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Point Of Care Testing:

Issues, Answers and Future Challenges
(Part 2 of a 2-part series)

by Dr. Sheila Dunn

Reprinted with Permission from Physicians Marketplace

This is the second article in a two-part series addressing the economic issues surrounding point of care testing (POCT). Last month's article looked at the prevalence of POCT and the importance of regulations in the decision to implement "nearpatient" testing.

Here, we address clinical and economic issues which determine, for the most part, whether POCT is feasible for a particular provider. Point of care tests are often more expensive to perform on a costpertest basis than their megalab counterparts for many reasons. First, tests designed for point of care settings contain numerous builtin checks and balances for errorfree operation. These new bells and whistles reduce test errors but do not come without a price. Despite a greater initial cost, there are numerous valid reasons why these tests are, in fact, more cost effective when performed at the point of care.

Faster test results reduce the total cost of care. In fact, real cost savings have little to do with decreasing the cost/test from, for example, $25 to $5. Rather, economic benefit will come from lower hospital admissions, fewer emergency room visits, and correct treatment plans. Such gains may offset any increased, marginal cost of reagents for performing POCT.

The financial differences in managing patient care in various settings are substantial: $1000$1500/day in an acute care facility versus $48$80 per 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.

Numerous costbenefit studies of hospitalbased POCT provide hard data that show savings to the healthcare system. One particular study equates the reduction in complications, hospital and ER visits to a savings of $1200.00 per patient per year for prothrombin time testing at the point of care.

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).

Future Challenges in POCT: The Managed Care Obstacle
A major challenge for POCT programs is the fact that some managed care organizations (MCOs) require that all testing be referred to a megafacility with whom the health plan has negotiated rockbottom test pricing. The absence of test results during the patient visit may hinder providers' ability to diagnose and treat patients properly.

To add insult to doctors' injuries, different MCOs have a variety of referral facilities to which tests must be sent. Doctors then become confused by differences in test result parameters. Using multiple referral facilities, a provider must be aware of different reference (normal) ranges and take this into account before making a diagnostic or therapeutic decision. For example, inoffice 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. Doctors often find it difficult to use test results from different testing sites to monitor changes in a patient's diagnosis and treatment. Also, referral facilities have different ordering procedures, sample collection and handling requirements, and result reporting methods. For medical management purposes, POCT is clearly superior.

Finally, and most ominously from a diagnostic standpoint, delayed test results diminish patient compliance, lead to errors in diagnosis, and require physicians to use anticipatory treatment while awaiting laboratory results. An example of inappropriate treatment is a prescription for an expensive antibiotic prior to receipt of a test result that would have confirmed that the antibiotic was unnecessary. Not only was money wasted, but the patient could develop a resistance to that medication in the future.

Cost savings also result from productivity increases inherent in POCT. For instance, providers "switch" both physically and mentally, between patient visits while awaiting laboratory information. Once lab data are available, physicians must again concentrate on that particular patient. The cost of "switching time" and the implications for quality of care are high. The 1015 minutes it takes for a physician to follow up on a delayed diagnostic test result is quite costly: a physician's time is the most expensive resource in a practice. POCT allows a clinician to quickly make an assessment and provide correct treatment without being interrupted or distracted while seeing other patients.

Provider and medical staff efficiency and productivity are maximized due to POCT. Not only does it enhance workflow for staff; it eliminates the need to log, package, track, and post results for tests sent to referral facilities, as well as the possibility of error that accompanies each of those steps. Using multiple referral facilities is confusing and extremely inefficient.

Since at least half of all medical facilities in the US perform POCT, and since it is of the same or better quality than referral testing, why do MCOs contract with referral facilities to provide testing for their members? A list of the probable reasons and our response is in Table 1.


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. Examples of these are provided in the text of this section.

Providers will test excessively if a financial incentive exists
Providers who view testing only as a way to generate revenue will always exist. We believe they are a minority of total providers. MCOs that reimburse providers based on the Medicare fee limitations will allow providers to afford to continue to provide valuable testing services to their members. Only reasonable profits are available under this fee schedule, certainly not enough to be an impetus to test more than is medically necessary. In fact, solo practitioners may find the Medicare fee allowances to be costprohibitive, i.e., after meeting CLIA requirements, certain lowvolume providers will not be able to break even. Studies have shown that having doctors perform their own testing is intrinsically selflimiting. Test utilization actually goes down.

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.

In response to managed care's restrictions, many doctors individually attempt to negotiate payment to retain their officebased 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.

POCT Increases the "Value" of Health Care
The American Association of Health Plans, the trade group for managed care plans, has a mission statement that includes a commitment to the principle that "patients come first." AAHP's philosophy of care extols the following standards of quality and professional ethics:

  • Patients should have the right care, at the right time, in the right setting. This includes comprehensive care for acute and chronic illnesses, as well as preventive care -- in the hospital, at the doctor's office, and at home.
  • All health care professionals should be held accountable for the quality of the services they provide and for the satisfaction of their patients.

POCT achieves these objectives by minimizing costs and maximizing "quality" which, in the case of health care, means restoring the patient to health as soon as possible. The faster the patient is restored to health, the less cost to the health care system.

POCT also fulfills AAHP's mission by maximizing the efficacy and efficiency of providers. This means the right care, at the right time, in the appropriate amount, or, in other words, not only seeing more patients (efficiency) but seeing a given patient less frequently (effectiveness).

Like MCOs, employers are also redefining the cost versus value issue of health care. Rather than focusing only on premium rates to judge the cost of health plans, purchasers of health care are increasingly looking at the "value" of health plans' offerings. A healthcare information manager for the phone giant GTE recently admitted:

"We're getting smart. We realize that value costs less. GTE spends $600 million yearly on direct health care costs. But lost time at work and lower productivity because of health problems costs much more, well over $1 billion a year."

Help Is On The Way
The Health Industry Distributors Association (HIDA) will soon to publish APOCT.....A CostBenefit Analysis which petitions MCOs to recognize the value of ambulatory 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 costeffectiveness 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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