Lab Strategies In an Era of Health Care Reform

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2 Lab Strategies In an Era of Health Care Reform Brian Jackson, MD, MS Director Medical Informatics Joe Miles, MT(ASCP), MHS Sr. Consultant Outreach Development

3 Agenda A look back at healthcare reform Healthcare reform today Impact on labs Lab opportunities Strategies that create greater clinical value

4 Fee For Service Health Maintenance Organizations Preferred Provider Organizations

5 Fragmented Care Referral Networks Fee for Service Integrated Services Accountable Care Bundled Payments

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10 Access Quality Cost

11 Model Current Examples Integrated delivery systems/networks (IDN) Geisinger Health System Kaiser Permanente Veterans Health Admin Fairview Health System Multispecialty group practices Cleveland Clinic Mayo Clinic Billings Clinic Virginia Mason Clinic Physician-hospital organizations (PHO) Catholic Healthcare Summit Medical Group Intermountain Health Care Kettering Health Network Methodist/ LeBonheur Healthcare HealthChoice Independent practice associations (IPA) Atrius Health Hill Physicians Group Monarch HealthCare Virtual physicians organizations Community Care of North Carolina North Dakota Cooperative Network Quality Health Network of Colorado

12 Key Characteristics Engagement of primary care physicians and effective specialty referrals Practice medicine according to scientific and evidence-based protocols Coordination of care within and throughout the health system Share electronic medical records and performance data Commitment to control costs and reduce waste and inefficiencies Alignment of financial incentives for all constituents Focused attention on the management of chronic illnesses Deliver care in ambulatory settings wherever possible Patient-centered culture at all levels

13 Clinical Integration: Paving the Path to Accountable Care Progression to the New Models Clinically Integrated; can begin contracting Clinical Integration Program Delivery System Improvement Financial Management and Accountability Population management: Accountable Care Organization; Bundled Payments Establish Structure & Network Information Technology Start 6-9 months 12 months months and beyond

14 HITECH Interoperability, Meaningful Use, CDS PPACA Health Insurance Exchanges, MLR, ACO

15 Lab Opportunities Pre-Analytical CLINICAL DIRECTION CPOE CDS Clinical pathways Analytical GENERATOR/ DISTRIBUTOR of clinical information Post-Analytical ANALYTICS Analysis of aggregate clinical data Integrator of clinical data

16 Strategies to Strengthen Labs Watch the Competition Tell the Story of Your Lab s Value Develop Outreach

17 Build Connectivity Lean Processes Create Cost Effectiveness

18 Understand the Big Picture Engage pathologists Develop Utilization Management Tools

19 Brian Jackson, MD, MS Medical Director, Medical Informatics Lab Strategies to Create Clinical Value

20 Lab Strategies to Create Clinical Value But we re already creating clinical value! How we can and need to do better Lessons from other disciplines Bookselling Digital music Pharmacy Bringing it all together Clinical leadership Analytics Decision support

21 Clinical Value Accurate Dx & mgmt Minimize total cost of care

22 Diagnostic Cycle MD orders test MD interprets and applies result Order and specimen submitted Lab sends report to MD Lab performs test

23 Diagnostic Cycle MD orders test MD interprets and applies result Order and specimen submitted Traditional Focus of Laboratories Lab sends report to MD Lab performs test

24 Diagnostic Cycle MD orders test MD interprets and applies result Primary Opportunities Order and specimen submitted Lab sends report to MD Lab performs test

25 How Effectively do Doctors Use Laboratory Tests? HPV as a prototypical example

26 HPV Guideline from ASCCP Women under 21 HPV testing is contraindicated Women 21 to 30 HPV testing should not be used in primary screening HPV testing may be used for evaluating certain cervical lesions (ASC-US) Women over 30 HPV testing may be used for evaluating cervical lesions and for screening If HPV and cytology negative only screen every 3 years

27 10/2003 1/2004 4/2004 7/ /2004 1/2005 4/2005 7/ /2005 1/2006 4/2006 7/ /2006 1/2007 4/2007 7/ /2007 1/2008 4/2008 7/ /2008 1/2009 4/2009 7/ /2009 Number of test orders per month from 110 hospitals and laboratories HPV Order Volumes by Age (National sample) less than 21 years years over 30 years Source: Shirts and Jackson, J Pathology Informatics

28 Number of tests Time to Repeat HPV Test following Negative Test

29 HPV, Back-of-Envelope Modeling Strategy Annual Pap alone Annual Cost (Rough estimate) $150/year Annual Pap w/hpv $250/year Pap w/hpv, 3-year intervals $83/year

30 Diagnostic Cycle MD orders test MD interprets and applies result Primary Opportunities Order and specimen submitted Lab sends report to MD Lab performs test

31 Example: Music Retailing

32 Music Retailing Today

33 Example: Book Retailing

34 Pharmacy 1980 s 2000 s and beyond Factory mindset Receive orders, process and distribute meds Professional mindset Active clinical role Oversee formularies Optimize individual med management Educate clinicians

35 Diagnostic Cycle Analytics to detect inappropriate orders User-friendly menus Order and specimen submitted Lab Formulary Committee MD orders test MD interprets and applies result Fully formatted reports Lab sends report to MD Diagnostic decision support Easy to put test in context and interpret Lab performs test

36 How Labs Can Add Clinical Value Clinical leadership Analytics Decision support

37 Clinical Leadership Laboratory Formulary Committees Visible Clinical Pathologists

38 Analytics Need to understand your doctors ordering practices Compare to: Peers National/local guidelines

39 Decision Support Doctors have questions about lab tests. Are we making it easy for them to get the answers?

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41 Summary In an ACO world, Clinical Value = Best Dx at Low $ Become clinical enterprise, not order-filling factory Need to integrate across the end user (physician) experience