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.
