Laboratory Services in Accountable Care Organizations

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1 Laboratory Services in Accountable Care Organizations

2 Laboratory Services in Accountable Care Organizations Published by: G2 Intelligence PO Box 509 New London, CT Customer Service: Fax:

3 2015 Plain Language Media, LLLP Printed in the United States of America G2 Intelligence PO Box 509 New London, CT Customer Service: Fax: Mark Ziebarth Pete Stowe President and Publisher Publisher Laboratory Services in Accountable Care Organizations Analyst Jenny Xu, Ph.D All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic or mechanical, without the prior written permission of Plain Language Media, LLLP, New London, CT. This document is protected by copyright law. It is illegal under federal law (17USC101 et seq.) to copy or fax any of the contents of this document even for internal use without permission. Violators risk criminal prosecution and penalties of up to $150,000 in damages per offense. To report copyright abuses, please contact Jim Pearmain at or 2 Notice: No part of this publication may be reproduced, stored in a retrieval system or transmitted by any means, electronic or

4 Table Of Contents Table of Contents CHAPTER 1: Overview and Outlook... 7 Report Objective...7 Report Scope...7 Target Audience...7 Methodology...8 Report Overview...9 Outlook for ACOs and Laboratory Services CHAPTER 2: ACO Market Landscape...21 ACO Background and Overview ACO Taxonomies ACO Growth The Future of ACOs CHAPTER 3: Structural Changes in Laboratory Services in ACOs...47 Overview Laboratory Service Provider Changes Laboratory Test Volume Dynamics Laboratory Outreach...74 CHAPTER 4: Financial Changes to Laboratory Services in ACOs...81 Overview Reimbursement Cuts for Laboratory Tests Laboratory Budget Cuts Payment Model Changes CHAPTER 5: Value of Laboratory Services in ACOs Laboratory Services Must Focus on Value in ACOs ACO s Value Perception of Laboratory Services - A Snapshot Effective Laboratory Value Initiatives in ACOs Summary CHAPTER 6: Key Insights, Implications and Recommendations Key Insights Implications and Recommendations for Action Conclusion APPENDIX A: Risk Stratification Methods About the Analyst About G2 Intelligence Notice: No part of this publication may be reproduced, stored in a retrieval system or transmitted by any means, electronic or 3

5 Table of Figures Value-Based Payment Models Laboratory Initiatives Shift Focus from Efficiency to Effectiveness ACO Taxonomy Growth in MSSP ACOs by Count Key Differentiators for Three Medicare ACO Models Distribution of Medicare ACOs by Population Density Share of Commercial ACOs by Payer Cigna s Collaborative Accountable Care (CAC) Aetna s ACO Strategy Growth in ACO Count Growth in Physician-Led ACOs vs. Hospital ACOs, Share of Government vs. Commercial ACOs, May Growth in ACO Covered Lives (Risk Contracts Only, in Millions) ACO Covered Lives by Sector, June Projected ACO Covered Lives (Risk Contracts Only, in Millions) Growth in ACO Reach Percent of Laboratories Closed Post-ACO Formation Percent of Laboratories Experienced Changes Post-ACO Formation Hospital and Health System Mergers and Acquisitions Physicians by Practice Setting Trends in Laboratory Consolidation Percent of ACOs Switched Contracts to Lower-Cost Laboratories ACOs Switched Contracts to These Types of Laboratories ACOs Lost Volume to These Types of Laboratories Overall Laboratory Test Volume Changes since Start of the ACO Scope of Increase/Decrease of Laboratory Test Volume Drivers of Laboratory Test Volume Increase Drivers of Laboratory Test Volume Decrease Prevention, Screening, and Wellness Test Volume Changes since Start of the ACO Scope of Increase/Decrease of Prevention, Screening, and Wellness Test Volume U.S. HHS Essential Health Benefits USPSTF Grade A and B Preventive Services Projected Numbers of New Cancer Cases/Growth Rates by Site (Number of People in Thousands)...71 Screening for Cancer (USPSTF Recommendations) Measures That Matter Identified by Medicaid s Million Hearts Program Percent of Laboratories Launching Outreach Initiatives by ACO Perception of Laboratory Value...74 Percent of Outreach Volume Lost to Competing Laboratories Changes in Laboratory Outreach since Start of the ACO Changes in Laboratory Outreach by ACO Length Elements of a Successful Laboratory Outreach Business Notice: No part of this publication may be reproduced, stored in a retrieval system or transmitted by any means, electronic or

6 ACO s Financial Compensation for Laboratory s Value Contribution Reasons for Laboratory Exclusion from Value-Based Compensation Percent of Laboratories Receiving Proper Financial Compensation by ACO Length Percent of Laboratories Receiving Lower Reimbursement Rates since Start of ACOs Progressive Medicare Reimbursement Cuts for CLFS P Laboratory Budget Cuts in ACOs Scope of Laboratory Budget Cuts in ACOs Value-Based Payment Models Payment Models Used by ACOs Methodology for Calculating Shared Savings and Losses for MSSP ACOs.. 96 Likelihood of Adopting Two-Sided Risk Model by MSSP ACOs Pay-for-Performance Inclusion in Laboratory Contracts Bundling and Capitation for Laboratory Services Hospital Laboratory Revenue by Patient Type Percent of Value-Based Payments by Segment Percent of At-Risk Payments vs. Not-At-Risk Payments Percent of Value-Based Payments by Payment Models Laboratory-Related Medicare ACO Quality Measures Perception of Laboratory Services by Respondent Type Percent of ACO Executives Who View Laboratory Services as Very Valuable ACO Executives View of the Significance of Laboratory Services to ACO Success Laboratory Directors Report of Laboratory s Value Contributions to ACOs Laboratory Directors Report of Laboratory s Value Recognition by ACOs Percent of Laboratories Actively Pursuing Value Initiatives by ACO Length Laboratory Value Initiatives in ACOs Laboratory Initiatives That Shape ACO s Perception of Laboratory Value Complexity Challenges in Clinical Decision Making Turning Test Data to Test Knowledge Tactics for Reducing Uncertainty among PCPs in Interpreting Laboratory Results Clinical Impact of Genetic Tests and Genomic Applications Connecting Laboratory Services to Patient Outcomes HIT Contributions to Improved ACO Performance Laboratory HIT Initiatives to Drive Interoperability Challenges Laboratories Encountered in Driving Interoperability Population Health Management Core Activities Risk Stratification and Associated Goals and Intervention Strategies for Each Patient Group Geisinger Uses Laboratory Data to Drive and Show Success of Care Gap Management Programs Drivers for Data Analytics Laboratories Contract with Vendors to Support ACO Performance Laboratory Services in Accountable Care Organizations Notice: No part of this publication may be reproduced, stored in a retrieval system or transmitted by any means, electronic or 5

7 Laboratory Initiatives in Population Health Management Mayo Clinic Testing Cascade: Pernicious Anemia Laboratory Test Utilization Initiatives Laboratory Services Influence Value in Two Ways Laboratory Initiatives Shift Focus from Efficiency to Effectiveness Laboratory Services Experience More Changes as ACOs Mature Laboratory Services Experience More Financial Changes in Commercial ACOs Laboratory Participation in ACO Discussions Laboratory Participation in ACO Discussions Impacts Ratings of Laboratory Value in ACOs Laboratory Participation Impacts Perceptions of Laboratory Services in ACOs Laboratory s Eligibility for Shared Savings in ACOs Participation in ACO Discussions Influences Laboratory s Eligibility for Shared Savings View of Laboratories as Contributors to ACO Success Influences Laboratory s Eligibility for Shared Savings Laboratory Engagement in Value Initiatives and ACO Leadership Notice: No part of this publication may be reproduced, stored in a retrieval system or transmitted by any means, electronic or

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