Bellaire Clincal Labs Essay

Since the late 1980s, Medicare has reimbursed physician services using the Medicare Physician Fee Schedule (MPFS), which encompasses 10,000 procedure codes. Each code is assigned resource-based relative value units (RVUs), which are designed to reflect physician work, practice expense, and malpractice expense. To adjust for local differences in cost of living, each RVU is modified using geographic practice cost indexes (GPCIs) and then converted to dollars using a “conversion factor.” This system rewards physicians who produce a high volume of services; not surprisingly, Medicare Part B expenditures have grown rapidly.

Melnick, G., & Fonkycj, K. (2013). Fair pricing law prompts most California hospitals to adopt policies to protect uninsured patients from high charges. Health Affairs, 32(6), 1101-1108. Retrieved from http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/1372932073?accountid=2532

Currently it is often difficult to make informed decisions about their care because of the opaque nature of health care pricing. Houk and Cleverly (2014) contend that pricing transparency could give health care providers a chance to garner increases in patient census; even if they do not have the least expensive price for a specific procedure, by allow health care providers the qualify why their services cost what they do. The demand for price transparency should be embraced in the future because it could create a forum that allow actual competition for patients and allow health care providers a chance to differentiate

The real problem as pertains to the reimbursement of managed care organizations is that these managed care has had an effect on slowing the rates of growth concerning the costs of hospitals and specialist physicians. For both the hospitals and practitioners, the sources of revenue have been shifted with over 20 percent of the charges being paid from the pocket, others coming from third parties who demand for complex accounting of the charges, lack a pre-authorization process and they can review in a retrospective manner and deny the reimbursement (Furrow et al., 2013). The

The College of American Pathologists or CAP is the accrediting organization for laboratory and testing personnel. CAP’s “accreditation process is so thorough, the Joint Commission [and CMS] accepts …their standards” in place of conducting their own survey of the hospital’s laboratory and personnel (Gartee, 2011, p. 47). This is because of the guidelines they follow to maintain their integrity and to remain the industry standard. In recent years, the “CAP [has] developed new check list” for continued improvements. Additionally, they are continuing to vet the requirements for the new next-generation sequencing or NGC-based test that is speeding laboratory procedures. So much so that the recent adoption of the new technology for clinical testing” was done prior to the new standards being approved (Aziz, et.al. 2015, p. 481).

Congress held hearings at which people who had been harmed by laboratory errors testified. These hearings revealed serious deficits in the quality of work from physician office laboratories and in Pap smear testing results (R. D. Feld, M. Schwabbauer, and J. D. Olson, 2001, The Clinical Laboratory Improvement Act [CLIA] and the physician's office laboratory; Virtual Hospital, University of Iowa College of Medi-cine [www.vh.org/adult/provider/pathology/CLIA/CLIAHP.html]). In 1988, Congress once again responded to public concerns about the quality of laboratory testing by passing CLIA '88. CLIA '88 expanded the laboratory standards set by CLIA '67 and extended them to include any facility performing a clinical test. Currently, under CLIA '88,

For this study, I control for the total expenses in prescriptions, office-based expenses, and emergency room

The preanalytical errors increases health care costs and decreases the patient satisfaction. The laboratory errors that happen at any stage of the total testing process have influence on quality of laboratory services. Any errors that happen during this total testing process will affect the patient care that also includes unnecessary recollection of samples, delay in reporting, misdiagnosis and treatment by the clinician. Although the errors can happen at any stage of the total testing process, preanalytical errors accounts for highest percentage (70%). The consequences associated with analytical errors are significantly reduced by the use of modern laboratory instruments. But pre analytical phase is still prone to more errors due to its complexity and different stages that involved within and outside laboratory. The inaccurate reporting of results due to preanalytical errors leads to unnecessary investigations and creating an additional burden to the healthcare system (Kaushik, & Green, 2014). According to Green (2013) the healthcare economist created a model to quantify the costs associated with laboratory errors and poor sample quality. It is based on operating costs, number of beds, test volume, number of rejected samples, instrument problems and the frequency of inaccurate results reported by laboratory and their impacts. As per this model

Accreditation benefits all stakeholders and stimulates continuous improvement The laboratory acquires national and international recognition, credibility and acceptance by public as well as clinical decision makers by providing accurate and reliable results. The laboratory also saves time and gains financially by getting correct results at first instance.[5,6] Accreditation programs can help drive improvements in the management of individual laboratories and laboratory networks and may also have positive spillover effects on the performance in other sectors of the health care system. (7 ) Other benefits reported from engaging in accreditation include increases in team work and internal cohesion, motivation to standardize procedures, integration

The company is trying to make a revenue off the affluent patient by charging them with as much as possible through increasing their number of treatments and one on one therapist time. Whereas, with the less affluent patient, the campany is taking advantage through biases due to therapists not offering the same quality of care. These patients aren’t getting as many visits and aren’t allowed as much time with the more clinically experienced therapists. In addition to the information gathered above I would like to see the total cost of therapy for an average affluent patient as compared to the total average estimated cost of therapy for an underinsured less affluent patient for a treatment plan. I wonder if when compared with their pain scale, if the outcome will be the same although the cost will be significantly different due to the number of visits and the type of therapist.

I briefly touched on payer contract negotiations in my other post, but this will be an important consideration for many healthcare organizations as the industry undergoes payment model changes. Our Care Management Directors recently asked me to do some analysis on the denials and appeals we receive, including looking the volume of denials for different insurance providers, the number of appeals, and the reason the claim was denied. This will help to determine which insurance providers are denying reimbursement of services or require several appeals before they will overturn their decision and approve payment. Additionally, by looking at the length of time between when the appeal is sent and when a payer response is received, we can determine

21. An explanation of the likely changes (legal, economic, political, technical and environmental) and their impact onthe finance of the business, that will take place over three years.

As you can see in the charts above, we projected the additional revenue gained based on profit margin

The services must be “shoppable” in that patients have ample time to compare the price and quality of the service and provider (Robinson, “Referencing Pricing Changes”). Therefore, implementing reference pricing for emergency medical services would not be useful but can be used with items like laboratory services and diagnostic imaging. Measurable quality must also be taken into account as consumers cannot be expected to evaluate decisions on price if quality has not been accurately accounted. In the case of CalPERS, they had access to hospital data detailing surgical volume for joint replacements and evaluations conducted by the California hospital quality reporting system. Using reference pricing for complex treatments would not be optimal as every case would highly depend on disease severity rather than outcome, making quality comparisons difficult. Markets for these services should also have low barriers of entry to allow for a broad range of choices and to promote price competition that would shift market prices downward. Finally, the most crucial factor affecting the success of this model is the ability to provide transparent information to consumers that can direct them to low-cost, high-value services. For CalPERS, members were informed of their choices via a list of recommended hospitals but this could be further improved by utilizing online-price transparency tools that can report the price and quality of a broad range of services. The implementation of these systems could engage consumers to make cost-conscious decisions while narrowing the variability of prices charged by providers

According to the IBMS Point of care testing (Near patient Testing) guidance on the Involvement of the clinical laboratory, Near patient testing describes the “analytical procedures performed by patients by health care professionals outside the conventional laboratory”. This is due to the advance in technology and the convenience of carrying to tests in locations such as operating theatres, hospital wards and general practice surgeries in primary care.