PLUGS History and Evolution

Transcription

1 Est. 2013

2 PLUGS History and Evolution Challenges High out-of-pocket cost for low-value testing, e.g., Genetics Labs bear the cost for the many patients who can t pay Issue exaggerated in pediatrics because of rare diseases PLUGS evolved beyond pediatrics and genetic tests to broad laboratory stewardship advocacy Today, we collaborate with: Adult and Pediatric Clinical Labs Lab IT and Healthcare Companies 3rd Party Payers including government

3 PLUGS Mission & Vision MISSION Improve test ordering, retrieval, interpretation and reimbursement. VISION Be #1 advocate for laboratory test stewardship. Value = Quality Cost

4 PLUGS Initiatives Case Management Tools for Stewardship Program Development National Committee for Laboratory Stewardship Insurance Advocacy

5 PLUGS Initiatives Laboratory Stewardship Program Guidance, Tools & Education to help hospital laboratories and practitioners implement their own laboratory stewardship programs. These programs improve patient safety by reducing errors, and significantly reduce laboratory testing expenses. Insurance Advocacy to guide national consensus policies related to laboratory tests and framework and guidance to build partnerships with local payors to improve efficiencies around test review and improve reimbursement outcomes. This will ultimately increase testing approval for patients who meet medical necessity criteria. Case Management service for genetic tests provided in partnership with Metis Genetics to clients who are interested in contracting additional laboratory genetic counseling services for case review. National Committee for Laboratory Stewardship (NCLS) is in the process of developing national standards and checklists for promoting and formalizing laboratory stewardship programs. The core elements will also be helpful for independent commercial clinical laboratories.

6 The Power of the PLUGS Network Our members represent over 150 institutions and counting Admera Health Akron Children's Hospital Arkansas Children s Hospital Baylor Genetics Baylor Scott & White Health-Scott & White Memorial BloodCenter of Wisconsin Blueprint Genetics Boston Children s Hospital Bronson Methodist Hospital Cardinal Glennon, SSMH Carle Foundation Hospital CentraCare Health Centura Health Laboratories Children s Healthcare of Atlanta Children's Hospital & Clinics of MN Children's Hospital of Colorado Children s Hospital of Los Angeles Children s Hospital of Philadelphia Children s Hospital of Pittsburgh of UPMC Children s Hospital of Wisconsin Children s Mercy Hospitals and Clinics Children s National Medical Center Children s of Alabama Cincinnati Children s Hospital Cleveland Clinic Cleveland Clinic Abu Dhabi Cook Children s Medical Center Dayton Children s Hospital Dell Children s Medical Center Fairview Health Services Froedtert Health GeneDx Laboratories Health Partners- Regions & Park Nicollet Hospital Intermountain/Primary Children s Hospital InformedDNA John Hopkins University Kaiser Permanente NW Regional Laboratory LAC+USC Medical Center Lancaster General Hospital Le Bonheur Children s Hospital Legacy Health Lurie Children s Hospital Chicago Mercy Diagnostics Mercy Kids Meriter-Unity Point Health MultiCare Tacoma General Nationwide Children's Hospital Nemours/Alfred I. dupont Hospital for Children Norton Healthcare Ochsner Health System Oregon Health & Sciences University Phoenix Children s Hospital Providence Health and Services Providence Sacred Heart Medical Center Quest Diagnostic Laboratory Royal North Shore Hospital Seattle Cancer Care Alliance SSM Health St. Mary's Hospital - Madison St. Louis Children s Hospital St. Lukes Health System Stanford Health Care Stony Brook University Hospital Texas Children s Hospital Tricore Reference Lab UCSF Benioff Children's Hospital Oakland University of Florida Shands University of Kansas Medical School Wichita University of Kentucky Chandler Medical Center University of Michigan University of Washington UW Health University Hospital Valley Children s Hospital Wake Forest Baptist Health Yale-New Haven Hospital York Hospital (WellSpan Health System)

7 Stewardship Program Development Tools Customized strategic assessment from the PLUGS Team Policies, procedures & communication templates that help providers reduce unnecessary testing & correct test orders Database for collecting, tracking, & analyzing cases Tool to assess the risk of errors in sendouts area Provider-satisfaction survey to solicit feedback regarding the program And much more

8 Be Connected PLUGS Sub-committees Laboratory Formulary Insurance Advocacy Weekly Newsletter Bi-monthly Member Meetings Website: Discussion Forum Office Hours/Call Center

9 Education Monthly Webinars Annual Conference Bi-monthly Member Meetings AMA Ask Me Anything

10 The savings from eliminating unnecessary genetic testing will pay for a PLUGS membership in about 5 days. The other 360 days of savings are for your health system and your patients.

11 APPENDIX 1: Case Management

12 Making the Case for Case Management 9,000 Net New Genetic Testing Products March 1 st, 2015 March 1 st, ,000 7, new testing products per day 6,000 5,000 4,000 3,000 2,000 1,000 0 Singles Panels Total March 1 st, 2017 Concert Genetics

13 Case Management from Reference Labs

14 Case Management in the Hospital Setting

15 Genetic Testing Case Management Benefits Goal of case management is to reduce inappropriate testing prevents misdiagnosis, protects patients and institutions financially, frees resources for patients who need appropriate care PRICE THRESHOLD > $2500 PRICE THRESHOLD > $ requests/week 10 requests/week Fee: $150/case review Fee: $150/case review 30% modification rate 30% modification rate $740 saved/request $470 saved/request ROI: $2220/week (-$450/week) = $1770 ROI: $4700/week (-$1500/week) = $3200 $92,040 annual savings $166,400 annual savings

16 PLUGS GeneTest Advisor Can Help!

17 GeneTest Advisor Workflow Client Lab Submits Genetic Test Request Client Lab communicates with provider Test Approved GC Case Review GC provides recommendation Test Modified If needed, GC requests more information GC communicates with provider Test Cancelled Was the correct test ordered? Is the test medically necessary Can sequential testing be considered? Are there alternate tests that are more appropriate? Has the optimal test & reference lab been selected? Is insurance preauthorization required?

18 APPENDIX 2: Insurance Advocacy

19 Insurance Advocacy Systematic Solutions to improve preauth processes / workflow Policy Creation & Improvement Standardize workflow within institution Right person doing right work Align approach with payer systems Focus on stewardship at all steps Develop rational policies using experts Distribute policies Create infrastructure to ensure policies are kept up-to-date

20 Insurance Advocacy: Systematic Solutions Standard SOP for genetic testing preauthorization Robust case review process supports efforts to obtain exemption from payer preauthorization process Strong partnership with local payer resulted in significant improvement in authorization & reimbursement for WES Streamlined process that is integrated in Cerner and improves insurance reimbursement rates, reduces time required to obtain authorization and significantly improves efficiency

21 Help Us, Help You Resources created for PLUGS members Policies Workflow Inspiring & educational talks Sample presentations to payers Insurance Preauthorization 101 > Learn More

22 A Collaboration to Develop Policies for Mitochondrial Conditions.. Mitochondrial Proposal & Funding to Develop rational genetic testing coverage policies for mitochondrial conditions Implement them in a major insurance product Promote the spread of these policies at healthcare institutions and insurance companies Funded by Seattle Children s Mitochondrial Research Guild

23 Estimated Timeline of Project ITEM Form project committee with an expert national committee of medical providers, genetic counselors, and laboratory directors. Mito test/condition policies: First 2 complete. Review and update of proposed testing algorithms for mitochondrial conditions. Form strategy for complex mito testing policies. Develop proposed policies for coverage of additional mito tests, including mitochondrial genome and nuclear mitome. Annual Committee meeting Advocate for adoption of these proposed policies by healthcare systems, insurance companies and other 3rd party payors such as employers and the government. TIMEFRAME 2 mos 4 mos 6 mos 8 mos 24 mos 12 mos 14 mos - 24 mos

24 Mitochondrial Committee Members Baylor Genetics Eric S. Schmitt, MS, PhD Blue Shield of California Stephanie Gandomi, MS, LCGC Children s Hospital of Philadelphia Kierstin Keller, MsGC Children s Hospital of Pittsburgh of UPMC Jodie M. Vento, MGC, LCGC Roxanne Acquaro, MS, LCGC Andrew McCarty, MSGC Kaiser Permanente Ashley Brazil, MS, LGC evicore Innovative Solutions Lindsey Steckling, MS, CGC University of Utah and Genome Medical Steven Bleyl, MD, PhD Invitae Tom Winder, PhD, FACMG Britt Johnson, PhD, FACMG Mayo Clinic College of Medicine Amy White, MS, CGC Concert Genetics Gillian Hooker, PhD, ScM, CGC Seattle Children s Hospital and University of Washington Russell Saneto, DO Seattle Children s Hospital Rhona Jack, PhD Darci Sternen, MS, LGC

25 Networking Strategies evicore Blue Shield Medicaid Committee and PLUGS members institutions insurance payor relations liaisons Payors Medical / Laboratory Community United Mitochondrial Disease Foundation (UMDF) National Education Conference Submit for publication in peer-reviewed journal PLUGS network Laboratories to incorporate knowledge into test coding Network with existing online resources to cross-reference Families/ Consumers UMDF Global Genes Condition-specific groups

26 PLUGS Collaboration on Exome Policy Through PLUGS, leaders from multiple labs partnered with evicore Healthcare* and other payers to create a whole exome sequencing policy. In the next year, the whole exome sequencing policy will be associated with > 9 MILLION THANK YOU to the collaborators! covered lives through multiple payers PreventionGenetics Christina Zaleski Seattle Children s Hospital Jimmy Bennett LabGC Team Le Bonheur Children s Hospital Roya Mostafavi evicore Melissa Bennett Johns Hopkins Carolyn Applegate Children s Hospital of Pittsburgh of UMPC Jodie Vento * A third party benefits manager servicing the insurance industry

27 Insurance Advocacy Goals for Systematic Solutions to improve preauth processes / workflow Share stories (both successes & opportunities) Advocate for single process that is closest to the patient Spread the message of stewardship

28 Insurance Advocacy Goals for Policy Creation & Improvement Disseminate policies Create new policies Epilepsy genetic testing Somatic genetic testing PLUGS Committee: Insurance Preauthorization / Advocacy Co-Chairs: Lindsay Zetzsche and Jodie Vento

29 APPENDIX 2: National Committee for Laboratory Stewardship (NCLS)

30 National Committee for Laboratory Stewardship MISSION Improve the quality and value of clinical care through establishing national standards for laboratory test utilization VISION To promote and enable the highest standards of effective test utilization in every clinical setting Committee members: Mike Astion Rob Carpenter Jane Dickerson Andrew Fletcher Joaquin Garcia Brian Jackson Dave Keren Joe Miles Gary Procop Ila Singh

31 Guidelines Published in J. of Applied Laboratory Medicine Transforming laboratory utilization review into laboratory stewardship: Guidelines by the PLUGS National Committee for Laboratory Stewardship Four basic elements of lab stewardship programs: Governance Interventions Data extraction and monitoring Review and improve

32 NCLS Progress and Goals Gather feedback from published guidelines Create detailed checklists

33 APPENDIX 4: Seattle Children s Hospital Lab Stewardship Program

34 Test Utilization: Four Big Problem Areas Misordering tests 2. Misinterpreting test results 3. Failure to retrieve and act on test result 4. Unnecessary cost to patients and healthcare system Source: Gandhi, TK, et al. Missed and Delayed Diagnoses in the Ambulatory Setting Ann Int Med. 2006;145(7).

35 Laboratory Test Stewardship Refers to a healthcare ethic that embodies responsible planning and management of resources Value = Quality Cost Source: National Research Council. Controlling Costs and Changing Patient Care?: The Role of UM. Washington, DC: The Natl Academies Press, 1989.

36 Lab Stewardship Interventions Gentle Posting of guidelines on the requisition Computerized reminders regarding utilization guidelines Educational lectures Consensus reference laboratory preselection for specialized testing Providing relative cost information in CPOE L E V E L S O F G U I D A N C E Medium Utilization report cards Changes to manual requisition Hiding tests in computerized provider order entry systems Periodically reviewing and updating physician preferences Strong Privileging specific tests to specialty providers Lab test formulary Utilization report card with peer or leadership review Requirement for high-level approval (e.g. Pathologist) or consultation (e.g. genetic counselor) CPOE: Hard stops Source: Baird G. The lab UM toolbox. Biochemia Medica. 2014; 24(2):

37 Case Patient Testing Analysis Review 12 y/o inpatient with hypoglycemia secondary to hyperinsulinism and associated seizures evaluated by Endocrinology Genetic testing recommended to work up possible genetic etiology vs. insulinoma Requested concurrent analysis of 8 genes including GLUT-1 Error caught on review by utilization management GC GLUT-1 (glucose transporter type-1) SLC2A1 gene De Vivo disease Order Modified GLUD-1 (glutamate dehydrogenase-1) GLUD1 gene Hyperinsulinemic hypoglycemia

38 Interventions at SCH H Y P O T H E S I S By implementing a review process for expensive genetic sendout tests, we will save $ and improve value for patients.

39 Case Review Process at Seattle Children s Order received by in-house genetics lab Sendout test request received in lab Lab GC reviews pending list sent to Lab GC / SO consultant Case Review & Adjudication 45% Additional information needed from ordering provider Approved Modified Cancelled 68% 22% 10%

40 Case Review Reduces Errors Reasons to MODIFY order Reasons to CANCEL order 61% 39% 22% n=935 10% n=425 24% 10% 14% 15% 14% 3% 11% 9% *Data collected Sept 2011 Nov 2016 N=4251 genetic cases Seattle Children s Hospital

41 Case Review ROI PRICE THRESHOLD > $2500 PRICE THRESHOLD > $ requests/week 10 requests/week 30 min./request 30 min./request 30% modification rate 30% modification rate $740 saved/request $470 saved/request ROI: $2220/week with 1.5 hr. consultant time ROI: $4700/week with 5 hr. consultant time $106,560 annual savings $225,600 annual savings

42 Surveys Reveal Positive Provider Response I really appreciate the efforts of the UM team. Given the state of our health care system we definitely need a team of experts to navigate these challenging waters! I think the lab UM team overall is doing a phenomenal job. Their services are definitely helpful, if not necessary, for genetics and non-genetic providers alike to appropriately plan and carefully select laboratory tests.

43 SCH Lab Stewardship Program Lab Test Formulary Case Review Diseasespecific Subcommittees Inpatient Interventions Insurance Advocacy

44 Case Review Mike & Jane >$2500 threshold 1-3 cases/wk Added LabGC FTE >$1000 threshold cases/wk Added LabGC FTE All genetic tests cases/wk New preauth process LabGC hired >$1000 threshold 5-10 cases/wk Implemented GeneConnect >$700 threshold cases/wk Expand preauth process 100 cases/wk 2.5FTE LabGC dedicated to UM

45 Case Review Improves Patient Safety Approved Sequential Error Rate Modified Cancelled SCH Stewardship Program aligns with hospital goals

46 Policies Hospital Lab Test Stewardship Committee Clinical Exome Sequencing Committee to review requests & develop practice standards Restrictions on genetic test orders in the inpatient setting

47 Initiatives Improve lab test formulary: Monitor MISC tests & determine when to build Guide systematic process for removing tests from the menu Example: MTHFR Notification process for providers, families & lab staff Improved patient care, reduced provider frustration, & reduced cost

48 Insurance Advocacy 2011 Patients/ Families complain about $$$ bills Oct 2014 Spring 2015 Preauth Pilot & data review Lab Stewardship Program Timeline Gold card status with one major Payer 2012 Lab UM Program established Fall 2012 Preauth Policy, but no standard process Fall 2015 New preauth/ UM workflow

49 SCH Lab Stewardship Program Summary 4565 requests reviewed Sept 2011 Nov % requests modified or cancelled GOLD Genetic Testing Preauthorization Process Gold Card SCH Goals >$1 million cost-avoidance