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Shaping the Future of Healthcare | www.thewrightcenter.org
Point of Care Testing for Enhancing Patient Centered Planned Care Delivery
Linda Thomas-Hemak, MD The Wright Center for Primary Care
PAFP Community Regional Lecture Series October 2, 2013
Shaping the Future of Healthcare | www.thewrightcenter.org
Learning Goals and Objectives
• Review Availability, Advantages , Disadvantages and Challenges of POCT.
• Describe how POCT for HbA1c and Lipids can contribute to improved team based planned care delivery in the patient-centered medical home.
• Demonstrate a plan for effective, affordable implementation of Point of Care HbA1c and Lipid testing, including factors such as staff buy-in and effective use of Health Information Technology.
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT Relevance
• Care emphasis is shifting toward prevention and early detection of disease, as well as effective, facilitated self-management of multiple chronic conditions with development of low-cost technologies for POCT.
• With miniaturized devices and wireless communication, doctors’ care for patients will change dramatically, and the role patients take in their own health care will increase.
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Shaping the Future of Healthcare | www.thewrightcenter.org
Definition and Aim of Point Of Care Testing
• Point-Of-Care Testing is defined as testing at the patient encounter in whatever venue patient care is delivered.
• The aim of POCT is to accelerate diagnostic and therapeutic processes.
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT Empowers Providers and Patients• Promotes evidence based planned care at every visit.
• Potential to address compliance, significantly impact health care delivery, enhance outcomes and reduce health disparities.
• Enhances the shift to predictive, personalized and preemptive medicine with the development of portable diagnostic and monitoring devices.
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Shaping the Future of Healthcare | www.thewrightcenter.org
Implementing POCT• Obtain leadership buy in to coordinate POCT
program in everyday workflow.• Understand POCT methodology and economics.• Financial modeling (Can we effort it?).• Define POCT role specific, team based work flow.• Keep it integrated in EMR MU and Lab interfaces.• Be certain lab orders are accommodated to avoid
duplicated testing and denied service coverage. • Implement and Evaluate.
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT “Lean” Benefits• Rapid turn around time for diagnosis and management
planning• Patient convenience• Reasonable cost• Improved patient planned care provided• Empowered patient self management• Improved office workflow through increased testing
efficiency and less call backs• Reduction of length of stay in ER venues• Reduced ER and Hospital referrals
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Shaping the Future of Healthcare | www.thewrightcenter.org
Additional POCT Advantages
• Small sample volume• Portable devices with wide menu of analytes• Unprocessed specimen• Ability to provide laboratory testing in a wider variety
of sites or circumstances• Reduced potential for sample deterioration
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT Disadvantages• Implementation is challenging and must be strategic.• Not all methods are appropriate for diagnosis or
monitoring treatment.• Kits/devices may not be FDA approved for all uses of a
similar test in central laboratories.• Different methodology, reliability, and precision• Variable coverage and affordability• Staff time and training• Staff inappropriate use outside of intended use or policy• Costs of specimen mistakes
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Shaping the Future of Healthcare | www.thewrightcenter.org
Affordability and Value : Complex POCT Economics
• Staffing, training and visit time • ↓ Call backs but potentially ↓ # of clinic visits • More efficient and potentially more aggressive chronic disease management• Less inappropriate Rx• Potentially enhanced patient self management• Fewer unnecessary ER visits and admissions • ↓ ER and Hospital LOS• ↓ blood and blood product use• Potentially enhanced outcomes and QOL
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT Improved Outcomes Examples
• Faster diagnosis and treatment decision making: Chest pain, Drug O/D
• Improved adherence to Rx: Diabetes & Glucometers• Faster therapeutic optimization : Anticoagulation• Reduced re-operation rate: Parathyroidectomy (with
rapid point-of-care PTH assays)• Improved patient satisfaction: ↓travel,
↓cost,↑ownership of diagnosis• No validated primary care health outcomes yet
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT Economics: CostCost must look at the whole process of patient care,rather than just the cost of an individual POCT methodvs. laboratory test methods.– Management, billing and HIT plans– training testing personnel – labor to process/analyze specimens– maintaining equipment, annual reagent/controls– depreciation costs– state licensing for volume and test complexity– proficiency programs for testing performed.
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT Cost Effectiveness• Many studies show POCT for various applications is a
useful complement to conventional laboratory testing. • POCT should not be viewed as a significant profit
generator. • The true value is lean improvement in care provided,
patient satisfaction with their healthcare and possibly outcomes.
• Future utilization will depend not only on technical advances, but also on enhancement in costs and reimbursement, as well as transformation from a volume driven to value based payment system.
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Shaping the Future of Healthcare | www.thewrightcenter.org
Available POCT
• Cardiac markers• Drug/toxicology• Hemoglobin A1c• INR• Heparin• D-Dimer for VTE• Magnesium & Lactate• Lipids
• Transcutaneous bilirubin• Micro-albumin, Creatinine• HIV• RSV, Influenza• Helicobacter pylori• Other bacteria• Urine dip tests including
pregnancy
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT We Utilize
• Sugar• Hg A1C • Lipid Profile• INR• Urinalysis and Pregnancy test• Lead and H&H• Rapid Strep• RSV• Rapid Flu A/B
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT Precision for HbA1c and Lipids
• Comparison studies to reference labs are standardized and available
• Scatter Plots useful• Correlation Coefficients > 95%• Correlation Variables < 2%
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Shaping the Future of Healthcare | www.thewrightcenter.org
HbA1c POCT Volumes All Patients
Total tests performed (11/1/12 – 4/30/13)• # HbA1c on All Patients (DM, Pre-Diabetics, PCOS,
Suspected diabetics) = 496• # HbA1c done on All Patients by POCT = 207• 42 % of all HbA1cs were performed in house for the
entire population
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Shaping the Future of Healthcare | www.thewrightcenter.org
HbA1c POCT Volume of Diabetic Patients
Total tests performed (11/1/12 – 4/30/13)• # HbA1c on DM Patients Total = 312• # HbA1c on DM Patients done by POCT = 174• 56 % of all HbA1cs were performed in house
for the diabetic population
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Shaping the Future of Healthcare | www.thewrightcenter.org
Lipids POCT Volumes All Patients
Total tests performed (11/1/12 – 4/30/13)• # Lipids on All Patients = 1136• # Lipids done on All patients by POCT = 80• Only 7% of all Lipid panels were performed in
house for the entire population
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Shaping the Future of Healthcare | www.thewrightcenter.org
Lipids POCT Volumes Diabetes Patients
Total tests performed (11/1/12 – 4/30/13)• # Lipids done on DM Patients Total = 225• # of Lipids done on DM patients by POCT = 44• 20% of all Lipid Panels were performed in
house for the diabetic population
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Shaping the Future of Healthcare | www.thewrightcenter.org
Patient Volume for HbA1c & Lipid POCT
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42%
56%
7%
20%
58%
44%
93%
80%
0%
20%
40%
60%
80%
100%
120%
HbA1c (All Patients)
HbA1c (Diabetic Patients)
Lipid Panel (All Patients)
Lipid Panel (Diabetic Patients)
Patients with testing done OFFSITEPatients with testing done POC
Shaping the Future of Healthcare | www.thewrightcenter.org
How HIT Can Promote Affordability and Value• POCT device costs and insurance checklists for
covered services• POCT affordability reports can track service counts,
charges and receipts• DM/HM Alerts can reflect coverage eligibility• Integrating with EMR Lab interfaces can optimize
tracking• Customized EMR lab orders avoids duplicate tests• Inventory reconciliation can capture lost charges
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Shaping the Future of Healthcare | www.thewrightcenter.org
POCT CHECK LIST OF WCPC
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87880-Strep Allowance CostMedicare $15.13 $1.87 $13.26 Profit
MA products $6.30 $1.87 $4.43 ProfitGeisinger $12.31 $1.87 $10.44 Profit
Blue Shield $15.29 $1.87 $13.42 ProfitFirst Priority Life $11.76 $1.87 $9.89 Profit
81025_Pregnancy Test Medicare $8.70 $1.00 $7.70 Profit
MA products $4.00 $1.00 $3.00 ProfitGeisinger $7.07 $1.00 $6.07 Profit
Blue Shield $7.83 $1.00 $6.83 ProfitFirst Priority Life $6.47 $1.00 $5.47 Profit
87807-RSVMedicare $16.49 $11.36 $5.13 Profit
MA Products $12.31 $11.36 $.95 ProfitGeisinger $12.31 $11.36 $.95 Profit
Blue Shield $11.89 $11.36 $.53 ProfitFirst Priority Life $15.00 $11.36 $3.64 Profit
87804-Rapid Flu A/BMedicare $16.49 x 2 = $32.98 $12.50 $20.48 Profit
Ma Products $11.35 x 2 = $22.70 $12.50 $10.20 ProfitGeisinger $12.31 x 2 = $24.62 $12.50 $12.12 Profit
Blue Shield $14.84 x 2 = $29.68 $12.50 $17.18 ProfitFirst Priority Life $11.76 x 2 = $23.52 $12.50 $11.02 Profit
Shaping the Future of Healthcare | www.thewrightcenter.org
POCT CHECK
LIST
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80061-Lipid Profile ALLOWANCE COSTMedicare $18.42 $10.80 $7.62 Profit
Ma Products $14.00 $10.80 $3.20 ProfitGeisinger $14.98 $10.80 $4.18 Profit
Blue Shield $15.25 $10.80 $4.45 ProfitFirst Priority Life $21.73 $10.80 $10.93 Profit
83036 - Hg A1CMedicare $13.34 $8.33 $5.01 Profit
Ma Products 0Geisinger $10.85 $8.33 $2.52 Profit
Blue Shield $9.63 $8.33 $1.30 ProfitFirst Priority Life $9.92 $8.33 $1.59 Profit
83655-LeadMedicare $16.64 $7.32 $9.32 Profit
Ma Products $10.00 $7.32 $2.68 ProfitGeisinger $13.53 $7.32 $6.21 Profit
Blue Shield $11.65 $7.32 $4.33 ProfitFirst Priority Life $12.37 $7.32 $5.05 Profit
85013 -Medicare $3.26 $0.58 $2.68 Profit
Ma Products $3.27 $0.58 $2.69 ProfitGeisinger $2.65 $0.58 $2.07 Profit
Blue Shield $2.34 $0.58 $1.76 ProfitFirst Priority Life $2.42 $0.58 $1.84 Profit
85018 -Medicare $3.26 $0.57 $2.69 Profit
Ma Products $3.27 $0.57 $2.70 ProfitGeisinger $2.65 $0.57 $2.08 Profit
Blue Shield $2.34 $0.57 $1.77 ProfitFirst Priority Life $2.42 $0.57 $1.85 Profit85610- Protime Profit Alone 99211 - Level 1 OV Profit w/Level 1
Medicare $5.40 $4.69 $.71 Profit $19.24 $19.95Ma Products $4.00 $4.69 $20.00 $19.31
Geisinger $4.39 $4.69 $20.08 $19.78Blue Shield $3.78 $4.69 $30.00 $29.09
First Priority Life $5.62 $4.69 $.93 Profit $26.00 $26.93
With the CoumadinClinic we charge a Level 1 visit along
with the 85610
Shaping the Future of Healthcare | www.thewrightcenter.org
Track, Promote and Determine Affordability
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Allowance Cost Profit80061-Lipid Profile
Medicare $18.42 $10.80 $7.62 Profit
Ma Products $14.00 $10.80 $3.20 Profit
Geisinger $14.98 $10.80 $4.18 Profit
Blue Shield $15.25 $10.80 $4.45 Profit
First Priority Life $21.73 $10.80 $10.93 Profit
83036 - HbA1cMedicare $13.34 $8.33 $5.01 Profit
Ma Products 0
Geisinger $10.85 $8.33 $2.52 Profit
Blue Shield $9.63 $8.33 $1.30 Profit
First Priority Life $9.92 $8.33 $1.59 Profit
Shaping the Future of Healthcare | www.thewrightcenter.org
6 Month Revenue Generated
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Shaping the Future of Healthcare | www.thewrightcenter.org
Affordability Punch Line
• HbA1c Per Service Collection $7.83 versus cost of $8.33 – Net Loss of $ 49 over 6 month period
• Lipids Per Service Collection $14.10 versus cost of $10.80– Net Profit of $280 over 6 month period
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Shaping the Future of Healthcare | www.thewrightcenter.org
Affordability Punch Line Excluding Uncovered Services
• HBA1C Per Service Collection $ 9.85 versus cost of $ 8.33
• Six Month Profit: $259
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Shaping the Future of Healthcare | www.thewrightcenter.org
Have we changed patient outcomes?• A complex question• Providers and patients reportedly like it and
believe it enhances planned care provision and chronic disease management at POC.
• Staff aren’t complaining.• There was no time based overlay in our
HBA1C or LDL process or outcomes run charts with POCT implementation.
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Shaping the Future of Healthcare | www.thewrightcenter.org
Conclusion
Selective POCT makes sense, especially for high volume primary care delivery test metrics like HbA1c and Lipids.
Test cost: reimbursement of HbA1c and Lipids are close to neutral.
Affordability and value delivery assessments are complex.
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Shaping the Future of Healthcare | www.thewrightcenter.org 31
Shaping the Future of Healthcare | www.thewrightcenter.org
For HbA1c testing we use
• Afinion AS100 Analyser for HbA1c
• The coefficient of Variability (CV) is 1.51% to 1.97%
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Shaping the Future of Healthcare | www.thewrightcenter.org
For Lipid testing we use
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• Cholestech LDX for lipid
• The Coefficient of Variability (CV) is 2-3%