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Issues & Answers:
Point Of Care Testing
by Dr. Sheila Dunn

The decision to perform "near-patient" testing involves both clinical and economic issuesand, there are no"one size fits all" answers. Point of care tests (POCT) generally cost more than tests designed for huge assembly-line type testing facilities. Can your customers afford to do them? Will managed care plans pay for them? Does a rapid test result provide better patient care?

The Cost Factor
POCTs are often more expensive to perform on a cost-per-test basis due to built-in checks and balances for error-free operation. These new bells and whistles reduce test errors but do not come without a price. Despite a greater initial cost, there are many valid reasons why these tests are, in fact, more cost effective when performed at the point of care.

Real cost savings has little to do with decreasing the cost/test from, for example, $25 to $5. Rather, economic benefit comes from lower hospital admissions, fewer emergency room visits, and correct treatment plans. Financial differences in managing patient care in various settings are substantial: $1000-$1500/day in an acute care facility vs $48-$80/patient encounter in an ambulatory care setting.

For example, due to a delay in receipt of test results, patients receive inappropriate or delayed therapy which costs the health care system additional dollars, not only for the medication, but also for repeat visits to health care providers, emergency facilities or hospitals. Such gains offset any increased, marginal cost of reagents for performing POCT.

The benefits of POCT can be divided into three general categories, all of which result in real savings to the health care system:

1. Psychosocial benefits (i.e., patients are more satisfied with their healthcare experience and understand and comply with provider treatment regimens);

2. More accurate results for some tests (delays and specimen deterioration contribute to unreliable test results); and

3. Clinical benefits (i.e., patients get better faster and return to work).

The Managed Care Obstacle
A major challenge for POCT is the fact that some managed care organizations (MCOs) require that all testing be referred to a mega-facility with whom the health plan has negotiated rock-bottom test pricing. The probable reasons for MCO test referral stipulations are given in Table 1.

To add insult to injury, different MCOs have a variety of referral facilities to which tests must be sent. Doctors then become confused by differences in test results and take this into account before making a diagnosis or treating a patient.

For example, in-office glucose test devices are performed on whole blood whereas glucose tests performed in referral laboratories use serum or plasma specimens. Not only are there differences in the "normal" reference ranges for tests performed on different types of specimens, but different instruments do not provide data that is interchangeable. Also, referral facilities have different ordering procedures, sample collection and handling requirements, and result reporting methods. For medical management purposes, POCT is clearly superior.

In response to managed care restrictions, many doctors individually negotiate payment to retain their office-based testing for three main reasons: it clearly improves physicians' clinical efficiency, (i.e., they can see more patients), it provides better patient satisfaction, and it improves clinical outcomes.

Help Is On The Way
The Health Industry Distributors Association (HIDA) will soon publish APOCTA Cost-Benefit Analysis which petitions MCOs to recognize the value of POCT and revise existing policies to ensure fair and appropriate reimbursement for these tests. Specifically, it seeks to convince MCOs who contract with regional or national testing vendors to:

1. Reverse policies which prohibit testing at the point of patient care;

2. Allow individual medical practices to determine which APOCT are appropriate for the patients encountered at that location;

3. Reimburse providers who wish to perform APOCT at fair market value; and

4. Participate with manufacturers and providers in long term studies to prove the overall cost-effectiveness of certain APOCT.

The study includes case management examples from physicians and other health care providers using real patient data to demonstrate the clinical, economic, and psychosocial benefits of APOCT to the healthcare customer, the patient.

POCT restriction by MCOs is clearly an instance of contractually obligating providers to reduce service levels as well as the quality of care. Perhaps, in the future, when the economy of POCT has been documented, MCOs will actually encourage - and reward- physicians for performing it.

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Table 1: Why MCOs Require Referral Testing
Reason For Referral Stipulation Response
 Referral testing is less expensive Referral testing is actually more expensive in the long term due to dissatisfied patients, dissatisfied providers, poorer patient outcomes, inaccurate results due to specimen deterioration, increased referrals or hospital admissions, decreased employee productivity, and improper expensive medication.
Providers will test excessively if a financial incentive exists Providers who view testing only as a way to generate revenue are a minority of total providers. MCOs should reimburse for POCT based on the Medicare fee limitations under which only reasonable profits are available, certainly not enough to be an impetus to test more than is medically necessary.
A national or regional contract is in place. Exceptions cannot be made for individual providers. Revise the national referral contract and encourage/ reimburse those providers who rely on POCT. Work with manufacturers, providers, etc. to generate outcomes and customer satisfaction data to quantitate the value of POCT.

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