Utilization Management in the Clinical Laboratory and Other Ancillary Services

299 Pages·2017·15.29 MB·English

by  Kent Lewandrowski

Kent Lewandrowski Editor
Patrick M. Sluss Associate Editor
Utilization Management in
the Clinical Laboratory and
Other Ancillary Services
123
Utilization Management in the Clinical Laboratory
and Other Ancillary Services
Kent Lewandrowski
Editor
Patrick M. Sluss
Associate Editor
Utilization Management
in the Clinical Laboratory
and Other Ancillary Services
Editor
Kent Lewandrowski
Division of Laboratory Medicine
Department of Pathology
Massachusetts General Hospital
and Harvard Medical School
Boston , MA , USA
Associate Editor
Patrick M. Sluss, PhD, MA
Pathology Service Core Laboratories
Massachusetts General Hospital
Boston , MA , USA
ISBN 978-3-319-34197-2 ISBN 978-3-319-34199-6 (eBook)
DOI 10.1007/978-3-319-34199-6
Library of Congress Control Number: 2016955239
© Springer International Publishing Switzerland 2017
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Pref ace
The rising cost of health care in the United States and most developed countries is creating
increasing pressure to control medical care expenditures. This is true regardless of whether the
payer is a government agency or a private sector insurance company. In the United States, mil-
lions of citizens lack health insurance altogether. These “self-pay” patients face fi nancial ruin
if they become seriously ill, and many must forgo even basic medical services including pre-
ventative care. The Affordable Care Act (ACA) of 2010 was intended to expand coverage for
the uninsured and to reduce projected health-care expenditures by restructuring the way in
which medical care was reimbursed. Previously the American health-care system was largely
based on a fee-for-service arrangement wherein providers were paid for each unit of service.
This encouraged hospitals and physicians to provide more care than was sometimes necessary
and resulted in a misalignment of incentives between payers and the providers. As described
in Chap. 1, the ACA includes provisions to shift reimbursement from the traditional fee-for-
service system that encourages increasing the volume of care to value-based contracts utilizing
bundled payments for episodes of care (or even entire populations). The ACA also includes
quality metrics and risk sharing arrangements to better align the incentives between payers and
providers. Whether the intended outcomes of the ACA are eventually realized or not will take
some years to be determined. Regardless of the eventual fate of the ACA, the pressure to con-
tain health-care costs will continue to increase. Similar pressures will be experienced in other
developed countries including those with largely government-fi nanced health-care systems.
A ncillary services including the clinical laboratory, radiology, and pharmacy are common
targets of utilization management programs. This is because these services are frequently per-
ceived to be overutilized and because they can be easily quantifi ed in terms of the units of
service provided and their attendant costs. The available menu of laboratory tests continues to
expand including the rapid introduction of high-cost genetic and molecular diagnostic assays.
As well, the number of pharmaceuticals and radiological procedures is also steadily expanding
with many new high-cost drugs and scans becoming available. The growth in technologies
available to medical providers will continue to drive increases in health-care costs. When this
is combined with the aging populations in most developed countries and increasing life spans,
the prospects for relentless and potentially ruinous increases in the cost of medical care are
drawing increasing concern.
There are a number of approaches that can be employed to reduce health-care expenditures
including:
1. Reducing reimbursements to providers for individual units of service
2. Arbitrarily reducing (or delaying) the amount of care that is provided
3. Improving the effi ciency of the health-care system such that units of care can be provided
at a lower unit cost
4. Implementing evidence-based utilization management programs to reduce or eliminate
unnecessary care
v
vi Preface
There is an extensive literature on utilization management of ancillary services as is illus-
trated by the bibliographies accompanying many of the chapters in this book. However, the
literature has been spread across multiple journals and other published sources spanning sev-
eral decades. It is therefore diffi cult for individuals who are exploring utilization management
initiatives to compile and assimilate what has been previously published as a starting point for
implementing a utilization management program. We realized the need for a textbook dedi-
cated to providing medical professionals with a concise but comprehensive review of utiliza-
tion management in the clinical laboratory. We also chose to include chapters on utilization
management in the pharmacy and in radiology. One chapter provides an international perspec-
tive Canada. In an effort to achieve as broad a representation of the topic as possible, we asked
a number of colleagues to contribute chapters refl ecting their own expertise and personal expe-
riences. The chapters included in the book are as follows:
“Health-Care Reform and Its Impact on Medical Reimbursement”
“Utilization Management in the Clinical Laboratory: An Introduction and Overview”
“Effective Governance Structure and Management of Utilization Programs”
“Informatics and Decision Support in Utilization Management”
“Utilization Management Employing Test Interpretations and Algorithms”
“Calculating Costs and Savings in Utilization Management”
“Benchmarking and Management Metrics in Utilization Management”
“Laboratory Formularies”
“Utilization and Other Resource Management in Clinical Chemistry”
“Utilization Management in Routine Hematology”
“Patient Blood Management”
“Utilization Management of Blood Derivatives”
“Utilization Management in the Clinical Microbiology Laboratory”
“Utilization Management in a Large Community Hospital”
“Utilization Management: The Role of Reference Laboratories”
“Utilization Management in Anatomic Pathology”
“Utilization Analysis in Hematopathology”
“Test Utilization: Controlling Cost in Reference Laboratory Testing”
“Utilization Management of Genetic Testing”
“ The Use of Physician Profi ling and Prior Approval (Gatekeeping) in Utilization
Management in the Clinical Laboratory”
“Test Utilization: The Essential Role of the Clinical Consultant”
“The Role of the Genetic Counselor in Utilization Management”
“Utilization Management in Radiology”
“Strategies for the Clinical and Financial Management of Drug Utilization”
“Laboratory Utilization Management in Canada”
“Utilization Management Initiatives That Can Be Imported into Healthcare Systems”
We wish to thank the authors for their willingness to contribute to this special edition and
hope that the information contained in the articles is both educational and of practical use to
those who are engaged in utilization management activities.
Boston, MA, USA Kent Lewandrowski
Patrick M. Sluss
Contents
1 Health-Care Reform and Its Impact in Medical Reimbursement ....................... 1
Luis Ticona
2 Utilization Management in the Clinical Laboratory:
An Introduction and Overview ............................................................................... 7
Kent Lewandrowski , Jason Baron , and Anand Dighe
3 Effective Governance Structure and Management of Utilization Programs ...... 31
Jeffrey S. Warren
4 Informatics, Analytics, and Decision Support in Utilization Management ........ 39
Jason Baron
5 Utilization Management Employing Test Interpretations and Algorithms ........ 53
Elizabeth M. Van Cott
6 Calculating Costs and Savings in Utilization Management ................................. 61
Patrick M. Sluss
7 Benchmarking and Management Metrics in Utilization Management .............. 75
Ida Bixho and Stacy E. F. Melanson
8 Laboratory Formularies .......................................................................................... 83
Petr Jarolim
9 Utilization and Other Resource Management in Clinical Chemistry ................. 89
Alan H. B. Wu
10 Utilization Management in the Routine Hematology Laboratory ...................... 95
Joseph Rudolf and Kent Lewandrowski
11 Patient Blood Management ..................................................................................... 105
Cyril Jacquot and Evan M. Bloch
12 Utilization Management of Blood Derivatives ....................................................... 135
Stephan Kadauke
13 Utilization Management in the Clinical Microbiology Laboratory..................... 141
Kent Lewandrowski , Eric S. Rosenberg , and John A. Branda
14 Utilization Management in a Large Community Hospital ................................... 151
Frederick L. Kiechle and Rodney C. Arcenas
15 Utilization Management: The Role of Reference Laboratories ........................... 171
Brian Jackson
16 Utilization Management in Anatomic Pathology .................................................. 177
Kent Lewandrowski
vii
viii Contents
17 Utilization Analysis in Hematopathology .............................................................. 189
Annette S. Kim , Claudio A. Mosse , Aaron C. Shaver , and Adam C. Seegmiller
18 Laboratory Utilization ............................................................................................. 203
Daniel Dante Yeh
19 Test Utilization: Controlling Costs in Reference Laboratory Testing ................. 211
Valerie L. Ng
20 Utilization Management of Genetic Testing .......................................................... 219
Jane A. Dickerson , Jessie H. Conta , and Christina M. Lockwood
21 The Use of Physician Profiling and Prior Approval (Gatekeeping)
in Utilization Management in the Clinical Laboratory ........................................ 235
Kent Lewandrowski and Jason Baron
22 Test Utilization: The Essential Role of the Clinical Consultant ........................... 247
Elizabeth Stewart and Valerie L. Ng
23 The Role of the Genetic Counselor in Utilization Management
of Genetic Testing ..................................................................................................... 261
Kelly Branda
24 Utilization Management in Radiology ................................................................... 267
Garry Choy and Alexander Ryu
25 Strategies for the Clinical and Financial Management of Drug Utilization ....... 273
Christopher Fortier , Prabashni Reddy , Nathan Thompson ,
and Andy Pulvemacher
26 Laboratory Utilization Management in Canada ................................................... 279
Christopher Naugler
27 Utilization Management Initiatives That Can Be Imported
into Healthcare Systems .......................................................................................... 287
Patrick M. Sluss
Index .................................................................................................................................. 291
About th e Editor
Kent Lewandrowski, MD is the director of Pathology, Laboratories and Molecular Medicine,
and associate chief of pathology at the Massachusetts General Hospital. He is also director of
the hospital point-of-care program and the quality chair of the Department of Pathology. He is
a professor at Harvard Medical School with research interests in the evaluation of point-of-care
technologies and outcomes studies concerning implementation of point-of-care testing. Dr.
Lewandrowski was trained in anatomic and clinical pathology at the Massachusetts General
Hospital and has been on the staff of the Department of Pathology since 1991. He is also editor
in chief of the medical journal P oint of Care: The Journal of Near Patient Testing Technologies .
Patrick M. Sluss, PhD, MA is one of the fi ve associate directors of the central laboratory core
that provides roughly 11 million test results per year for clinicians at the Massachusetts General
Hospital. He also directs the clinical pathology laboratory at Spaulding Rehabilitation Hospital
and is an Associate Professor of Pathology at Harvard Medical School. Dr. Sluss received his
PhD in Physiology and Biophysics from the Colorado State University (1981) and completed
his NIH postdoctoral training in Biochemistry at Albany Medical College in New York (1984).
Dr. Sluss joined the faculty at Massachusetts General Hospital in 1991. His clinical and
research interests have focused on the development and clinical implementation of methods
for the measurement of protein and steroid biomarkers.
ix
Contributors
Rodney C. Arcenas M icrobiology, Molecular Microbiology Laboratory, Department of
Clinical Pathology, M emorial Regional Hospital, Pathology Consultants of South Broward,
LLP , Hollywood , FL , USA
Jason Baron Department of Pathology , Massachusetts General Hospital , Boston , MA , USA
Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
Ida Bixho D epartment of Pathology and General Internal Medicine/Primary Care, B righam
and Women’s Hospital , Boston , MA , USA
Evan M. Bloch Department of Pathology Transfusion Medicine Division, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
John A. Branda Department of Pathology , Massachusetts General Hospital , Boston , MA ,
USA
Kelly Branda Informed DNA , St. Petersburg , FL , USA
Garry Choy Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
Jessie H. Conta Department of Laboratories , Seattle Children’s Hospital , Seattle , WA , USA
Elizabeth M. Van Cott Massachusetts General Hospital , Boston , MA , USA
Jane A. Dickerson Department of Laboratories , Seattle Children’s Hospital , Seattle , WA , USA
Anand Dighe D epartment of Pathology, M assachusetts General Hospital and Harvard
Medical School , Boston , MA , USA
Christopher Fortier Department of Pharmacy , Massachusetts General Hospital , Boston ,
MA , USA
Brian Jackson ARUP Laboratories , University of Utah , Salt Lake City , UT , USA
Cyril Jacquot Departments of Laboratory Medicine and Hematology, Children’s National
Medical Center, Washington, DC , USA
Petr Jarolim Department of Pathology , Brigham and Women’s Hospital, Harvard Medical
School , Boston , MA , USA
Stephan Kadauke Department of Pathology , Massachusetts General Hospital , Boston ,
MA , USA
Frederick L. Kiechle Department of Clinical Pathology , Memorial Regional Hospital,
Pathology Consultants of South Broward, LLP , Hollywood , FL , USA
Annette S. Kim Department of Pathology , Brigham and Women’s Hospital , Boston , MA , USA
Kent Lewandrowski Division of Laboratory Medicine, Department of Pathology ,
Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA
xi