Leveraging the Clinical Laboratory in the Accountable Care Era James M Crawford, MD, PhD
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1 Leveraging the Clinical Laboratory in the Accountable Care Era James M Crawford, MD, PhD Senior Vice President for Laboratory Services North Shore-LIJ Health System Chair, Department of Pathology Hofstra North Shore-LIJ School of Medicine Manhasset, NY
2 Leveraging Clinical Laboratory Data in the Accountable Care Era James M Crawford, MD, PhD Senior Vice President for Laboratory Services North Shore-LIJ Health System Chair, Department of Pathology Hofstra North Shore-LIJ School of Medicine Manhasset, NY
3 Disclosure Association of American Medical Colleges (AAMC) Chair sequence, Council Acad Societies Association of Pathology Chairs (APC) anything that moves : ACO, Health IT College of American Pathologists (CAP) anything that moves : ACO, Health IT Biomedical Research Alliance of New York (BRANY)* Vice Chair, Managing Committee *CRO for Clinical Trials
4 Drivers of Healthcare Reform 3/2009: American Recovery and Reinvestment Act HITEC 3/2010: Patient Protection and Affordable Care Act ACO 6/2012: Supreme Court Electronic Health Records, Meaningful Use Physician Network Consolidation: Private Payers, Employers Shared Risk Full Risk ACOs PCMH
5 The Changing Healthcare Delivery Landscape
6 The Changing Healthcare Delivery Landscape How is Pathology going to play a role?
7 NSLIJ: The Road to Success
8 NSLIJ Labs: The Car-in-Front
9 Reference laboratories Hospitals (26% of market) Network of SNFs 200+ practice locations
10 Centralized Laboratory Network Current (CLN) Outreach Hospital Lab RRL Plainview Southside Huntington Forest Hills Clinical Trials BARC Syosset SIUH North SIUH South LHH Core Lab Staten Island Lab NJ, Brklyn, SI Physician s Offices Nursing Homes Manhasset LIJ Glen Cove Franklin Physician s Offices Nursing Homes Non-System Hospital Reference Testing
11 Centralized Laboratory Network Current (CLN) Outreach Hospital Lab RRL Plainview Southside Huntington Forest Hills Clinical Trials BARC Quest Syosset SIUH North SIUH South LHH Core Lab NJ, Brklyn, SI Physician s Offices Manhasset Nursing Homes LIJ Glen Cove Franklin Physician s Offices Nursing Homes Non-System Hospital Reference Testing
12 SIUH Dept of Pathology & Laboratory Medicine: Pouch Terminal
13 SIUH Dept of Pathology & Laboratory Medicine: Pouch Terminal
14 Core + NS + LIJ Community LX SIUH NSLIJ Pathology and Laboratory Medicine Surgical Pathology Cases/year: North Shore-LIJ Mount Sinai Medical Center New York Mayo Clinic The Ohio State University The Cleveland Clinic University of Pittsburgh
15 Core-NS-LIJ Millions Comm LX SIUH NSLIJ Pathology and Laboratory Medicine Clinical Laboratory Tests/year: North Shore-LIJ Mayo Clinic Henry Ford The Cleveland Clinic
16 Your Value as a Laboratory Competitive Cost Safety and Quality Service Delivery Data Delivery Data Analytics Against the largest national labs The highest standards To Patients To Healthcare Providers To the Electronic Health Record To Providers (? Mobile Apps?) To Patients (Patient Portals) Managed Care Contracting Hospital Expense Management Healthcare Delivery Patient Outcomes
17 The Costs of Healthcare: 2010 Total $2.5 T Hospital care $661 B ($44B Hospital Lab) Physicians $320 B Drugs $235 B Dentists $ 94 B Outpatient Care Centers $ 43 B Physician Imaging $ 38 B Outpatient Hospital Imaging $ 25 B Medical and Diagnostic Labs $ 18 B ( In Vitro Dx ) Dental Labs $ 4 B Behavioral Health $ 2 B Research $ 44 B
18 National Laboratory Market = $62B* Quest 12% 8% LabCorp 62% 10% NSLIJ Labs $302M; 0.5% Hospital Labs Independent & Physician Office Labs *Laboratory Industry Outlook 2011, G-2 Report
19 CLIA Database 2012 Total POLs Laboratories Registered 232, ,634 Waiver 153,568 66,903 Provider Performed Microscopy 37,299 29,875 Compliance (CMS surveys) 19,354 12,597 Accreditation 15,658 5,704 COLA* 6,463 CAP 5,728* The Joint Commission 2,380 AABB 122* American Osteopathic Assoc 128 American Soc Histo Immuno 122 *Commission on Laboratory Accreditation *our universe
20 Downstate New York Outreach Market = $1.2B LabCorp 10% 30% Bioreference Lab Quest 40% 6% 6% NSLIJ Labs 4% $104M (9%) 5% Sunrise (Sonic USA) Enzi Other
21 Managed Care Opening Gambit Clawback Exclusive contract with national lab Negotiating back to a Carve-In
22 Managed Care Opening Gambit Clawback Financial Performance Costs Client Service Support of ACO Exclusive contract with national lab Negotiating back to a Carve-In How? Contribution to Health System Hospital savings Cost-per-Test Patient Experience Physician Satisfaction Coordinated Care Patient Outcomes Overall cost of Healthcare
23 Cost-per-Test Salaries and Benefits Reagents Rent and Utilities Repairs and Maintenance Depreciation Other
24 Cost-per-Test Salaries and Benefits Reagents Rent and Utilities Repairs and Maintenance Depreciation Other VOLUME Productivity Efficiency
25 Lab Revenue vs. Cost Fee-for-Service system Shared Risk/Full Risk Revenue opportunity Medical Loss Ratio Cost and Utilization Management applies regardless of Payment Model (you also have to manage Revenue Cycle during the transition)
26 Your Value as a Laboratory Competitive Cost Safety and Quality Service Delivery Data Delivery Data Analytics Against the largest national labs The highest standards To Patients To Healthcare Providers To the Electronic Health Record To Providers (? Mobile Apps?) To Patients (Patient Portals) Managed Care Contracting Hospital Expense Management Healthcare Delivery Patient Outcomes
27 Lab-run Phlebotomy Item Addressed Hospital Management Laboratory Management Walk-in Blood Draw 8:00am 5:00pm 6:30am 7:00pm Wait Time Complaints: > 20min <5min Off-tower AM Draws 11am 1pm By 9:00am Off-tower INR Results Complaints By 11:00am Staffing 4 Phlebomists * flex *32 Patient Service Centers around region
28 Home Care NSLIJ Core Laboratories: HOME PHLEBOTOMY DRAWS 200 per 2.4 Tests/draw = ~ 500 tests/day >100,000 Tests / year on 40,000 patients = 2% of our population of 1.6M unique patients To what end, and with what benefit?
29 2012 Physician-Engagement Survey 1380 Physicians (16%) 16 hospital sites 300 Ambulatory sites Pathology Services Highest ranked Ancillary service Both Client Service and Quality AP and CP
30 Enterprise EHR Ambulatory Laboratory Data Interoperability Enterprise EHR - Hospital Non-Enterprise EHR Inpatient-Ambulatory
31 Enterprise EHR Ambulatory Laboratory Data Interoperability Enterprise EHR - Hospital X X X Non-Enterprise EHR Inpatient-Ambulatory
32 Enterprise EHR Ambulatory Laboratory Data Interoperability Enterprise EHR - Hospital * HIE* * * Non-Enterprise EHR Inpatient-Ambulatory *Health Information Exchange *Laboratory Information System
33 First: Mobile Health Am J Public Health 1930; 20: 80-84
34 PCMH vs ACO Hospitals Emergency SNF, Rehab PCMH Practices Pharmacy, Laboratory, Imaging Mobile Health Living at Home
35 Objectives: Healthcare Providers Mobile Apps Synchronize smoothly with EHR Capture all billable events Capture all biometrics and medications CPOE for Lab Testing Push Lab Values out Upload right information at right time on right patient to right provider Do not degrade patient-centered focus Are secure
36 Your Value as a Laboratory Competitive Cost Safety and Quality Service Delivery Data Delivery Data Analytics Against the largest national labs The highest standards To Patients To Healthcare Providers To the Electronic Health Record To Providers (? Mobile Apps?) To Patients (Patient Portals) Managed Care Contracting Hospital Expense Management Healthcare Delivery Patient Outcomes
37 ACO: Population-based Healthcare Outcomes Patient Centered Medical Home HIT Personalized Medicine
38 Integrated Data: the Patient Data Interoperability current: Ambulatory EHR, Inpatient EHR, Laboratory, Claims, Medications future: Emergency (EDIS), Imaging (PACS), Pharmacy, Dentistry Laboratory must take initiative in driving interoperability. Data Completeness EHR = structured data meaningful use Data Access: Information at the point-of-care Includes Mobile Technologies for laboratory data. EXECUTION: The Care Plan Access and input: multiple providers Critical Pathway: the chronological order of execution
39 Integrated Data: the Population Population Segmentation by disease condition by beneficiary coverage (contracts) by Care Plans: What do your patients need, when, and in what order? Population Reporting Patient Registries Population Metrics How does our Laboratory Data inform Population Outcomes? THE LEARNING HEALTHCARE SYSTEM The best data is your own Monitor your practice patterns and outcomes Modify, innovate, improve
40 The Race to the Bottom = Margin
41 Rebalancing = Margin Utilization Interpretation Care Coordination
42 Managed Care Fee-for-Service Shared Risk Strong incentive for utilization Utilization is a cost We will have to justify Utilization of our services, And Valuation thereof. BUILD YOUR OWN STORY
43 James M Crawford, MD, PhD jcrawford1@nshs.edu
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