Produce Optimal Results or Perish: Technology and Information Force Economic Discipline on Healthcare Providers

Just as 51 fiscal intermediaries and carriers added complexity and inconsistency to the processing of laboratory services 20 years ago, we find ourselves in a similar position today with the inconsistent handling of coverage and reimbursement for MDx claims by 13 MACs.
Prior inconsistencies and their negative impact on the diagnostic industry were finally addressed through the negotiated rule making process that brought standardization and order to an otherwise chaotic system that benefited or penalized labs simply by the luck of the draw of the contractor that won their jurisdiction contract.

In today’s environment, where MAC’s are struggling with the MDx claims adjudication process and trying to maintain the integrity of the Medicare program, Palmetto GBA has stepped up to the bar with an attempt to simplify and standardize the process.

At a time when technology in diagnostics produces new and rapidly growing diagnostic tests that now not only impact the choice of therapy, but also monitor its progress and open the door to personalized medicine, we also find that information technology can provide the solution for disseminating this complex and ever changing information to physicians. Computing power was ultimately the linchpin to unleashing the mapping of the human genome and thus a whole new world of diagnostics and personalized medicine. And in this ever changing environment, Technology is also the solution to distill this information and deliver it to the appropriate parties in an easy to understand decision support model. HIT and web services from content providers offers the infrastructure to facilitate analysis of results and thus the provision of targeted decision support fostering a paradigm change that shifts the tides of diagnostics to personalized medicine with decision support, optimal outcomes and ultimately value based pricing.

Technology solutions will provide immediate information at the finger tips of the physician to shift the practice of medicine from defensive ordering and over utilization to intelligent on demand decision support that provides the right test at the right time for both selection of therapy and therapy management.

Historically health care has been the only industry with misaligned incentives where medical errors have resulted in financial rewards. While payors have concocted a number of schemes to control utilization from bundling to capitation, without precise information, they have achieved only mixed results with cost savings in the short run that lack optimization of patient results. In the final analysis technology and information will force economic discipline for healthcare providers to produce optimal results or perish.

~ Lâle White

Note: XiFin’s Rina Wolf will be speaking at Executive War College, Tuesday, May 2, 2012 in a session entitled “Getting Paid for Molecular and Genetic Tests: Latest Changes in How Government and Private Payers Want to Reimburse Labs.” Rina is our Vice President of Strategic Commercialization, Consulting & Industry Affairs. Ms. Wolf is a nationally recognized expert in the field of laboratory commercialization and reimbursement, with over 20 years of experience in the diagnostic laboratory industry, specializing in Molecular Diagnostic Laboratories. She lectures extensively on these topics and has consulted for many laboratories and laboratory associations throughout the U.S.