In times of changing payment systems that have cut lab test reimbursement while also placing more value on population health management, clinical labs would do well to look beyond their traditional role as centers of testing and explore how they might contribute to population-level analysis and care management, according to the authors of two studies helmed by TriCore Reference Laboratories and published in The Journal of Applied Laboratory Medicine. The current regulatory climate indicates that labs should consider a role in chronic care management, the study authors contend.
Systematic reimbursement cuts under the Protecting Access to Medicare Act (PAMA) has made it increasingly difficult for labs to maintain operations. “Labs need to find other ways to generate a revenue stream from the data they have,” David Grenache, TriCore’s chief scientific officer, told CLN Stat. Grenache also serves as AACC president.
Through TriCore’s participation with the Project Santa Fe Foundation, this reference lab based in Albuquerque realized the value of using its data to identify gaps in care and risk in non-lab venues. There is nothing unique about TriCore’s strategy, said Rick VanNess, MS, TriCore’s director for product management. “We simply look for patients with testing indicative of the condition. However, one intuitive thing we do is ask for health plans to provide member eligibility files so that we can quickly find the members that have this condition.”
In one of the studies, TriCore demonstrated how it used this strategy to improve health plan compliance with diabetes testing within a Medicaid population. “We show the math that deciphers how much an HbA1c test is worth to a Medicaid health plan in terms of bonuses, which is more than five times the clinical lab fee schedule,” said VanNess.
The National Committee on Quality Assurance’s Healthcare Effectiveness Data and Information Set on Comprehensive Diabetes Care mandates yearly HbA1c and urine albumin-to-creatinine ratio (ACR) tests for patients with diabetes. TriCore collaborated with Blue Cross Blue Shield of New Mexico (BCBSNM) to see if its lab data could enhance the payer’s diabetes care management services.
“A managed care organization such as BCBSNM already uses claim and prescription data to identify members for these types of services. Laboratory data offers a clearer picture of what’s going on with the patient,” said Kathleen Swanson, TriCore’s senior clinical solutions specialist and a coauthor of the two studies. Labs utilize longitudinal and metadata that can shave years off typical processes payers use to monitor diabetic patients, Swanson said.
TriCore used the payer’s Medicaid enrollment file to identify members and evaluate HbA1c results to determine members’ diabetes status. Among a large sample of more than 6,000 members with diabetes, TriCore extracted 600, providing data on half to BCBSNM for care management over a 5-month period. The other half, a control group, underwent regular BCBSNM identification reliant on claim data. TriCore only provided its insights for the study group. Members in both groups received a phone call to educate them about their diabetes and care management alternatives.
TriCore monitored HbA1c and ACR test completion rates among both cohorts. Significantly more study group members received an HbA1c and ACR test, 25% and 14% respectively, compared to those in the control group (18% and 9%). “This is because our information is more accurate and more reliable than the claims data health plans rely on,” added Swanson. TriCore then calculated the monetary penalty Medicaid managed care organizations are subject to in New Mexico, finding an additional $3.6 million value that clinical labs add beyond the cost per diabetes-related test. “Everyone wonders what the value of an HbA1c test is. We hope this conveys a different perspective,” noted VanNess.
A big takeaway for labs: understand the reimbursement methods of health plans, as these monetary incentives are in place for Medicare as well. “The more you understand, the more your organization will be able to help derive different strategies for engaging payers ,” advised Swanson.
TriCore now gets paid differently because of the additional value it provides. “Now that we know the value of a care gap, we will move to our next phase of value-based care by going at risk for those care gaps followed by outcomes,” explained VanNess. While it’s very difficult to track a completed HbA1c test to an outcome, “if we start with the value of that HbA1c care gap, get paid to close it over the next few years, then we can measure outcomes and move to actual value-based care,” he added.
The other study demonstrated that longitudinal, clinical laboratory results are just as accurate as the U.S. Centers for Disease Control and Prevention’s (CDC) population disease surveillance method.
One advantage of the former is a reduction in labor—CDC calls a random number of people to estimate diabetes occurrence, which is labor-intensive and costly, said Teo Borunda Duque, TriCore’s clinical solutions specialist and primary author of the paper.
New Mexico relies on CDC’s Behavioral Risk Factor Surveillance System (BRFSS) to acquire most of its information on diabetes surveillance and incidence. For the study, TriCore investigators used HbA1c results in the company’s data repository to develop a model that estimated diabetes prevalence in New Mexico residents, using the BRFSS as the comparative gold standard. They also leveraged American Diabetes Association guidelines on HbA1c ranges to divide this population into different groups, tracking patients over a 5-year period through each patient’s last HbA1c result and TriCore’s identification number.
Compared to CDC’s derived diabetes rate of 10.4% in New Mexico, TriCore’s derived rate was 10.63%. “Laboratory data was collected in real time, providing a real time representation of diabetes, an advantage over the 2- to 3-year reporting delay that BRFSS faces,” reported Duque. This timeliness factor combined with the lab’s longitudinal analysis, made it easier to track intervention outcomes such as patient education, closing care gaps, and allocation of resources.
The results should encourage other labs to see what they could do for the populations they serve, said Duque. Labs could also use their data to inform population health for a variety of groups, including public health officials, state and national groups, or local groups.
While it’s true that labs have a tremendous amount of data at their fingertips, leveraging it to their advantage takes people and resources, Grenache acknowledged. “There has to be a conscious commitment for labs to engage in this activity.”