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.
2

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.
3

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.
4

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.
5

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.
6

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
7

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
8

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
9

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
10

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
11

POCT Economics: Cost
Cost must look at the whole process of patient care,
rather than just the cost of an individual POCT method
vs. 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.
12

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.
13

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
14

POCT We Utilize
• Sugar
• Hg A1C
• Lipid Profile
• INR
• Urinalysis and Pregnancy test
• Lead and H&H
• Rapid Strep
• RSV
• Rapid Flu A/B
15

POCT Precision for HbA1c and Lipids
• Comparison studies to reference labs are
standardized and available
• Scatter Plots useful
• Correlation Coefficients > 95%
• Correlation Variables < 2%
16

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
17

HbA1c POCT Volume of Diabetic Patients
• # 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
18

Lipids POCT Volumes All Patients
• # 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
19

Lipids POCT Volumes Diabetes Patients
• # 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
20

Patient Volume for HbA1c & Lipid POCT
21
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 d
OFFSITE
Patients with testing d
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
22

POCT
CHECK
LIST OF
WCPC
23
87880-Strep Allowance Cost
Medicare $15.13 $1.87 $13.26 Profit
MA products $6.30 $1.87 $4.43 Profit
Geisinger $12.31 $1.87 $10.44 Profit
Blue Shield $15.29 $1.87 $13.42 Profit
First Priority Life $11.76 $1.87 $9.89 Profit
81025_Pregnancy Test
MA products $4.00 $1.00 $3.00 Profit
87807-RSV
MA Products $12.31 $11.36 $.95 Profit
Geisinger $12.31 $11.36 $.95 Profit
Blue Shield $11.89 $11.36 $.53 Profit
87804-Rapid Flu A/B
Medicare $16.49 x 2 = $32.98 $12.50 $20.48 Profit
Ma Products $11.35 x 2 = $22.70 $12.50 $10.20 Profit
Geisinger $12.31 x 2 = $24.62 $12.50 $12.12 Profit
Blue Shield $14.84 x 2 = $29.68 $12.50 $17.18 Profit
First Priority Life $11.76 x 2 = $23.52 $12.50 $11.02 Profit

POCT
CHECK
LIST
24
80061-Lipid Profile ALLOWANCE COST
Ma Products $14.00 $10.80 $3.20 Profit
83036 - Hg A1C
Ma Products 0
83655-Lead
85013 -
85018 -
85610- Protime Profit Alone 99211 - Level 1 OV Profit w/Level 1
Medicare $5.40 $4.69 $.71 Profit $19.24 $19.95
Ma Products $4.00 $4.69 $20.00 $19.31
Geisinger $4.39 $4.69 $20.08 $19.78
Blue Shield $3.78 $4.69 $30.00 $29.09
First Priority Life $5.62 $4.69 $.93 Profit $26.00 $26.93
With the Coumadin
Clinic we charge a
Level 1 visit along
with the 85610

Track, Promote and Determine Affordability
25
Allowance Cost Profit
80061-Lipid Profile
83036 - HbA1c
Ma Products 0

6 Month Revenue Generated
26

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
27

Affordability Punch Line Excluding
Uncovered Services
• HBA1C Per Service Collection $ 9.85 versus
cost of $ 8.33
• Six Month Profit: $259
28

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.
29

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.
30

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%
32

For Lipid testing we use
33
• Cholestech LDX for
lipid
• The Coefficient of
Variability (CV) is 2-3%

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