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Clinical Laboratories and Pathology Groups

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Clinical Laboratories and Pathology Groups

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Two New Definitive Healthcare Surveys Show Use of Inpatient Telehealth is Outpacing Outpatient Telehealth Services

Medical laboratories may find opportunities guiding hospital telehealth service physicians in how clinical lab tests are ordered and how the test results are used to select the best therapies

Telehealth is usually thought of as a way for patients in remote settings to access physicians and other caregivers. But now comes a pair of studies that indicate use of telehealth in inpatient settings is outpacing the growth of telehealth for outpatient services.

This is an unexpected development that could give clinical laboratories new opportunities to help improve how physicians in telehealth services use medical laboratory tests to diagnose their patients and select appropriate therapies.

Dual Surveys Compare Inpatient and Outpatient Telehealth Service Use

Definitive Healthcare (DH) of Framingham, Mass., is an analytics company that provides data on hospitals, physicians, and other healthcare providers, according to the company’s website. A survey conducted by DH found that use of telehealth solutions—such as two-way video webcams and SMS (short message service) text—has increased by inpatient providers from 54% in 2014 to 85% in 2019, a news release stated.

Meanwhile, a second Definitive Healthcare survey suggests use of telehealth in outpatient physician office settings remained essentially flat at 44% from 2018 to 2019, according to another news release.

For the inpatient report, Definitive Healthcare polled 175 c-suite providers and health information technology (HIT) directors in hospitals and healthcare systems. For the outpatient survey, the firm surveyed 270 physicians and outpatient facilities administrators.

DH’s research was aimed at learning the status of telehealth adoption, identifying the type of telehealth technology used, and predicting possible further investments in telehealth technologies.  

Most Popular Inpatient Telehealth Technologies

On the inpatient side, 65% of survey respondents said the most used telehealth mode is hub-and-spoke teleconferencing (audio/video communication between sites), Healthcare Dive reported. Also popular:

Fierce Healthcarereports that the telehealth technologies showing the largest increase by hospitals and health networks since 2016 are:

  • Two-way video/webcam between physician and patient (70%, up from 47%);
  • Population health management tools, such as SMS text (19%, up from 12%);
  • Remote patient monitoring using clinical-grade devices (14%, up from 8%);
  • Mobile apps for concierge services (23%, up from 17%).

“Organizations are finding new and creative ways through telehealth to fill gaps in patient care, increase care access, and provide additional services to patient populations outside the walls of their hospital,” Kate Shamsuddin, Definitive Healthcare’s Senior Vice President of Strategy, told Managed Healthcare Executive.

DH believes investments in telehealth will increase at hospitals as well as physician practices. In fact, 90% of respondents planning to adopt more telehealth technology indicated they would likely start in the next 18 months, the news releases state.

Most Popular Outpatient Telehealth Technologies

In the outpatient telehealth survey, 56% of physician practice respondents indicated patient portals as the leading telehealth technology, MedCity News reported. That was followed by:

  • Hub-and-spoke teleconferencing (42%);
  • Concierge services (42%);
  • Clinical- and consumer-grade remote patient monitoring products (21% and 12%).

While adoption of telehealth technology was flat over the past year, 68% of physician practices did use two-way video/webcam technology between physician and patient, which is up from 45% in 2018, Fierce Healthcare reported.

The graph above, taken from the Definitive Healthcare 2019 survey, shows the percentage of telehealth use among surveyed outpatient settings. “The results show how telehealth continues to be one of the core linchpins for providers,” Kate Shamsuddin, Definitive Healthcare’s Senior Vice President of Strategy, told Healthcare Dive. (Graphic copyright: Definitive Healthcare.)

MedCity News reports that other telehealth technologies in use at physician practices include:

  • Mobile apps for concierge service (33%);
  • Two-way video between physicians (25%);
  • SMS population management tools (20%).

Telehealth Reimbursement and Interoperability Uncertain

Why do outpatient providers appear slower to adopt telehealth, even though they generally have more patient encounters than inpatient facilities and need to reach out further and more often?

Definitive Healthcare reports that 20% of physician practice respondents are “satisfied with the practice’s current solutions and services,” and though telehealth reimbursement is improving, 13% are unsure they will be reimbursed for telehealth services.

The Centers for Medicare and Medicaid Services (CMS) states that Medicare Part B covers “certain telehealth services,” and that patients may be responsible for paying 20% of the Medicare approved amount. CMS also states that, effective in 2020, Medicare Advantage plans may “offer more telehealth benefits,” as compared to traditional Medicare.

“There is not only a need for more clarity around reimbursement policies, but also a need for more interoperable telehealth solutions that can be accessed through electronic health record or electronic medical record systems, as well as a better understanding about what types of telehealth options are available,” said Jason Krantz (above), CEO, Definitive Healthcare, in the outpatient telehealth survey news release. (Photo copyright: Definitive Healthcare.)

The increase in telehealth use at hospitals—as well as its increased adoption by physician offices—may provide clinical laboratories with opportunities to assist telehealth doctors with lab test use and ordering. By engaging in telehealth technology, such as two-way video between physicians, pathologists also may be able to help with the accuracy of diagnoses and timely and effective patient care.

—Donna Marie Pocius

Related Information:

Definitive Healthcare Survey: Inpatient Telehealth Adoption on the Rise

Definitive Healthcare Survey: 2019 Outpatient Telehealth Adoption Remains Flat

Telehealth Use Jumps at Inpatient Settings

Telehealth Use Jumps at Inpatient Facilities While Outpatient Adoption Remains Flat: Survey

Inpatient Telehealth Adoption Surges

Comparing and Contrasting Outpatient and Inpatient Providers’ Use of TelehealthMedicare: Coverage of Telehealth

New AHA Report Finds Hospital Outpatient Revenue Nearing Inpatient Revenue, While CMS Proposes Paying Less for In-hospital Healthcare Services

Clinical laboratories that service both settings could be impacted as new CMS proposed rule attempts to align Medicare’s payment policies for outpatient and in-patient settings

Hospital outpatient revenue is catching up to inpatient revenue, according to data released from the American Hospital Association (AHA). This increase is part of a growing trend to reduce healthcare costs by treating patients outside of hospital settings. It’s a trend that is supported by the White House and Medicare and continues to impact clinical laboratories, which serve both hospital inpatient and outpatient customers.

The AHA published this study data in its annual Hospital Statistics, 2019 Edition. The data comes from a 2017 survey of 5,262 US hospitals. The report includes data about utilization, revenue, expenses, and other indicators for 2017, as well as historical data.

The AHA statistics on outpatient revenue suggest providers nationwide are working to keep people out of more expensive hospital settings. Hospitals, like medical laboratories, appear to be succeeding at developing outpatient and outreach services that generate needed operating revenue.

This aligns with Medicare’s push to make healthcare more accessible through outpatient settings, such as urgent care clinics and physician’s offices. A growing trend Dark Daily has covered extensively.

Outpatient Revenue Climbs

In its coverage of the AHA’s study, Modern Healthcare reported that 2017 hospital net inpatient revenue was $498 billion and net outpatient revenue was $472 billion.

The Becker’s Hospital CFO Report notes that gross inpatient revenue in 2017 was $92.7 billion higher than gross outpatient revenue. But in 2016, gross inpatient revenue was much further ahead—$129.5 billion more than gross outpatient revenue. The “divide” between inpatient and outpatient revenue is narrowing, Becker’s reports.


The graphic above illustrates the shrinking gap between hospital inpatient and outpatient revenues. “Outpatient revenue will ultimately eclipse inpatient revenue,” Chuck Alsdurf, Director of Healthcare Finance Policy and Operational Initiatives at the Healthcare Financial Management Association (HFMA), told Modern Healthcare. (Graphic copyright: Modern Healthcare/AHA.)

 The Becker’s report also stated:

  • Admissions increased by less than 1% to 34.3 million in 2017, up from 34 million in 2016;
  • Inpatient days were flat at 186.2 million;
  • Outpatient visits rose by 1.2% to 766 million in 2017; and,
  • Outpatient revenue increased 5.7% between 2016 and 2017.

Similar Study Offers Additional Insight into 2018 Outpatient Revenue

A benchmarking report by Crowe, a public accounting, consulting, and technology firm, which analyzed data from 622 hospitals for the period January through September of 2017 and 2018, showed the following, as reported by RevCycleIntelligence:

  • Inpatient volume was up 0.6% in 2018 and gross revenue per case grew by 5.3%;
  • Outpatient services rose 2.4% in 2018 and gross revenue per case was up 7.1%.

Physicians’ Offices Have Lower Prices for Some Hospital Outpatient Services

Everything, however, is relative. When certain healthcare services traditionally rendered in physician’s offices are rendered, instead, in hospital outpatient settings, the numbers tell a different story.

In fact, according to the Health Care Cost Institute (HCCI), the price for services was “always higher” when performed in an outpatient setting, as compared to doctor’s offices.

HCCI analyzed services at outpatient facilities as well as those appropriate to freestanding physician offices. They found the following differences in 2017 prices:

  • Diagnostic and screening ultrasound: $241 in physician’s office—$650 in hospital outpatient setting;
  • Level 5 drug administration: $254 in office—$664 in hospital outpatient setting;
  • Upper airway endoscopy: $527 in office—$2,679 in hospital outpatient setting.

One example where hospital outpatient settings provide similar services at increased costs is in drug administration, as the graphic above illustrates. “The difference was higher than I expected. With some services, the price is two or three times higher when rendered in the outpatient setting,” Julie Reiff, HCCI researcher and report author, told Fierce Healthcare. (Graphic copyright: HCCI.)

Medicare Proposed Rule Would Change How Hospital Outpatient Clinics Get Paid

Meanwhile, the Centers for Medicare and Medicaid Services (CMS) has released its final rule (CMS-1695-FC), which make changes to Medicare’s hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs.

In a news release, CMS stated that it “is moving toward site neutral payments for clinic visits (which are essentially check-ups with a clinician). Clinic visits are the most common service billed under the OPPS [Medicare’s Hospital Outpatient Prospective Payment System). Currently, CMS often pays more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting.”

“CMS is also proposing to close a potential loophole through which providers are billing patients more for visits in hospital outpatient departments when they create new service lines,” the news release states.

Hospitals are fighting the policy change through a lawsuit, Fierce Healthcare reported.

In summary, clinical laboratories based in hospitals and health systems are in the outpatient as well as inpatient business. Medical laboratory tests contribute to growth in outpatient revenue, and physician offices compete with clinical laboratories for some outpatient tests and procedures. Thus, a new site-neutral CMS payment policy could affect the payments hospitals receive for clinic visits by Medicare patients.

—Donna Marie Pocius

Related Information:

AHA Hospital Statistics 2019

AHA Data Show Hospitals’ Outpatient Revenue Nearing Inpatient

Hospitals’ Outpatient Revenue Inching Closer to Inpatient Revenue

“My Net Revenue is Stable,” said No CFO Ever . . .

Revenue Unable Despite Outpatient Volume Growth

Shifting Care from Office to Outpatient Settings: Services are Increasingly Performed in Outpatient Settings with Higher Prices

From Physician Offices to Outpatient Settings and Costs Go Up, HCCI Study Finds

CMS Empowers Patients and Ensures Site Neutral Payment Proposed Rule

Independent Clinical Laboratories in Maryland May Need to Step-up Outreach with Hospitals as New CMS Program Launches Jan. 1

Clinical laboratory leaders will want to pay close attention to a significant development in Maryland. The state’s All-Payer Medicare program—the nation’s only all-payer hospital rate regulation system—is broadening in scope to include outpatient services starting Jan. 1. The expanded program could impact independent medical laboratories, according to the Maryland Hospital Association (MHA), which told Dark Daily that those labs may see hospitals reaching out to them.

The Centers for Medicare and Medicaid Services (CMS) and the state of Maryland expect to save $1 billion by 2023 in expanding Maryland’s existing All-Payer Model—which focused only on inpatient services since 2014—to also include primary care physicians, skilled nursing facilities, independent clinical laboratories, and more non-hospital settings, according to a CMS statement.

Healthcare Finance notes that it represents “the first time, CMS is holding a state fully at risk for the total cost of care for Medicare beneficiaries.”

Value of Precision Medicine and Coordination of Care to Clinical Labs

“If a patient receives care at a [medical] laboratory outside of a hospital, Maryland hospitals would be looking at ways to coordinate the sharing of that freestanding laboratory information, so that the hospital can coordinate the care of that patient both within and outside the hospital setting,” Erin Cunningham, Communications Manager at MHA, told Dark Daily. Such a coordinating of efforts and sharing of clinical laboratory patient data should help promote precision medicine goals for patients engaged with physicians throughout Maryland’s healthcare networks.

The test of the new program—called the Total Cost of Care (TCOC) Model—also could be an indication that Medicare officials are intent on moving both inpatient and outpatient healthcare providers away from reimbursements based on fees-for-services.

CMS and the state of Maryland said TCOC gives diverse providers incentives to coordinate, center on patients, and save Medicare per capita costs of care each year.

“What they are really doing is tracking how effective we are at managing the quality and the costs of those particular patients that are managed by the physicians and the hospitals together,” Kevin Kelbly, VP and Chief Financial Officer at Carroll Hospital in Westminster, told the Carroll County Times. “They will have set up certain parameters. If we hit those parameters, there could be a shared savings opportunity between the hospitals and the providers,” he added. (Photo copyright: LifeBridge Health.)

The TCOC runs from 2019 through 2023, when it may be extended by officials for an additional five years.

How Does it Work?

The TCOC Model, like the earlier All-Payer Model, will limit Medicare’s costs in Maryland through a per capita, population-based payment, Healthcare Finance explained.

It includes three programs, including the:

  • Maryland Primary Care Program (MDPCP), designed to incentivize physician practices by giving additional per beneficiary, per month CMS payments, and incentives for physicians to reduce the number of patients hospitalize;
  • Care Redesign Program (CRP), which is a way for hospitals to make incentive payments to their partners in care. In essence, rewards may be given to providers that work efficiently with the hospital to improve quality of services; and,
  • Hospital Payment Program, a population-based payment model that reimburses Maryland hospitals annually for hospital services. CMS provides financial incentives to hospitals that succeed in value-based care and reducing unnecessary hospitalizations and readmissions.

CMS and Maryland officials also identified these six high-priority areas for population health improvement:

  • Substance-use disorder;
  • Diabetes;
  • Hypertension;
  • Obesity;
  • Smoking; and
  • Asthma.

“We are going to save about a billion dollars over the next five years, but we are also providing better quality healthcare. So it’s going to affect real people in Maryland, and it helps us keep the whole healthcare system from collapsing, quite frankly,” Maryland Gov. Larry Hogan, told the Carroll County Times.

OneCare in Vermont, Different Approach to One Payer

Maryland is not the only state to try an all-payer model. Vermont’s OneCare is a statewide accountable care organization (ACO) model involving the state’s largest payers: Medicare, Medicaid, and Blue Cross and Blue Shield of Vermont, Healthcare Dive pointed out. The program aims to increase the number of patients under risk-based contracting and, simultaneously, encourage providers to meet population health goals, a Commonwealth Fund report noted.

Both Maryland’s and Vermont’s efforts indicate that payment plans which include value-based incentives are no longer just theory. In some markets, fees-for-service payment models may be gone for good.

Clinical laboratory leaders may want to touch base with their colleagues in Maryland and Vermont to learn how labs in those states are engaging providers and performing under payment programs that, if successful, could replace existing Medicare payment models in other states.

—Donna Marie Pocius

 

Related Information:

Maryland’s Total Cost of Care Model

Maryland All-Payer Model Expands to Include Outpatient Services

Gov. Hogan Sees Maryland Model as Example for U.S. Healthcare

The Maryland Model

Gov. Larry Hogan, Federal Government Sign Maryland Model All-Payer Contract

CMS Expands Maryland’s All-Payer Program to Outpatient Services

Vermont’s Bold Experiment in Community Driven Healthcare Reform

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