point of care testing for enhancing patient centered planned care delivery

Shaping the Future of Healthcare | www.thewrightcenter.org

Point of Care Testing for Enhancing Patient Centered Planned Care Delivery

Linda Thomas-Hemak, MD The Wright Center for Primary Care

PAFP Community Regional Lecture Series October 2, 2013


Learning Goals and Objectives

• Review Availability, Advantages , Disadvantages and Challenges of POCT.

• Describe how POCT for HbA1c and Lipids can contribute to improved team based planned care delivery in the patient-centered medical home.

• Demonstrate a plan for effective, affordable implementation of Point of Care HbA1c and Lipid testing, including factors such as staff buy-in and effective use of Health Information Technology.

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POCT Relevance

• Care emphasis is shifting toward prevention and early detection of disease, as well as effective, facilitated self-management of multiple chronic conditions with development of low-cost technologies for POCT.

• With miniaturized devices and wireless communication, doctors’ care for patients will change dramatically, and the role patients take in their own health care will increase.

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Definition and Aim of Point Of Care Testing

• Point-Of-Care Testing is defined as testing at the patient encounter in whatever venue patient care is delivered.

• The aim of POCT is to accelerate diagnostic and therapeutic processes.

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POCT Empowers Providers and Patients• Promotes evidence based planned care at every visit.

• Potential to address compliance, significantly impact health care delivery, enhance outcomes and reduce health disparities.

• Enhances the shift to predictive, personalized and preemptive medicine with the development of portable diagnostic and monitoring devices.

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Implementing POCT• Obtain leadership buy in to coordinate POCT

program in everyday workflow.• Understand POCT methodology and economics.• Financial modeling (Can we effort it?).• Define POCT role specific, team based work flow.• Keep it integrated in EMR MU and Lab interfaces.• Be certain lab orders are accommodated to avoid

duplicated testing and denied service coverage. • Implement and Evaluate.

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POCT “Lean” Benefits• Rapid turn around time for diagnosis and management

planning• Patient convenience• Reasonable cost• Improved patient planned care provided• Empowered patient self management• Improved office workflow through increased testing

efficiency and less call backs• Reduction of length of stay in ER venues• Reduced ER and Hospital referrals

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Additional POCT Advantages

• Small sample volume• Portable devices with wide menu of analytes• Unprocessed specimen• Ability to provide laboratory testing in a wider variety

of sites or circumstances• Reduced potential for sample deterioration

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POCT Disadvantages• Implementation is challenging and must be strategic.• Not all methods are appropriate for diagnosis or

monitoring treatment.• Kits/devices may not be FDA approved for all uses of a

similar test in central laboratories.• Different methodology, reliability, and precision• Variable coverage and affordability• Staff time and training• Staff inappropriate use outside of intended use or policy• Costs of specimen mistakes

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Affordability and Value : Complex POCT Economics

• Staffing, training and visit time • ↓ Call backs but potentially ↓ # of clinic visits • More efficient and potentially more aggressive chronic disease management• Less inappropriate Rx• Potentially enhanced patient self management• Fewer unnecessary ER visits and admissions • ↓ ER and Hospital LOS• ↓ blood and blood product use• Potentially enhanced outcomes and QOL

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POCT Improved Outcomes Examples

• Faster diagnosis and treatment decision making: Chest pain, Drug O/D

• Improved adherence to Rx: Diabetes & Glucometers• Faster therapeutic optimization : Anticoagulation• Reduced re-operation rate: Parathyroidectomy (with

rapid point-of-care PTH assays)• Improved patient satisfaction: ↓travel,

↓cost,↑ownership of diagnosis• No validated primary care health outcomes yet

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POCT Economics: CostCost must look at the whole process of patient care,rather than just the cost of an individual POCT methodvs. laboratory test methods.– Management, billing and HIT plans– training testing personnel – labor to process/analyze specimens– maintaining equipment, annual reagent/controls– depreciation costs– state licensing for volume and test complexity– proficiency programs for testing performed.

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POCT Cost Effectiveness• Many studies show POCT for various applications is a

useful complement to conventional laboratory testing. • POCT should not be viewed as a significant profit

generator. • The true value is lean improvement in care provided,

patient satisfaction with their healthcare and possibly outcomes.

• Future utilization will depend not only on technical advances, but also on enhancement in costs and reimbursement, as well as transformation from a volume driven to value based payment system.

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Available POCT

• Cardiac markers• Drug/toxicology• Hemoglobin A1c• INR• Heparin• D-Dimer for VTE• Magnesium & Lactate• Lipids

• Transcutaneous bilirubin• Micro-albumin, Creatinine• HIV• RSV, Influenza• Helicobacter pylori• Other bacteria• Urine dip tests including

pregnancy

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POCT We Utilize

• Sugar• Hg A1C • Lipid Profile• INR• Urinalysis and Pregnancy test• Lead and H&H• Rapid Strep• RSV• Rapid Flu A/B

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POCT Precision for HbA1c and Lipids

• Comparison studies to reference labs are standardized and available

• Scatter Plots useful• Correlation Coefficients > 95%• Correlation Variables < 2%

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HbA1c POCT Volumes All Patients

Total tests performed (11/1/12 – 4/30/13)• # HbA1c on All Patients (DM, Pre-Diabetics, PCOS,

Suspected diabetics) = 496• # HbA1c done on All Patients by POCT = 207• 42 % of all HbA1cs were performed in house for the

entire population

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HbA1c POCT Volume of Diabetic Patients

Total tests performed (11/1/12 – 4/30/13)• # HbA1c on DM Patients Total = 312• # HbA1c on DM Patients done by POCT = 174• 56 % of all HbA1cs were performed in house

for the diabetic population

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Lipids POCT Volumes All Patients

Total tests performed (11/1/12 – 4/30/13)• # Lipids on All Patients = 1136• # Lipids done on All patients by POCT = 80• Only 7% of all Lipid panels were performed in

house for the entire population

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Lipids POCT Volumes Diabetes Patients

Total tests performed (11/1/12 – 4/30/13)• # Lipids done on DM Patients Total = 225• # of Lipids done on DM patients by POCT = 44• 20% of all Lipid Panels were performed in

house for the diabetic population

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Patient Volume for HbA1c & Lipid POCT

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42%

56%

7%

20%

58%

44%

93%

80%

0%

20%

40%

60%

80%

100%

120%

HbA1c (All Patients)

HbA1c (Diabetic Patients)

Lipid Panel (All Patients)

Lipid Panel (Diabetic Patients)

Patients with testing done OFFSITEPatients with testing done POC


How HIT Can Promote Affordability and Value• POCT device costs and insurance checklists for

covered services• POCT affordability reports can track service counts,

charges and receipts• DM/HM Alerts can reflect coverage eligibility• Integrating with EMR Lab interfaces can optimize

tracking• Customized EMR lab orders avoids duplicate tests• Inventory reconciliation can capture lost charges

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POCT CHECK LIST OF WCPC

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87880-Strep Allowance CostMedicare $15.13 $1.87 $13.26 Profit

MA products $6.30 $1.87 $4.43 ProfitGeisinger $12.31 $1.87 $10.44 Profit

Blue Shield $15.29 $1.87 $13.42 ProfitFirst Priority Life $11.76 $1.87 $9.89 Profit

81025_Pregnancy Test Medicare $8.70 $1.00 $7.70 Profit

MA products $4.00 $1.00 $3.00 ProfitGeisinger $7.07 $1.00 $6.07 Profit


87807-RSVMedicare $16.49 $11.36 $5.13 Profit

MA Products $12.31 $11.36 $.95 ProfitGeisinger $12.31 $11.36 $.95 Profit

Blue Shield $11.89 $11.36 $.53 ProfitFirst Priority Life $15.00 $11.36 $3.64 Profit

87804-Rapid Flu A/BMedicare $16.49 x 2 = $32.98 $12.50 $20.48 Profit

Ma Products $11.35 x 2 = $22.70 $12.50 $10.20 ProfitGeisinger $12.31 x 2 = $24.62 $12.50 $12.12 Profit

Blue Shield $14.84 x 2 = $29.68 $12.50 $17.18 ProfitFirst Priority Life $11.76 x 2 = $23.52 $12.50 $11.02 Profit


POCT CHECK

LIST

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80061-Lipid Profile ALLOWANCE COSTMedicare $18.42 $10.80 $7.62 Profit

Ma Products $14.00 $10.80 $3.20 ProfitGeisinger $14.98 $10.80 $4.18 Profit


83036 - Hg A1CMedicare $13.34 $8.33 $5.01 Profit

Ma Products 0Geisinger $10.85 $8.33 $2.52 Profit


83655-LeadMedicare $16.64 $7.32 $9.32 Profit



85013 -Medicare $3.26 $0.58 $2.68 Profit



85018 -Medicare $3.26 $0.57 $2.69 Profit


Blue Shield $2.34 $0.57 $1.77 ProfitFirst Priority Life $2.42 $0.57 $1.85 Profit85610- Protime Profit Alone 99211 - Level 1 OV Profit w/Level 1

Medicare $5.40 $4.69 $.71 Profit $19.24 $19.95Ma Products $4.00 $4.69 $20.00 $19.31

Geisinger $4.39 $4.69 $20.08 $19.78Blue Shield $3.78 $4.69 $30.00 $29.09

First Priority Life $5.62 $4.69 $.93 Profit $26.00 $26.93

With the CoumadinClinic we charge a Level 1 visit along

with the 85610


Track, Promote and Determine Affordability

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Allowance Cost Profit80061-Lipid Profile

Medicare $18.42 $10.80 $7.62 Profit

Ma Products $14.00 $10.80 $3.20 Profit

Geisinger $14.98 $10.80 $4.18 Profit

Blue Shield $15.25 $10.80 $4.45 Profit

First Priority Life $21.73 $10.80 $10.93 Profit

83036 - HbA1cMedicare $13.34 $8.33 $5.01 Profit

Ma Products 0

Geisinger $10.85 $8.33 $2.52 Profit

Blue Shield $9.63 $8.33 $1.30 Profit

First Priority Life $9.92 $8.33 $1.59 Profit


6 Month Revenue Generated

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Affordability Punch Line

• HbA1c Per Service Collection $7.83 versus cost of $8.33 – Net Loss of $ 49 over 6 month period

• Lipids Per Service Collection $14.10 versus cost of $10.80– Net Profit of $280 over 6 month period

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Affordability Punch Line Excluding Uncovered Services

• HBA1C Per Service Collection $ 9.85 versus cost of $ 8.33

• Six Month Profit: $259

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Have we changed patient outcomes?• A complex question• Providers and patients reportedly like it and

believe it enhances planned care provision and chronic disease management at POC.

• Staff aren’t complaining.• There was no time based overlay in our

HBA1C or LDL process or outcomes run charts with POCT implementation.

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Conclusion

Selective POCT makes sense, especially for high volume primary care delivery test metrics like HbA1c and Lipids.

Test cost: reimbursement of HbA1c and Lipids are close to neutral.

Affordability and value delivery assessments are complex.

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Shaping the Future of Healthcare | www.thewrightcenter.org 31


For HbA1c testing we use

• Afinion AS100 Analyser for HbA1c

• The coefficient of Variability (CV) is 1.51% to 1.97%

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For Lipid testing we use

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• Cholestech LDX for lipid

• The Coefficient of Variability (CV) is 2-3%

point of care testing for enhancing patient centered planned care delivery

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