News, Analysis, Trends, Management Innovations for
Clinical Laboratories and Pathology Groups

Hosted by Robert Michel

News, Analysis, Trends, Management Innovations for
Clinical Laboratories and Pathology Groups

Hosted by Robert Michel
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Push by ACOs to Give Patients a Stake in Their Healthcare Provides Opportunities for Engagement by Clinical Laboratories and Pathologists

With payouts riding on patient outcomes and value, ACO providers will welcome innovative services that clinical labs and pathologist could provide that improve patient outcomes

Both private health insurance companies and employers are betting on value-based insurance as the key to improving healthy behavior in patients. This will require more patient engagement in managing their chronic conditions. It will also include motivating patients to consider less expensive treatment options, particularly when the more expensive treatment path has limited benefits.

In this way, accountable care brings the patient into picture. It is a trend that opens the door for innovative clinical laboratories and anatomic pathology group practices to develop medical laboratory testing services that payers and employers recognize as contributing to improved patient outcomes—and for which they will adequately reimburse the laboratories providing these services.

Private Health Insurers Have More Flexibility in Design of Health Plans (more…)

California’s New Health Insurance Exchange May be Unexpectedly Low, but Co-pays for Outpatient Services Are Relatively High

High Co-pays for Lab Tests May Create a Collection Nightmare for Clinical Laboratories
As new facts about the prices of premiums and the amount of patient co-pays for California’s health information exchange—called Covered California—are published, the news is not likely to be favorable for clinical laboratories and anatomic pathology groups in the Golden State.

Of particular note is that Covered California has published a requirement that patients will be charged a $35 co-pay for medical laboratory testing. Some lab industry executives have pointed out that it will be a challenge to collect these co-pays. They expect labs will incur higher costs attempting to collect these co-pays while at the same time seeing a substantial increase in levels of bad debt. However, all of this will not happen until 2014, when Covered California begins providing health insurance coverage.

For one category of insured beneficiaries, there is a bit of good news. Insurance exchange premiums for individuals not covered by employer health plans will be lower than previously expected. Covered California will charge, on average, $321 per month on average for the “Silver,” medium-tier plan, noted Peter V. Lee, Executive Director of Covered California, in a report published by the Wall Street Journal. (more…)

Vanderbilt University Medical Center Forms Nation’s Largest Clinically Integrated Network that includes Its Own Health Insurance Offering

Clinically integrated networks is one market trend in response to shift away from fee-for-service payment and toward value-based provider reimbursement

One fast-developing trend is that of academic centers forming integrated networks with various providers within a community and a surrounding region. This is related to a movement to establish accountable care organizations (ACOs). But it is also a response to actions by payers to narrow their networks and exclude high-cost providers, such as academic centers.

This business model has a mutual goal. Each integrated network is anchored by an academic medical center and is designed to foster closer interaction between the academic subspecialists and the wider clinical community. For pathologists and clinical lab managers, such integrated provider networks may often encourage participating physicians to send their reference and esoteric medical laboratory test referrals to the academic center and not to the physicians’ primary laboratory provider. (more…)

Consolidation of Nation’s Health Insurers Is Bad Medicine for Local Labs and Pathologists

While no one was looking, nine big insurers grabbed 76.7% of privately-insured patients!

Consolidation of major health insurance companies in recent years is a trend which reinforced the market clout of the nation’s two largest lab companies at the expense of local laboratories and pathology groups. However, few pathologists and clinical lab managers know precisely how much market power is currently concentrated into the hands of only a few health insurance companies.

Dark Daily now unveils a remarkable analysis. At this moment, just nine companies control 76.7% of all privately-insured individuals in the United States! Moreover, the three biggest of these health insurance firms—UnitedHealth Group, WellPoint, and Aetna—collectively cover 85.6 million of the185 million Americans enrolled in private health plans. That’s 48.3% of the total U.S. market.

As shown in the table below, when the other six companies are added—Humana, HealthCare Service Corp., Cigna Group, Kaiser, Highmark and Health Net—the nine biggest health insurers cumulatively insure 141.9 million of the 185.1 million Americans with private health insurance—or 76.7% of the total.
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UnitedHealth Offers Medicare 15 Ways to Save $540 Billion, While Improving Care Quality

List of recommendations based on UnitedHealth’s extensive database and experience

Every sector of the healthcare industry is offering both Congress and the Center for Medicare & Medicaid Services (CMS) advice on how to reform the system to improve quality of care, while reducing costs. Too often, the search for ways to save money that can be redirected to covering uninsured is a game of taking money from one existing health service and shifting it to another.

Recently UnitedHealth Group (NYSE:UNH) stepped into this debate over how to save money. In important ways, it is better positioned to provide this advice than most other entities. For example, UnitedHealth Group is the nation’s largest insurer in terms of revenue. UNH funds and organizes care for 70 million Americans. It arranges $115 billion in health care services provided by 5,000 hospitals and 650,000 physicians nationwide. Because of this, UNH’s Center for Modernization and Reform has collected more data on clinical services provided and resulting healthcare outcomes than anyone else.
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