emergency medical workers and mobile clinical laboratory technicians may soon have a point-of-care blood test that can identify patients having a stroke from its earliest moments. Currently being developed by Sarissa Biomedical at the University of Warwick in England, the SMARTChip is a finger-prick blood test that reportedly could cut diagnostic time to under five minutes.
Such a device could be a lifesaver for stroke victims. It would speed treatment decisions, ensure more patients receive treatment, and provide medical laboratories with an opportunity to play a crucial role in saving stroke victims’ lives and monitoring the progress of their recovery.
Development in
Detecting Stroke Lags Behind Other Major Killers
Currently, there is no quick way to diagnose a stroke. Time-consuming CT and MRI scans and other tests must be used to evaluate the type of stroke a patient has had and to rule out other possible causes of symptoms that mimic a stroke. Every minute a major stroke is left treated, the brain loses an estimated 1.9 million neurons.
SMARTChip may change that. If the portable SMARTChip proves
its diagnostic abilities in additional trials, it means stroke patients in the
future may be able to begin receiving treatment sooner, perhaps while in an
ambulance to the hospital.
The biosensor’s arrays measure compounds in blood called purines, which are produced within cells that are deprived of oxygen. During an ischemic stroke, purine levels surge when a blood clot blocks blood flow to the brain.
“Survival rates for heart attack victims have risen dramatically over the last 20 years,” noted Nicholas Dale, PhD, a neuroscientist and professor at the University of Warwick in Coventry, England. “In part, this has come from faster diagnostic tools such as ECG monitors, and rapid biochemical tests. By comparison, stroke patients have got a raw deal. No equally simple biochemical tests exist in stroke. For neuroscientists, this is depressing.”
Clinical trials at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust followed 375 stroke patients who were administered the SMARTChip blood test when admitted to the hospital and again 24 hours later.
Chris Imray, PhD, a professor and vascular surgeon at UHCW NHS Trust, told MidTECH, an organization supporting healthcare innovation in NHS West Midlands, that the device has passed its first hurdle.
“SMARTChip has been developed to address the need for rapid diagnostic tests to inform clinical decision making in the early critical period following a stroke …,” Imray stated in a 2019 MidTECH case study.
“We were able to prove that on the onset of a stroke the
brain releases a detectable quantity of purines into the blood,” he continued.
“SMARTChip is able to measure these purines in the blood and help diagnose the
symptoms of a stroke faster, which means that our patients get the care that
they need as quickly as possible.”
Dale notes the next step for the SMARTChip device will be a
“multicenter paramedic-led clinical trial in early 2019 for the evaluation of
diagnostic accuracy.”
Identifying Type of
Stroke Critical to Correct Treatment
Stroke is the fifth leading cause of death in the US, according to the US Centers for Disease Control and Prevention (CDC). Strokes are also one of the primary causes of serious disability among Americans.
“Use of rapid blood tests to identify patients with stroke is a very important and exciting area of research, and the results of this trial are awaited with keen interest by the stroke community,” Richard Perry, MD, a consultant neurologist at University College London Hospitals, told the Daily Mail.
However, Perry adds a word of caution regarding the SMARTChip’s potential, telling the Daily Mail it is unclear whether tracking purine-release levels will enable doctors to distinguish between an ischemic or hemorrhagic stroke. Most strokes (87%) are ischemic strokes, which occur when blood flow through an artery becomes blocked. This is typically caused by a blood clot in the brain. A hemorrhagic stroke happens when an artery in the brain leaks blood or ruptures.
“These two types of stroke require very different treatment
strategies, so distinguishing them early is another important goal for blood
biomarker studies,” Perry said.
According to ClinicalTrials.gov, the SMARTChip Stroke Study’s estimated completion date is June 2019. If this device ultimately makes it way to the commercial market, clinical laboratories will be looking for ways to build on its leading-edge technology with value-add testing for the monitoring of stroke patients.
These new additions to the Synaptic Health Alliance demonstrate an increasing belief among insurers that blockchain will improve the accuracy and exchange of critical healthcare data
Is blockchain technology ready for widespread use within healthcare? New developments show a growing interest among major health insurers to incorporate blockchain technology into their ongoing operations. As this happens, clinical laboratories will need a strategy, since a large proportion of all health data is made up of medical laboratory test results.
Dark Daily previously reported on how blockchain technology—with its big data and systemwide integration to existing healthcare provider directories—could alter how clinical laboratories obtain/store testing information and bill/receive payment for services rendered. We also covered how blockchain could enable insurers to instantly verify beneficiary’s coverage and attain interoperability between disparate electronic healthcare record (EHR) systems, including laboratory EHRs.
Now, insurers Aetna and Ascension have joined founding members UnitedHealthcare,Multiplan, Quest Diagnostics, Optum, and Humana in the Synaptic Health Alliance (SHA). These organizations formed SHA last year to “leverage [blockchain] technology to facilitate reaching across industry and competitive lines, creating a provider data exchange—a cooperatively owned, synchronized distributed ledger to collect and share changes to provider data,” according to the organization’s website.
What should be on the
minds of every hospital and independent medical laboratory administrator is
what will be required to engage in information exchange with such a
distributed, non-centralized provider ledger.
What is Blockchain and How Does it Apply to Healthcare and Diagnostic
Providers?
The SHA defines
blockchain as “a shared, distributed digital ledger on which transactions are
chronologically recorded in a cooperative and tamper-free manner [such as a] spreadsheet
that gets duplicated multiple times across a network of computers, which is
designed to regularly update the spreadsheet.”
Though the SHA’s efforts are still being tested, medical laboratories and pathology groups should note how Quest’s “physical relationship” with healthcare providers—as Jason O’Meara, Senior Director of Architecture at Quest Diagnostics describes it—gives the blood company an advantage. “The first day a practice opens up, they need internet, a telephone provider, and they have to have a diagnostics provider,” he told FierceHealthcare.
“Each of our organizations expends a tremendous amount of
energy and effort trying to get this data as good as it can be,” O’Meara
continued. “The challenge is—when we’re doing this in independent silos—it
leads to duplication of efforts.”
O’Meara notes that while health plans collect needed
information for months after a new practice opens, Quest often knows of these
new locations “several weeks in advance” because new locations need supplies
and the capability to order diagnostic tests from day one.
This physical-relationship advantage applies to all clinical
laboratories, because they often are the first to know—and provide supplies
to—new provider offices.
This informative video describes three ways blockchain will change healthcare. Click here to view the video or click on the image above. (Photo/video copyright: The Medical Futurist.)
Trimming Costs
through Redundancy Elimination
Federal regulations require healthcare providers and payers
to maintain frequently updated directories of care providers and services. These
directories are then used across and between health networks to determine
service availability, coverage options, and other critical elements related to obtaining
care and reimbursements.
“Who weren’t accepting new patients despite the
directory saying that they were; and,
“Incorrect or disconnected phone numbers.”
In other words, CMS found that in its own MAO directories, about
half of the information enrollees need to make important healthcare choices is either
incorrect or out of date!
The SHA intends to change that by using blockchain to create
a shared, up-to-the-minute accurate resource with interoperability between all
participating providers.
By allowing alliance participants to consolidate directory
updates, the system could eliminate silos and drastically reduce time and money
spent applying updates to directories individually at each provider.
“We want this to be a public utility that every health plan
and provider can participate on,” O’Meara
told FierceHealthcare. “There’s no
other technology we’re aware of that would allow for that type of robustness.”
Other Efforts to use
Blockchain in Healthcare
In January, HealthPayerIntelligence (HPI) outlined another strategic initiative similar to the SHA involving Aetna, Anthem, Health Care Service Corporation (HCSC), IBM, and PNC Bank to create a “health utility network” using blockchain technology “to improve data accuracy for providers, regulators, and other stakeholders, and give our members more control over their own data.”
Lori Steele, Global Managing Director for IBM Healthcare and Life Sciences, told HPI that“blockchain’s unique attributes make it suitable for large networks of members to quickly exchange sensitive data in a permissioned, controlled, and transparent way.”
She continued, “The fact that these major healthcare players
have come together to collaborate indicates the value they see in working
together to explore new models that we think could drive more efficiency in the
healthcare system and ultimately improve the patient experience.”
As medical laboratories continue to endure the financial pressures of healthcare reform, blockchain appears to offer yet another way to increase efficiencies, improve accuracy and accountability, and exchange data between disparate information systems.
While many possible uses for this technology remain in
proof-of-concept and pilot-testing phases, pathologists and medical laboratory
administrators looking to stay ahead of trends will want to keep up with
blockchain as it continues to mature.