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Clinical Laboratories and Pathology Groups

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

Hosted by Robert Michel
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Kaiser Family Foundation Reports on Prior Authorization Denial Rates by Medicare Advantage Plans

Another report finds nearly half of all healthcare systems planning to opt out of Medicare Advantage plans because of issues caused by prior authorization requirements

Prior-authorization is common and neither healthcare providers (including clinical laboratories) nor Medicare Advantage (MA) health plans are happy with the basic process. Thus, labs—which often must get prior-authorization for molecular diagnostics and genetic tests—may learn from a recent KFF study of denial rates and successful appeals.

“While prior authorization has long been used to contain spending and prevent people from receiving unnecessary or low-value services, it also has been [the] subject of criticism that it may create barriers to receiving necessary care,” KFF, a health policy research organization, stated in a news release.

Nearly all MA plan enrollees have to get prior authorization for high cost services such as inpatient stays, skilled nursing care, and chemotherapy. However, “some lawmakers and others have raised concerns that prior authorization requirements and processes, including the use of artificial intelligence to review requests, impose barriers and delays to receiving necessary care,” KFF reported.

“Insurers argue the process helps to manage unnecessary utilization and lower healthcare costs. But providers say prior authorization is time-consuming and delays care for patients,” Healthcare Dive reported.

“There are a ton of barriers with prior authorizations and referrals. And there’s been a really big delay in care—then we spend a lot of hours and dollars to get paid what our contracts say,” said Katie Kucera (above),Vice President and CFO, Carson Tahoe Health, Carson City, Nev., in a Becker’s Hospital CFO Report which shared the health system’s plan to end participation in UnitedHealthcare commercial and Medicare Advantage plans effective May 2025. Clinical laboratories may want to review how test denials by Medicare Advantage plans, and the time cost of the appeals process, affect the services they provide to their provider clients. (Photo copyright: Carson Tahoe Health.)

Key Findings of KFF Study

To complete its study, KFF analyzed “data submitted by Medicare Advantage insurers to CMS to examine the number of prior authorization requests, denials, and appeals for 2019 through 2022, as well as differences across Medicare Advantage insurers in 2022,” according to a KFF issue brief.

Here are key findings:

  • Requests for prior authorization jumped 24.3% to 46 million in 2022 from 37 million in 2019.
  • More than 90%, or 42.7 million requests, were approved in full.
  • About 7.4%, or 3.4 million, prior authorization requests were fully or partially denied by insurers in 2022, up from 5.8% in 2021, 5.6% in 2020, and 5.7% in 2019.
  • About 9.9% of denials were appealed in 2022, up from 7.5% in 2019, but less than 10.2% in 2020 and 10.6% in 2021.
  • More than 80% of appeals resulted in partial or full overturning of denials in the years studied. Still, “negative effects on a person’s health may have resulted from delay,” KFF pointed out.

KFF also found that requests for prior authorization differed among insurers. For example:

  • Humana experienced the most requests for prior authorization.
  • CVS plans had the highest denial rate with 13%.
  • Anthem had the lowest with 4.2%.

Among all MA plans, the share of patients who appealed denied requests was small. The low rate of appeals may reflect Medicare Advantage plan members’ uncertainty that they can question insurers’ decisions, KFF noted.

Providers Opt Out of MA Market

Nearly 33 million people are members of Medicare Advantage plans, and seniors have about 40 different plans to choose from in 2025, according to the American Association for Medicare Supplement Insurance.

It’s a big market. Nevertheless, “between onerous authorization requirements and high denial rates, healthcare systems are frustrated with Medicare Advantage,”  according to a Healthcare Financial Management Association (HFMA) survey of 135 health system Chief Financial Officers.

According to the CFOs surveyed, 19% of healthcare systems stopped accepting one or more Medicare Advantage plans in 2023, and 61% are planning or considering ending participation in one or more plans within two years.

“Nearly half of health systems are considering dropping Medicare Advantage plans,” Becker’s reported.

Federal lawmakers acted, introducing three bills to help improve timeliness, transparency, and criteria used in prior authorization decision making. Starting in 2023, KFF reported, the federal Centers for Medicare and Medicaid Services (CMS) published final rules on the bills:

Rule One (effective June 5, 2023), “clarifies the criteria that may be used by Medicare Advantage plans in establishing prior authorization policies and the duration for which a prior authorization is valid. Specifically, the rule states that prior authorization may only be used to confirm a diagnosis and/or ensure that the requested service is medically necessary and that private insurers must follow the same criteria used by traditional Medicare. That is, Medicare Advantage prior authorization requirements cannot result in coverage that is more restrictive than traditional Medicare.”

Rule Two (effective April 8, 2024), is “intended to improve the use of electronic prior authorization processes, as well as the timeliness and transparency of decisions, and applies to Medicare Advantage and certain other insurers. Specifically, it shortens the standard time frame for insurers to respond to prior authorization requests from 14 to seven calendar days starting in January 2026 and standardizes the electronic exchange of information by specifying the prior authorization information that must be included in application programming interfaces starting in January 2027.”

Rule Three (effective June 3, 2024), requires “Medicare Advantage plans to evaluate the effect of prior authorization policies on people with certain social risk factors starting with plan year 2025.”

KFF’s report details how prior authorization affects patient care and how healthcare providers struggle to get paid for services rendered by Medicare Advantage plans amid the rise of value-based reimbursements.

Clinical laboratory leaders may want to analyze their test denials and appeals rates as well and, in partnership with finance colleagues, consider whether to continue contracts with Medicare Advantage health plans.

—Donna Marie Pocius

Related Information:

Use of Prior Authorization in Medicare Advantage Exceeded 46 Million Requests in 2022

Medicare Advantage Plans Denied a Larger Share of Prior Authorization Requests in 2022 than in Previous Years

Medicare Advantage Prior Authorization Denials Increased in 2022

One of the Worst Situations a CFO Can Be In: Inside a System’s Split with UnitedHealth

2024 CFO Pain Points Study

One Health System’s Secret to Medicare Advantage Success

AMA Issues Proposal to Help Circumvent False and Misleading Information When Using Artificial Intelligence in Medicine

Pathologists and clinical laboratory managers will want to stay alert to the concerns voiced by tech experts about the need to exercise caution when using generative AI to assist medical diagnoses

Even as many companies push to introduce use of GPT-powered (generative pre-trained transformer) solutions into various healthcare services, both the American Medical Association (AMA) and the World Health Organization (WHO) as well as healthcare professionals urge caution regarding use of AI-powered technologies in the practice of medicine. 

In June, the AMA House of Delegates adopted a proposal introduced by the American Society for Surgery of the Hand (ASSH) and the American Association for Hand Surgery (AAHS) titled, “Regulating Misleading AI Generated Advice to Patients.” The proposal is intended to help protect patients from false and misleading medical information derived from artificial intelligence (AI) tools such as GPTs.

GPTs are an integral part of the framework of a generative artificial intelligence that creates text, images, and other media using generative models. These neural network models can learn the patterns and structure of inputted information and then develop new data that contains similar characteristics.

Through their proposal, the AMA has developed principles and recommendations surrounding the benefits and potentially harmful consequences of relying on AI-generated medical advice and content to advance diagnoses.

Alexander Ding, MD

“We’re trying to look around the corner for our patients to understand the promise and limitations of AI,” said Alexander Ding, MD (above), AMA Trustee and Associate Vice President for Physician Strategy and Medical Affairs at Humana, in a press release. “There is a lot of uncertainty about the direction and regulatory framework for this use of AI that has found its way into the day-to-day practice of medicine.” Clinical laboratory professionals following advances in AI may want to remain informed on the use of generative AI solutions in healthcare. (Photo copyright: American Medical Association.)

Preventing Spread of Mis/Disinformation

GPTs are “a family of neural network models that uses the transformer architecture and is a key advancement in artificial intelligence (AI) powering generative AI applications such as ChatGPT,” according to Amazon Web Services.

In addition to creating human-like text and content, GPTs have the ability to answer questions in a conversational manner. They can analyze language queries and then predict high-quality responses based on their understanding of the language. GPTs can perform this task after being trained with billions of parameters on massive language datasets and then generate long responses, not just the next word in a sequence. 

“AI holds the promise of transforming medicine,” said diagnostic and interventional radiologist Alexander Ding, MD, AMA Trustee and Associate Vice President for Physician Strategy and Medical Affairs at Humana, in an AMA press release.

“We don’t want to be chasing technology. Rather, as scientists, we want to use our expertise to structure guidelines, and guardrails to prevent unintended consequences, such as baking in bias and widening disparities, dissemination of incorrect medical advice, or spread of misinformation or disinformation,” he added.

The AMA plans to work with the federal government and other appropriate organizations to advise policymakers on the optimal ways to use AI in healthcare to protect patients from misleading AI-generated data that may or may not be validated, accurate, or relevant.

Advantages and Risks of AI in Medicine

The AMA’s proposal was prompted by AMA-affiliated organizations that stressed concerns about the lack of regulatory oversight for GPTs. They are encouraging healthcare professionals to educate patients about the advantages and risks of AI in medicine. 

“AI took a huge leap with large language model tool and generative models, so all of the work that has been done up to this point in terms of regulatory and governance frameworks will have to be treated or at least reviewed with this new lens,” Sha Edathumparampil, Corporate Vice President, Digital and Data, Baptist Health South Florida, told Healthcare Brew.

According to the AMA press release, “the current limitations create potential risks for physicians and patients and should be used with appropriate caution at this time. AI-generated fabrications, errors, or inaccuracies can harm patients, and physicians need to be acutely aware of these risks and added liability before they rely on unregulated machine-learning algorithms and tools.”

According to the AMA press release, the organization will propose state and federal regulations for AI tools at next year’s annual meeting in Chicago.

In a July AMA podcast, AMA’s President, Jesse Ehrenfeld, MD, stressed that more must be done through regulation and development to bolster trust in these new technologies.

“There’s a lot of discomfort around the use of these tools among Americans with the idea of AI being used in their own healthcare,” Ehrenfeld said. “There was a 2023 Pew Research Center poll [that said] 60% of Americans would feel uncomfortable if their own healthcare provider relied on AI to do things like diagnose disease or recommend a treatment.”

WHO Issues Cautions about Use of AI in Healthcare

In May, the World Health Organization (WHO) issued a statement advocating for caution when implementing AI-generated large language GPT models into healthcare.

A current example of such a GPT is ChatGPT, a large language-based model (LLM) that enables users to refine and lead conversations towards a desired length, format, style, level of detail and language. Organizations across industries are now utilizing GPT models for Question and Answer bots for customers, text summarization, and content generation and search features. 

“Precipitous adoption of untested systems could lead to errors by healthcare workers, cause harm to patients, erode trust in AI, and thereby undermine (or delay) the potential long-term benefits and uses of such technologies around the world,” commented WHO in the statement.

WHO’s concerns regarding the need for prudence and oversight in the use of AI technologies include:

  • Data used to train AI may be biased, which could pose risks to health, equity, and inclusiveness.
  • LLMs generate responses that can appear authoritative and plausible, but which may be completely incorrect or contain serious errors.
  • LLMs may be trained on data for which consent may not have been given.
  • LLMs may not be able to protect sensitive data that is provided to an application to generate a response.
  • LLMs can be misused to generate and disseminate highly convincing disinformation in the form of text, audio, or video that may be difficult for people to differentiate from reliable health content.

Tech Experts Recommended Caution

Generative AI will continue to evolve. Therefore, clinical laboratory professionals may want to keep a keen eye on advances in AI technology and GPTs in healthcare diagnosis.

“While generative AI holds tremendous potential to transform various industries, it also presents significant challenges and risks that should not be ignored,” wrote Edathumparampil in an article he penned for CXOTECH Magazine. “With the right strategy and approach, generative AI can be a powerful tool for innovation and differentiation, helping businesses to stay ahead of the competition and better serve their customers.”

GPT’s may eventually be a boon to healthcare providers, including clinical laboratories, and pathology groups. But for the moment, caution is recommended.

JP Schlingman

Related Information:

AMA Adopts Proposal to Protect Patients from False and Misleading AI-generated Medical Advice

Regulating Misleading AI Generated Advice to Patients

AMA to Develop Recommendations for Augmented Intelligence

What is GPT?

60% of Americans Would Be Uncomfortable with Provider Relying on AI in Their Own Health Care

Navigating the Risks of Generative AI: A Guide for Businesses

Contributed: Top 10 Use Cases for AI in Healthcare

Anatomic Pathology at the Tipping Point? The Economic Case for Adopting Digital Technology and AI Applications Now

ChatGPT, AI in Healthcare and the future of Medicine with AMA President Jesse Ehrenfeld, MD, MPH

What is Generative AI? Everything You Need to Know

WHO Calls for Safe and Ethical AI for Health

GPT-3

Amazon Care Pilot Program Offers Virtual Primary Care to Seattle Employees; Features Both Telehealth and In-home Care Services That Include Clinical Laboratory Testing

Experts say Amazon could be planning a roll-out of healthcare services to its Prime members and others

Clinical laboratory leaders will want to note that the Telehealth and home healthcare industries have expanded with the launch of Amazon Care, a virtual medical clinic and home care services program from global retailer Amazon.com, Inc. (NASDAQ:AMZN).

Amazon is piloting Amazon Care as a benefit for its 53,000 Seattle-area employees and their families, according to published reports. Could this indicate the world’s largest online retailer is moving into the primary care space? If so, clinical laboratory leaders will want to follow this development closely, because the program will need clinical laboratory support.

Amazon has successfully disrupted multiple industries in its corporate life and some experts speculate Amazon may be using its own employees to design a new medical delivery model for national roll-out.

The S&P report goes on to state, “In as little as five years, the Seattle-based e-commerce company could interlink its system of capabilities and assets to launch various healthcare products, insurance plans, virtual care services, and digital health monitoring to a broader population. The rollout would be part of a larger plan by Amazon to deliver convenient, cost-effective access to care and medications across the U.S., likely tied to Amazon’s Prime membership program, according to experts.”

Modern Healthcare reported that Amazon Care services include telemedicine and home visits to employees enrolled in an Amazon health insurance plan.

Experts contacted by S&P Global Market Intelligence suggest Amazon:

  • Plans a “suite of customized health plans and services for businesses and consumers;”
  • May offer health services to its five million seller business and more than 100 million Amazon Prime members; and
  • Sees healthcare as a growing market and wants greater involvement in it.

How Amazon Care Works

Amazon Care offers online, virtual care through a downloadable mobile device application (app) as well as in-person home care for certain medical needs, such as:

  • Colds, allergies, infections, and minor injury;
  • Preventative consults, vaccines, and lab tests;
  • Sexual health services; and
  • General health inquiries.

Becker’s Hospital Review reported that once a participant downloads the Amazon Care app to a smartphone or tablet and signs up for the program, he or she can:

  • Communicate with healthcare providers via text or video;
  • Plan personal visits if needed;
  • Set payment methods in their user profile; and
  • Receive a “potential diagnosis” and treatment plan.
The graphic above is taken from the S&P Global Market Intelligence report, which states, “Amazon is one of several tech firms vying for a share of the healthcare market where national spending is expected to reach $6.0 trillion by 2027, up from $3.6 trillion in 2018, according to the Centers for Medicare and Medicaid Services.” (Graphic copyright: S&P Global Market Intelligence.)

“The service eliminates travel and wait time, connecting employees and their family members to a physician or nurse practitioner through live chat or voice,” an Amazon spokesperson told CNBC, “with the option for in-person follow-up services from a registered nurse ranging from immunizations to instant strep throat detection.”

The “mobile health nurse” may also collect clinical laboratory specimens, the Verge reported.

Amazon has partnered with Oasis Medical Group, a family primary care practice in Seattle, to provide healthcare services for Amazon Care patients.

Paving the Way to Amazon Care

The Healthcare Financial Management Association (HFMA) compares Amazon’s piloting of Amazon Care to similar healthcare projects that studied population health by first involving employee health plans.

HFMA’s analysis noted that Amazon Care is similar to Haven, a patient advocate organization based in Boston and New York that was created in 2018 by Amazon, JPMorgan Chase, and Berkshire Hathaway to lower healthcare costs and improve outcomes for participating companies.

Tech Crunch reported that in 2018 Amazon also purchased PillPack for nearly $1 billion and integrated its prescription delivery services into Amazon Care. 

More recently, Amazon acquired Health Navigator and plans to bring those offerings to Amazon Care as well, CNBC reported. Founded in 2014, Health Navigator provides caregivers with symptom-checking tools that enable remote diagnoses.

Should Telemedicine Firms Be Nervous?

Dark Daily recently reported on Doctor on Demand’s launch of its own virtual healthcare telehealth platform called Synapse. The e-briefing also covered Doctor on Demand’s partnership with Humana (NYSE:HUM) to provide virtual primary care services to the insurer’s health plan members, including online doctor visits at no charge and standard medical laboratory tests for a $5 copayment.

So, should telemedicine firms be concerned about Amazon competing in their marketplace? Business Insider predicts Amazon will need time to beef up its medical resources to serve people online and in-person through Amazon Care.

But that’s the point of Amazon’s pilot, isn’t it? What comes from it will be interesting to watch.

“Meanwhile, telemedicine firms can ink strategic partnerships and strengthen their existing payer relationships to safeguard against Amazon’s surge into the space,” Business Insider advised.    

It remains to be seen how medical laboratory testing and reports would fit into an expanded Amazon Care health network. Or, how clinical laboratories will get “in-network” with Amazon Care, as it grows to serve customers beyond Amazon’s employees.

As Dark Daily recently advised, medical laboratory leaders will want to ensure their lab’s inclusion in virtual care networks, which someday may include Amazon Care.

—Donna Marie Pocius

Related Information:

Amazon Pilots Virtual Health Clinic for Employees

Amazon Could Roll Expanded Healthcare Plans, Services into Prime: Experts

National Health Expenditures Data

Amazon Launches Amazon Care, A Virtual Medical Clinic for Employees

Amazon is Now Offering Virtual Care to its Employees

Six Glimpses into the Amazon Care App, Employees’ ‘First Stop for Healthcare’

Analysis: Implications for Providers as Amazon Offers its Employees Access to a Virtual Clinic  

Amazon Acquires Health Navigator for Amazon Care, its Pilot Employee Healthcare Program

Amazon Acquires Digital Health Start-up Health Navigator

Amazon Piloting a Virtual Care Platform as the Company’s Next Big Step into Healthcare

As Primary Care Providers and Health Insurers Embrace Telehealth, How Will Clinical Laboratories Provide Medical Lab Testing Services?

As Primary Care Providers and Health Insurers Embrace Telehealth, How Will Clinical Laboratories Provide Medical Lab Testing Services?

When patients use telehealth, how do they choose medical laboratories for lab test orders their virtual doctors have authorized?

Doctors On Demand is expanding the nation’s primary care services by launching a virtual care telehealth platform for health insurers and employers. This fits into a growing nationwide trend toward increased use of remote and virtual doctor’s visits. But how should clinical laboratories and anatomic pathology groups prepare for fulfilling virtual doctors’ lab test orders in ways consistent with current scope-of-practice laws?

The rise of virtual care is made possible by innovations in digital and telecommunication technology. Driven by studies showing more patients are opting out of conventional primary care visits that take too much time or are too far away, the healthcare industry is responding by bringing medical services—including pathology and clinical laboratory—closer to patients through retail settings and urgent care clinics.

Many pathologists and clinical laboratory managers are unaware of how swiftly patients are becoming comfortable with getting their primary care needs met by other types of caregivers, including virtually. Recently, the Health Care Cost Institute (HCCI) published data showing that visits to primary care physicians declined 18% from 2012 to 2016 among adults under 65 who had employer-sponsored insurance. However, during these same years, visits with nurse practitioners and physician’s assistants increased by 129%!

Another way that providers are making it easier for patients to access healthcare is through the Internet.

Doctor On Demand, a San Francisco-based virtual care provider, is targeting insurers and employers with its Synapse telehealth platform, which integrates into existing health plan networks and enables virtual primary care, according to a news release.

“Through our fully integrated technology platform, we’re putting the patient first and introducing continuity of care not previously available through virtual care solutions,” said Hill Ferguson, CEO of Doctor On Demand in a statement announcing the launch of Synapse on the Humana (NYSE:HUM) health plan network. (Photo copyright: The Business Journals.)

How Synapse Works

Humana is using Synapse in its new On Hand virtual primary care plan, the news release states. Humana said its members have no copay for the virtual doctor visits and $5 copays for standard medical laboratory tests and prescriptions. Synapse’s “smart referrals” function sends referrals to in-network clinical laboratories, imaging providers, and pharmacies, Healthcare Dive reported.

“Humana has a deep footprint, and this is a payer looking to create a virtual primary care network as a way to contain cost and thinking about how care is coordinated and delivered,” Josh Berlin, a Principal and Healthcare Co-Practice Leader with advisory firm Citrin Cooperman, told FierceHealthcare.

Changing Primary Care Relationships

Another insurer advancing telehealth is Oscar Health, which offers its own Doctor on Call telehealth platform. The New York City-based health plan reported in a year-end review that 82% of its members had set up a profile that gave them access to a concierge care team and 24/7 telemedicine services, including clinical laboratory test results. 

During 2018, Oscar’s concierge teams addressed 1.2 million questions from 77% of its members, the insurer said.

The graphic above, taken from research conducted by the Health Care Cost Institute (HCCI), shows that while virtual primary care has been expanding, conventional visits to primary care physicians fell 18% from 2012 to 2016 among adults under 65 who had employer-sponsored insurance. Simultaneously, visits with nurse practitioners and physician’s assistants increased by 129%! This indicates a shift in how patients view access to primary care physicians and may explain why telehealth is becoming an attractive option. How will clinical laboratories fit into this new healthcare paradigm? (Photo copyright: HCCI.)

Becker’s Hospital Review reports that telehealth usage by Oscar’s members is five times higher than the average for the healthcare industry.

Will Clinical Laboratories Receive Virtual Referrals?

In a way, it has never been easier for patients to see a primary care doctor or research symptoms. Additionally, the Internet makes it possible for patients to self-diagnose, though not always to the benefit of healthcare providers or the patients.

So, how should clinical laboratories respond to this growing expansion of virtual care doctors? Experts advise lab leaders to reach out to health plans soon and determine their inclusion in virtual healthcare networks. Labs also may benefit by making test scheduling and reporting accessible and convenient to insurance company members and consumers choosing telehealth.

During his keynote presentation at the 24th Annual Executive War College in May, Ted Schwab, a Los Angeles area Healthcare Strategist and Entrepreneur, said, “If you use Google in the United States to check symptoms, you’ll find 350 different electronic applications that will give you medical advice—meaning you’ll get a diagnosis over the Internet. These applications are winding their way somewhere through the regulatory process. (See Schwab’s expanded comments on this trend in, “Strategist Explains Key Trends in Healthcare’s Transformation,” The Dark Report, October 14, 2019.)

Schwab advises that in this “time of change” it’s critical for labs to take proactive measures. “What we know today is that providers—including clinical laboratories and pathology groups—who do nothing will get trampled. However, those providers that do something proactively will most likely be the winners as healthcare continues to transform.”

—Donna Marie Pocius

Related Information:

Doctor On Demand Launches Synapse, a New Virtual Care Platform Delivering Next Generation Primary Care for Health Plans and Employer Populations

Telemedicine Startup Doctor On Demand Taps Giant Health Partner to Debut Virtual Primary Care Plan

Doctor On Demand Rolls Out Virtual Care Platform for Primary Care

Humana and Doctor On Demand Launch Virtual Primary Care Plan to Bring More Services With Lower Costs to Patients, Insurers, and Employers

Trends in Primary Care Visits

Humana and Doctor On Demand Launch Virtual Primary Care Plan

Oscar Health’s Telemedicine Use Five Times Greater than Health Insurance Average

Strategist Explains Key Trends in Healthcare’s Transformation

25th Annual Executive War College Conference on Laboratory and Pathology Management

Are Recent Predictions Regarding the Future of Healthcare Positive or Negative for Clinical Laboratories?

Medical laboratories that develop appropriate clinical strategies may find opportunities to leverage several new technologies expected to have a big impact on providers

Industry experts often speculate how developing technologies will impact healthcare. However, clinical laboratory leaders may be surprised by how much blockchain, medical malls, and Uber Health are expected to alter healthcare delivery in the next decade.

An article in FierceHealthcare states that “Healthcare is on the cusp of a technology revolution. Technology is primed to disrupt healthcare more explosively than it has any other industry.”

Medical advancements certainly impact clinical laboratories and anatomic pathology groups, and any acceleration in these developing technologies applied to healthcare will certainly be of interest to lab leaders who want to ensure their labs are ready.

Blockchain Provides Healthcare Security, Privacy, and Interoperability

Authored by Sloan Gaon, CEO, PulsePoint, the FierceHealthcare article predicts that blockchain will be an important feature in the future of healthcare. It will allow patients to have an online, accurate health record that is accessible only to necessary parties in real time. Consumers will be able to maintain, control, and share their data as they wish while increasing the security, privacy, and interoperability of their health information.

“A primary care physician could access a complete medical history of the member, while the radiologist could be limited to only the specifics he or she needs to perform the task at hand. For each, it’s about accessing the right data at the right time, and the blockchain technology could enable this type of specific ‘need-to-know’ medical history access,” wrote Bruce Broussard, President and CEO of Humana in a LinkedIn article.

The blockchain records can be shared among a network of computers and kept secure via cryptography. And the technology allows for easy transferability among different networks, improving performance and outcomes for patients. Broussard also stated that blockchain technology will provide more efficient payment for insurance claims.

“With transparency and automation, greater efficiencies will lead to lower administration costs, faster claims, and less money wasted. Blockchain enables claims to be paid without an intermediary, since health plan members are connecting directly with their providers. These consumers can also access their permanent electronic health records in a secure fashion, enabling them to have a real-time understanding of their health,” he wrote.

Should blockchain achieve widespread adoption as a platform for patient health information, the clinical laboratory industry will need to address the problem of different test methodologies and different reference ranges for test results. If blockchain makes it feasible to bring all pieces of a single patient’s cumulative health data into a single record, then clinical labs will need to address that problem in an effective way.

In his FierceHealthcare article, Sloan Gaon, CEO of PulsePoint, said “Technology will drive innovation, automation, transparency and efficiency, rendering the current healthcare landscape unrecognizable. As technology garners healthcare’s gold seal of approval, its effects will upend the industry, shrinking costs and improving outcomes.”

Medical Malls a Win-Win for Healthcare Providers and Retail Locations

With big shopping malls dying due to economic recessions and the emergence of online retail destinations, property owners are seeking new tenants. In the summer of 2017, there were still about 1,100 malls remaining in the US, however, a quarter of them were at a risk of closing within five years, Time noted that year.

As healthcare organizations expand, there is an overwhelming need for suitable space that is accessible for consumers at a reasonable price. Fading shopping malls with their convenient locations, sturdy foundations, and large parking lots could fill that gap.

In February of 2017, Avita Health System opened a boutique hospital in a space once occupied by an anchor store in a mall located in Ontario, Ohio. The healthcare provider purchased a 185,000 square-foot space that was formerly a Lazarus department store.

Mansfield News Journal reported that when the hospital opened, it included a walk-in clinic, an emergency room, surgical suites, pre-operative and post-operative areas, an onsite pharmacy, imaging services, a clinical laboratory, and 30 acute care beds.

Other services, including a Level II Cath lab, a maternity center, and the installation of a 3T Magnetic Resonance Imaging (3T MRI) machine, have been added since the facility opened. And there’s room for more expansion at the site.

Vanderbilt Medical Group (VMG) now occupies the entire second level of One Hundred Oaks Mall, in Nashville, Tenn. Their services at the once-struggling retail shopping center include 22 specialty clinics in 450,000 square feet of space designed by architecture firm Gresham Smith.

Patients can pick up a pager at the VMG facility and then shop on the lower level while waiting to be paged to see a healthcare professional or receive test results.

“More important than the significant increase in our available clinical space is the overall concept and design which is focused on providing our patients, faculty, and staff with a new paradigm for health and wellness. The convenience, accessibility, and innovative ways of providing care for our patients are a true transformation of both the architecture and the way our patients experience healthcare,” said Cyril Stewart, former Director of Facility Planning for Vanderbilt University Medical Center (VUMC) in a testimonial on the Gresham Smith website.

Non-Emergency Medical Transportation and Uber Health

Kaiser Family Foundation (KFF) reported in 2016 that “Medicaid’s non-emergency medical transportation (NEMT) benefit facilitates access to care for low income beneficiaries who otherwise may not have a reliable affordable means of getting to healthcare appointments. NEMT also assists people with disabilities who have frequent appointments and people who have limited public transit options and long travel times to healthcare providers, such as those in rural areas.”

The Hospital and Healthsystem Association of Pennsylvania (HAP) reported that an average of 3.6 million Americans miss their healthcare appointments annually due to lack of or unreliable transportation. These missed appointments can cause an avalanche of future problems, including increased visits to emergency rooms, extended hospital stays, and higher costs for providers.

Uber Health is positioned to become a major player in the field of non-emergency medical transportation (NEMT). The Verge reported in 2018 that independent research organization Transit Cooperative Research Program (TCRP) estimated that the NEMT market was worth more than $3 billion.

“If there are people who are missing their appointments because they’re using an unreliable bus service to get to and from their healthcare provider, this is a great solution for them,” Christopher Weber, General Manager and Senior Project Manager at Uber Health, told The Verge. “The types of individuals this is valuable for really is limitless.”

Uber health’s mobile device application (app) enables patients and healthcare providers to schedule non-emergency medical transportation for medical appointments within a few hours or up to a 30-day notice. It is also available both as an online dashboard and as an application-programming interface (API) for software developers to integrate the service into their proprietary healthcare tools.

An Uber (NYSE:UBER) account is not required, as notifications about rides can be sent to patients via text messages.

Clinical laboratory leaders may want to develop strategies around these three predictions to increase business and maximize profits. Since more healthcare organizations will soon be linked via blockchain, and an increased number of consumers could start using non-emergency medical transportation, such as Uber Health, to get to medical appointments, becoming familiar with these technologies could prove to be beneficial to labs.

In addition, medical facilities cropping up in former mall spaces will require medical laboratories to be onsite to support care and provide lab test results within an acceptable turnaround time.

—JP Schlingman

Related Information:

Industry Voices—How the Future of Healthcare Will be Shaped by the Likes of Uber, CVS

Blockchain: Transformational Technology for Health Care

Why the Death of Malls is about More than Shopping

Avita Ontario Hospital Poised to Open

Mall Landlords Welcome Medical Clinics as Retail Ails

Fighting the Blight: Reinventing Retail space for Vanderbilt Health

Uber is Driving Patients to Their Doctors in a Big Grab for Medical Transit Market

Association of Rideshare-Based Transportation Services and Missed Primary Care Appointments: A Clinical Trial

Study Finds Missed Medical Appointments Not Affected by Free Ride Services

Medicaid Non-Emergency Medical Transportation: Overview and Key Issues in Medicaid Expansion Waivers

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