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Just What The Doctor Ordered:

Outpatient Anticoagulation Services

by Dr. Sheila Dunn

Reprinted with Permission from Physicians Marketplace

Talk about not being able to leave work at the office? Well, during our first attempt at gardening this year my neighbor Henry, a cardiologist, popped open a cold one, leaned his head across the fence, and asked for my help. At Henry's Friday afternoon staff meeting, the senior physician of his large group practice asked all seven physicians to come up with a way to either save significant resources or generate additional revenue.

Like most other medical practice in America, Henry's cardiology practice has been hit hard by managed care payment reductions. In fact, their largest managed care plan cut the group's bonus significantly due to patient satisfaction issues and, to a smaller extent, because of patient outcome issues. The senior physician wanted one suggestion from each physician by the next weekly staff meeting. All Henry had managed to come up with was to cut costs by removing non-physician employee insurance benefits.

I replied: Let me get this straight. You need to come up with a service or product that your practice can implement to save money or generate revenue. Right? I already had a great idea but wanted to make sure it would be appropriate for his practice.

Do you have patients on warfarin (Coumadin) therapy? I asked. Henry explained that he had several such patients, so I asked him if his practice had anticoagulation testing services.

No, we send patients to the hospital for testing, he said. Although our hospital is only a 10 minute drive from the cardiology practice, parking is a nightmare and patients have to walk several hundred yards to reach the drawing center.

I was amazed that such an intelligent person didn't make the connection between these circumstances and patient satisfaction. Imagine taking your car in for a tune up and having the mechanic tell you that, in order to finish the job, you needed to run down to the auto supply store, wait in line, hope the part was in stock, and bring it back for installation! To add insult to injury, your car won't be ready for 2 days!

Only a small portion of the medical industry has fully embraced the idea of customer service. In fact, some physicians become downright hostile when their patients are referred to as 'customers.' But, medical practices that take into consideration their patient's time and non-medical concerns are coming out ahead in today''s managed health care environment. For some practices, a way to show your concern for patients'' medical and non-medical needs involves providing a one-stop shop for anticoagulation testing services.

If your practice can answer "yes" to the following 3 questions, you should consider offering on-site anticoagulation testing:

  • Do you have patients who are on long term Coumadin therapy?
  • Do you see newly-anticoagulated patients whose drug levels are not yet stable?
  • How about those who take Coumadin for a limited amount of time, such as prophylactically following hospital discharge for orthopedic surgery?

If you've answered "yes" to any of the above, also consider patients who:

  • Have poor venous access. Whole blood fingerstick samples are more comfortable for these patients.
  • Do not have easy access to laboratory services and require frequent testing.
  • Have had their blood samples misplaced or mixed up by the referral laboratory.

More than 3 million patients in the US take long-term anticoagulants and must routinely monitor their prothrombin time (PT), but there are many patients who should be on the drug but aren't. Dr. Jack Ansell, a pioneer researcher in this field, estimates that only about 40% of atrial fibrillation patients take Coumadin.

Lab Testing? No Way...
At this point Henry was shaking his head. "No way we're getting into lab testing." "We used to have a whole lab about 10 years ago, but closed it down when CLIA regulations came about."

I explained that these instruments are CLIA-waived, meaning that all they had to do was get a CLIA license ($150 every two years) and follow the instructions for the test. Unknown proficiency testing samples will not be sent and no federal agents will come calling, thank you very much.

"Listen Sheila, you know that monitoring Coumadin levels is serious stuff. It's not like we're talking about a urine dipstick. Can you really trust those things?"

Are Whole Blood Fingerstick PT Instruments Accurate?
The Coagucheck (Roche Diagnostics) provides results comparable to standard plasma prothrombin time determinations. (see Note 1) Several studies have demonstrated that anticoagulation testing performed by this fingerstick method is less variable than routine laboratory methods. In fact, the Coagucheck is both easy to use and accurate and provides a prothrombin time-international normalized ratio (PT-INR) result from a single drop of blood in about two minutes.

At this point, my Henry mentioned a few patients (an elderly couple who came in once a week and a young woman who took time from work for frequent testing) who could benefit from on-site testing. But can this type of testing program generate revenue? he needed to know.

Will It Generate Revenue?
I explained that, after an initial investment of about $1500, he could expect to generate revenue in the following ways:

1. Keep your patients coming back. Patients may change doctors or healthcare facilities if they hear that routine testing is available more conveniently elsewhere. The cost of one lost patient over the lifetime of a practice is estimated to be over $200,000!

2. Provide better outcomes. Faster results often contribute to more stable drug dosages. More stable INR's coupled with better patient compliance with therapy avoid negative outcomes. HMO bonus checks will increase when patient complications decrease.

3. Free up your support staff to do clinical duties; nurses can spend less time on paperwork and telephone calls and concentrate on revenue generating activities. Nurses and physicians' time is the most valuable asset of any medical practice. Why waste it playing telephone tag?

4. Generate revenue. It costs about $7.00 per coumadin-related encounter when testing is performed at a remote location (encounter for this purpose is defined as pulling the chart for appointments, entries, coping, reviews or insertions). Although it costs slightly more $11.00 for each patient encounter when testing is performed in-house, reimbursement averages about $21.00 (See Note 3).

5. Save time and increase efficiency by explaining dosage changes in person and going over any lifestyle issues with the patient. Immediate feedback really improves patients' understanding and results in fewer repeat calls.

"So here you have it, Henry. Put yourself in your patients' shoes. There's no way you would wait in line at the parts store rather than doing business with a company that provides one-stop shopping. Do you really think your patients want to drive, park, walk, wait, walk, drive and then wait a few days for a test result? Making your office a one-stop shop also gives you an edge up on the local competition."

I'm not sending Henry a bill this time, but next time, the "cold one" is on him.


1. Douketis, James D. et al. Accuracy of a portable international normalization ratio monitor in outpatients receiving long-term oral anticoagulant therapy: comparison with a laboratory reference standard using clinically relevant criteria for agreement. Thrombosis Research. 1998; Vol. 92:11-17. (Return to text.)

2. Williams, James R. Reengineering Practices For Oral Anticoagulation Monitoring. Health Care Innovations, The Journal of the Association of Managed Healthcare Organizations. March/April 1997 Vol. 7 No.2. (Return to text.)

3. The Physician's Guide to preventing strokes and lowering health risks in patients with atrial fibrillation. Northwestern University Medical School, Chicago, IL. Chapter 5,6. (Return to text.)


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