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Taiwan’s Containment of COVID-19 Outbreak Demonstrates Importance of Rapid Response, Including Fast Access to Clinical Laboratory Tests

By taking early measures to combat the spread, the country had a medical laboratory test for COVID-19 available as early as Jan. 24, and was able to focus medical laboratory testing on the most at-risk individuals

With the Coronavirus disease 2019 (COVID-19) outbreak dominating headlines and medical laboratories under growing pressure to increase testing capacity, Taiwan’s rapid response to the pandemic could provide a critical model for other countries to follow.

Given its proximity to mainland China—just 81 miles—and the large number of individuals who frequently travel back and forth between the countries, Taiwan was at risk of having the second-highest number of imported COVID-19 cases, according to a model developed by researchers at Johns Hopkins University and the University of New South Wales Sydney. News reports indicate that, each year, about 60,000 flights carry 10 million passengers between Taiwan and China.

But after the first reports emerged of the infection in Wuhan, China, “Taiwan quickly mobilized and instituted specific approaches for case identification, containment, and resource allocation to protect the public health,” wrote C. Jason Wang, MD, PhD; Chun Y. Ng, MBA, MPH; and Robert H. Brook, MD, ScD, in an article for the Journal of the American Medical Association (JAMA), titled, “Response to COVID-19 in Taiwan Big Data Analytics, New Technology, and Proactive Testing.”

Data from Taiwan’s Centers for Disease Control (CDC) and Central Epidemic Command Center (CECC) indicate that the country has managed to contain the outbreak thanks to these aggressive actions.

As of March 19, Taiwan’s CECC reported a total of 108 laboratory-confirmed COVID-19 infections. That compares with 81,155 in China, 41,035 in Italy, and 10,755 in the US, according to data compiled by the Center for Systems Science and Engineering at Johns Hopkins University. When the World Health Organization (WHO) reports on the number of COVID-19 cases by country, it includes the number of COVID-19 cases from Taiwan under the totals for the People’s Republic of China. WHO made this decision several years ago, under pressure by China to not recognize Taiwan as an independent nation.

The World Population Review website says Taiwan’s population is about 23.8 million. But its infection rate is low even on a per capita basis: Approximately 45 infections per million population, compared with 6,784 in Italy, 564 in China, and 326 per million in the US.

The JAMA authors noted that Taiwan was prepared for an outbreak after its experience with the severe acute respiratory syndrome (SARS) pandemic in 2003, which also originated in China.

Timeline of COVID-19 Outbreak at the Earliest Stages

Taiwan apparently learned a lesson about preparedness from the SARS outbreak the rest of the world did not and that enabled the tiny nation to respond immediately to the novel Coronavirus threat.

The country’s efforts began on Dec. 31 with inspections of flight arrivals from Wuhan. “When there were only a very few cases [of COVID-19] reported in China, [Taiwanese health authorities] already went onto every airplane that came from Wuhan,” C. Jason Wang, MD, PhD, an Associate Professor of Pediatrics and Director of the Center for Policy, Outcomes, and Prevention at Stanford University and lead author of the JAMA report, told Vox. “Health officials came on the airplane and checked people for symptoms,” he added.

Travelers who had recently visited Wuhan and displayed symptoms of pneumonia were quarantined at home for 14 days. Taiwan’s CDC reported that quarantined individuals were being tested for the 2019-nCoV coronavirus (later renamed to SARS-CoV-2) soon after it was identified. The CECC, activated in January to coordinate the government’s response, reported the first confirmed imported case on Jan. 21.

On Jan. 24, their CDC announced that testing for the virus was being performed at the CDC and eight designated hospitals. Testing included samples from physicians around the country. As of Feb. 17, daily testing capacity was about 1,300 samples, the JAMA authors reported.

Wang told Vox that aggressive measures to identify and isolate at-risk individuals at the earliest stages reduced the volume of clinical laboratory tests that had to be performed. “Here in the US and elsewhere, we’re now seeing community spread,” he said. “It’s probably been here for a while. And so now we’re trying to see, ‘Oh, how many people should we test?’ Then, you really need to have a very large capacity in the beginning.”

“I think the US has enormous capacity that’s currently not being used,” C. Jason Wang, MD, PhD (above), Associate Professor of Pediatrics and Director of the Center for Policy, Outcomes, and Prevention at Stanford University and lead author of the JAMA report, told Vox. “We have big tech companies that really could do a lot, right? We ought to get the big companies together. Get the governors together, get the federal government agencies to work with each other, and try to find innovative ways to think about how to best do this. We’ve got the smartest people here in the US because they come from everywhere. But right now, those are untapped resources. They’re not working together. And the federal government, the agencies, they need to collaborate a little more closely.” (Photo copyright: Stanford University.)

More Actions by Authorities

The JAMA report supplementary materials notes a total of 124 actions taken by Taiwanese authorities between Jan. 20 and Feb. 24 to contain the outbreak. In addition to the border inspections, quarantines and testing, they included integration of data between the country’s National Health Insurance Administration and National Immigration Agency, so authorities, and later hospitals, could identify any patient who had recently traveled to China, Hong Kong, or Macau.

The steps also included:

  • An escalating series of travel restrictions, eventually including suspension of most passenger flights from Taiwan to China, as well as a suspension of tours to Hong Kong or Macau.
  • Use of government-issued cell phones to monitor quarantined individuals.
  • Fines for individuals breaking the 14-day home quarantine.
  • Fines for incoming travelers who failed to provide accurate health information.
  • Fines for disseminating false information or rumors about the epidemic.
  • Fines and jail sentences for profiteering on disease-prevention products.
  • Designation of military camps and other government facilities for quarantine.
  • Nationwide disinfection of universities, colleges, and public spaces around schools.

The government also took aggressive action to ensure adequate supplies of surgical masks, including stepped-up manufacturing, export bans, price limits, and a limit of one to three masks per purchase.

The JAMA authors noted that government officials issued daily press briefings to educate the public about the outbreak. Communication efforts also included public service announcements by Taiwan Vice President Chen Chien-jen, a trained epidemiologist.

A poll taken in Taiwan on Feb. 17 and 18 indicated high approval ratings for officials’ response to the crisis.

The JAMA authors also noted some “challenges” in the government’s response. For example, most real-time public communication was in Mandarin Chinese and sign language, leaving out non-Taiwanese citizens in the country. And the cruise ship Diamond Princess, later found to have infections on board, was allowed to dock near Taipei and disembark passengers. There are also questions about whether similar policies can be sustained through the end of a pandemic.

Still, “well-trained and experienced teams of officials were quick to recognize the crisis and activated emergency management structures to address the emerging outbreak,” the JAMA authors wrote. “Taiwan is an example of how a society can respond quickly to a crisis and protect the interests of its citizens.”

One noteworthy difference in the speedy response to recognition of a novel coronavirus in Taiwan, compared to recognition of the same novel coronavirus in the United States, was the fast availability of clinical laboratory tests for COVID-19 in Taiwan.

Pathologists and clinical laboratory professionals here in the US are frustrated that their skills and talents at developing and validating new assays on an accelerated timeline were not acknowledged and leveraged by government officials as they decided how to respond to the emergence of the novel coronavirus now called SARS-CoV-2. 

—Stephen Beale

Related Information:

Taiwan CDC Press Releases about COVID-19

Is Taiwan’s Impressive Response to COVID-19 Possible in Canada?

Taiwan Has Been Shut Out of Global Health Discussions. Its Participation Could Have Saved Lives

Taiwan Has Only 77 Coronavirus Cases. Its Response to the Crisis Shows That Swift Action and Widespread Healthcare Can Prevent an Outbreak

What the U.S. Can Learn from Taiwan’s Response to Coronavirus

What Taiwan Can Teach the World on Fighting the Coronavirus

As Coronavirus Hot Spots Grow, Taiwan Beating the Odds Against COVID-19

They’ve Contained the Coronavirus. Here’s How

How Many Tests for COVID-19 Are Being Performed Around the World?

CDC Ranks Two More Drug-Resistant Microbes as ‘Urgent Threat’ to Americans; Clinical Laboratories Are Advised to Increase Awareness of Antimicrobial Resistance

In a separate study, HHS finds a 40% increase in sepsis cases, as more patients succumb to infections without effective antibiotics and antimicrobial drugs

Given the drastic steps being taken to slow the spread of the Coronavirus in America, it’s easy to forget that significant numbers of patients die each year due to antibiotic-resistant bacteria (ARB), other forms of antimicrobial resistance (AMR), and in thousands of cases the sepsis that follows the infections.

This is why the Centers for Disease Control and Prevention (CDC) issued the report “Antibiotic Resistance Threats in the United States, 2019 (2019 AR Threats Report)” last fall. The federal agency wants to call attention the emergence of new antibiotic-resistant bacteria and fungi. In its report, the CDC lists 18 bacteria and fungi that pose either urgent, serious, or concerning threats to humans. It also placed one fungus and two bacteria on a “watch” list.

The CDC’s website states that “more than 2.8 million antibiotic-resistant infections occur in the US each year, and more than 35,000 people die as a result.” And a CDC news release states, “on average, someone in the United States gets an antibiotic-resistant infection every 11 seconds and every 15 minutes someone dies.”

Those are huge numbers.

Clinical laboratory leaders and microbiologists have learned to be vigilant as it relates to dangerously infectious antimicrobial-resistant agents that can result in severe patient harm and death. Therefore, new threats identified in the CDC’s Antibiotic Resistance Threats in the United States report will be of interest.

Drug-resistant Microbes That Pose Severe Risk

The CDC has added the fungus Candida auris (C. auris) and carbapenem-resistant Acinetobacter (a bacteria that can survive for a long time on surfaces) to its list of “urgent threats” to public health, CDC said in the news release. These drug-resistant microbes are among 18 bacteria and fungi posing a greater threat to patients’ health than CDC previously estimated, Live Science reported.

In 2013, the CDC estimated that about two million people each year acquired an antibiotic-resistant (AR) infection that killed as many as 23,000. However, in 2019, the CDC reported that those numbers were low and that the number of deaths due to AR infections in 2013 was about twice that amount. During a news conference following the CDC announcement, Michael Craig (above), a Senior Adviser for the CDC’s Antibiotic Resistance Coordination and Strategy Unit said, “We knew and said [in 2013] that our estimate was conservative … and we were right,” Live Science reported. In 2019, CDC reported 2.8 million antibiotic-resistant infections annually with more than 35,000 related deaths in the US alone. (Photo copyright: Centers for Disease Control and Prevention.)

The CDC considers five threats to be urgent. Including the latest additions, they are:

Dark Daily has regularly covered the healthcare industry’s ongoing struggle with deadly fungus and bacteria that are responsible for hospital-acquired infections (HAI) and sepsis. This latest CDC report suggests healthcare providers continue to struggle with antimicrobial-resistant agents.

Acinetobacter Threat Increases and C. auris a New Threat since 2013

Carbapenem-resistant Acinetobacter, a bacterium that causes pneumonia and bloodstream and urinary tract infections, escalated from serious to urgent in 2013. About 8,500 infections and 700 deaths were noted by the CDC in 2017. 

C. auris, however, was not addressed in the 2013 report at all. “It’s a pathogen that we didn’t even know about when we wrote our last report in 2013, and since then it’s circumvented the globe,” said Michael Craig, Senior Adviser for the CDC’s Antibiotic Resistance Coordination and Strategy Unit, during a news conference following the CDC announcement, Live Science reported.

Today, C. auris is better understood. The fungus resists emerging drugs, can result in severe infections, and can be transmitted between patients, CDC noted.

Last year, Dark Daily reported on C. auris, noting that as of May 31 the CDC had tracked 685 cases. (See, “Potentially Fatal Fungus Invades Hospitals and Public Is Not Informed,” August 26, 2019.)

By year-end, CDC tracking showed 988 cases in the US.

More Patients Getting Sepsis as Antibiotics Fail: HHS Study

In a separate study published in Critical Care Medicine, a journal of the Society of Critical Care Medicine (SCCM), the US Department of Health and Human Services  (HHS) found that antibiotic-resistant bacteria and fungi are resulting in more people acquiring sepsis, a life-threatening condition, according to an HHS news release.

Sepsis increased by 40% among hospitalized Medicare patients from 2012 through 2018, HHS reported.   

“These (untreatable infections) are happening here and now in the United States in large numbers. This is isn’t some developing world thing. This isn’t a threat for 2050. It’s a threat for here and now,” Cornelius “Neil” Clancy, MD, Associate Chief of Veterans Affairs Pittsburg Health System (VAPHS) and Opportunistic Pathogens, told STAT.

It is troubling to see data about so many patient deaths related to antibiotic-resistant infections and sepsis cases when the world is transfixed by the Coronavirus. Nevertheless, it’s important that medical laboratory leaders and microbiologists keep track of how the US healthcare system is or is not responding to these new infectious agents. And, to contact infection control and environmental services colleagues to enhance surveillance, ensure safe healthcare environments and equipment, and adopt appropriate strategies to prevent antibiotic-resistant infections.   

—Donna Marie Pocius

Related Information:

CDC:  Biggest Threats and Data: 2019 Antibiotic Resistance Threats in the United States

More People in the U.S. Dying from Antibiotic-Resistant Infections Than Previously Estimated; Significant Progress Since 2013 Could be Lost Without More Action

These Two Drug-Resistant Microbes Are New “Urgent Threats” to Americans’ Health

CDC Report: 35,000 Americans Die of Antibiotic-Resistant Infections Each Year

The Superbug Candida Auris is Giving Rise to Warnings and Big Questions

On the Emergency of Candida Auris Climate Change, Azoles, Swamps, and Birds

Largest Study of Sepsis Cases Among Medicare Beneficiaries Finds Significant Burden

Sepsis Among Medicare Beneficiaries: The Burdens of Sepsis 2012 to 2018

Dark Daily: Hospital-Acquired Infection

Potentially Fatal Fungus Invades Hospitals and Public is Not Informed

Proteomics May Hold Key to Understanding Aging’s Role in Chronic Diseases and Be Useful as a Clinical Laboratory Test for Age-related Diseases

Researchers are discovering it’s possible to determine a person’s age based on the amount of protein in the blood, but the technology isn’t always correct

Mass spectrometry is increasingly finding its way into clinical laboratories and with it—proteomics—the study of proteins in the human body. And like the human genome, scientists are discovering that protein plays an integral part in the aging process.

This is a most interesting research finding. Might medical laboratories someday use proteomic biomarkers to help physicians gauge the aging progression in patients? Might this diagnostic capability give pathologists and laboratory leaders a new product line for direct-to-consumer testing that would be a cash-paying, fast-growing, profitable clinical laboratory testing service? If so, proteomics could be a boon to clinical laboratories worldwide.

When research into genomics was brand-new, virtually no one imagined that someday the direct-to-consumer lab testing model would offer genetic testing to the public and create a huge stream of revenue for clinical laboratories that process genetic tests. Now, research into protein and aging might point to a similar possibility for proteomics.

For example, through proteomics, researchers led by Benoit Lehallier, PhD, Biostatistician, Instructor of Neurology and Neurological Sciences, and senior author Tony Wyss-Coray, PhD, Professor of Neurology and Neurological Sciences and co-director of the Stanford Alzheimer’s Disease Research Center at Stanford University in California, gained an understanding of aging that suggest intriguing possibilities for clinical laboratories.

In their study, published in Nature, titled, “Undulating Changes in Human Plasma Proteome Profiles Across the Lifespan,” the scientists stated that aging doesn’t happen in a consistent process over time, reported Science Alert.  

The Stanford researchers also found that they can accurately determine a person’s age based on the levels of certain proteins in his or her blood.

Additionally, the study of proteomics may finally explain why blood from young people can have a rejuvenating effect on elderly people’s brains, noted Scientific American.

Each of these findings is important on its own, but taken together, they may have interesting implications for pathologists who follow the research. And medical laboratory leaders may find opportunities in mass spectrometry in the near future, rather than decades from now.

Three Distinct Stages in Aging and Other Findings

The Stanford study found that aging appears to happen at three distinct points in a person’s life—around the ages 34, 60, and 78—rather than being a slow, steady process.

The researchers measured and compared levels of nearly 3,000 specific proteins in blood plasma taken from healthy people between the ages of 18 and 95 years. In the published study, the authors wrote, “This new approach to the study of aging led to the identification of unexpected signatures and pathways that might offer potential targets for age-related diseases.”

Along with the findings regarding the timeline for aging, the researchers found that about two-thirds of the proteins that change with age differ significantly between men and women. “This supports the idea that men and women age differently and highlights the need to include both sexes in clinical studies for a wide range of diseases,” noted a National Institutes of Health (NIH) report.

“We’ve known for a long time that measuring certain proteins in the blood can give you information about a person’s health status—lipoproteins for cardiovascular health, for example,” stated Wyss-Coray in the NIH report. “But it hasn’t been appreciated that so many different proteins’ levels—roughly a third of all the ones we looked at—change markedly with advancing age.”

Tony Wyss-Coray, PhD (above), Professor of Neurology and Neurological Sciences at Stanford University, was senior author of the proteomics study that analyzed blood plasma from 4,263 people between the ages 18-95. “Proteins are the workhorses of the body’s constituent cells, and when their relative levels undergo substantial changes, it means you’ve changed, too,” he said in a Stanford Medicine news article. “Looking at thousands of them in plasma gives you a snapshot of what’s going on throughout the body.” (Photo copyright: Stanford University.)

Differentiating Aging from Disease

Previous research studies also found it is indeed possible to measure a person’s age from his or her “proteomic signature.”

Toshiko Tanaka, PhD, Research Associate with the Longitudinal Study Section, Translational Gerontology Branch, National Institute of Aging (NIG), National Institute of Health (NIH), Baltimore, led a study into proteomics which concluded that more than 200 proteins are associated with age.

The researchers published their findings in Aging Cell, a peer-reviewed open-access journal of the Anatomical Society in the UK, titled, “Plasma Proteomic Signature of Age in Healthy Humans.” In it, the authors wrote, “Our results suggest that there are stereotypical biological changes that occur with aging that are reflected by circulating proteins.”

The fact that chronological age can be determined through a person’s proteomic signature suggests researchers could separate aging from various diseases. “Older age is the main risk factor for a myriad of chronic diseases, and it is invariably associated with progressive loss of function in multiple physiological systems,” wrote the researchers, adding, “A challenge in the field is the need to differentiate between aging and diseases.”

Can Proteins Cause Aging?

Additionally, the Stanford study found that changes in protein levels might not simply be a characteristic of aging, but may actually cause it, a Stanford Medicine news article notes.

“Changes in the levels of numerous proteins that migrate from the body’s tissues into circulating blood not only characterize, but quite possibly cause, the phenomenon of aging,” Wyss-Coray said.

Can Proteins Accurately Predict Age? Not Always

There were, however, some instances where the protein levels inaccurately predicted a person’s age. Some of the samples the Stanford researchers used were from the LonGenity research study conducted by the Albert Einstein College of Medicine, which investigated “why some people enjoy extremely long life spans, with physical health and brain function far better than expected in the 9th and 10th decades of life,” the study’s website notes.

That study included a group of exceptionally long-lived Ashkenazi Jews, who have a “genetic proclivity toward exceptionally good health in what for most of us is advanced old age,” according to the Stanford Medicine news article.

“We had data on hand-grip strength and cognitive function for that group of people. Those with stronger hand grips and better measured cognition were estimated by our plasma-protein clock to be younger than they actually were,” said Wyss-Coray. So, physical condition is a factor in proteomics’ ability to accurately prediction age.

Although understanding the connections between protein in the blood, aging, and disease is in early stages, it is clear additional research is warranted. Not too long ago the idea of consumers having their DNA sequenced from a home kit for fun seemed like fantasy.

However, after multiple FDA approvals, and the success of companies like Ancestry, 23andMe, and the clinical laboratories that serve them, the possibility that proteomics might go the same route does not seem so far-fetched.

—Dava Stewart

Related Information:

Our Bodies Age in Three Distinct Shifts, According to More than 4,000 Blood Tests

Fountain of Youth? Young Blood Infusions ‘Rejuvenate’ Old Mice

Undulating Changes in Human Plasma Proteome Profiles Across the Lifespan

Blood Protein Signatures Change Across Lifespan

Plasma Proteomic Signature of Age in Healthy Humans

Stanford Scientists Reliably Predict People’s Age by Measuring Proteins in Blood

Advancements That Could Bring Proteomics and Mass Spectrometry to Clinical Laboratories

Might Proteomics Challenge the Cult of DNA-centricity? Some Clinical Laboratory Diagnostic Developers See Opportunity in Protein-Centered Diagnostics

Federal Advisory Committee Seeks Public Comments on Revising CLIA Regulations, says Keynote Speaker at 13th Annual Lab Quality Confab in Atlanta

At The Dark Report’s annual Lab Quality Confab for clinical laboratory administrators, managers, and quality team members, experts outline how disruption in healthcare requires labs to improve processes and cut costs

ATLANTA, Oct. 15, 2019—Clinical laboratory professionals have a chance to advise the federal Centers for Disease Control and Prevention (CDC) on how the federal government could revise the regulations under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). That’s according to one of the keynote speakers on Wednesday at The Dark Report’s 13th Annual Lab Quality Confab (LQC), which began here on Tuesday.

Reynolds M. Salerno, PhD, Director of the Division of Laboratory Systems (DLS) for the CDC in Atlanta, explained that the agency is collecting comments from the public and from its Clinical Laboratory Improvement Advisory Committee (CLIAC) on how to revise the CLIA regulations.

This is an opportunity for clinical laboratory directors, pathologists, and other lab professionals, to comment on the proposed revisions to CLIA before or during the upcoming CLIAC meeting on Nov. 6.

The agenda for the meeting is posted on the CDC’s website.

Public to be Heard on CLIA Regulations

“For the first time in its 26-year history, the council has called for three workgroups to address how to revise CLIA,” Salerno said. The workgroups will address these topics:

“It’s a dramatic step for the government to ask the laboratory community how to revise the CLIA regulations,” Salerno commented. Chartered in 1992, the advisory council meets twice a year, once in April and once in November.

CLIAC issued a summary report of its April 10-11 meeting. It also published an agenda for its upcoming meeting in Nov. 6.

In the coming weeks, Dark Daily will publish more information on how clinical laboratory professionals can comment on the important issue of CLIA revisions.

Digital slides from Salerno’s keynote address are posted on LQC’s presentations website.

Clinical Laboratory Testing is Increasing in Value, Keynote Speaker Says

As a service to clinical laboratories, Salerno outlined many of the services the CDC’s Division of Laboratory Systems provides for free to clinical labs, including information on such topics as:

During his remarks at the 13th Annual Lab Quality Confab in Atlanta, Salerno had good news for the clinical laboratory professionals in attendance. He said that lab testing was becoming a more valued commodity in healthcare because physicians and other providers were growing increasingly confident in lab test results. [Photo copyright: The Dark Report.]

Healthcare System Disruption Impacts Providers, Including Clinical Laboratories

Other keynote speakers addressed how disruption in the US healthcare systems affects provider organizations in significant ways. For clinical laboratories, such disruption has resulted in reduced payment and demands for quality improvement and shorter turnaround times.

For all these reasons, quality management systems may be every clinical laboratory’s best strategy to survive and thrive, the keynote speakers said.

The first keynoter was Robert L. Michel, Editor-in-Chief and Publisher of The Dark Report. Michel’s remarks focused on how price cuts from Medicare, Medicaid, private payers, and the drive for value-based payment, are requiring labs to do more with less. For this reason, quality management systems are necessary for all labs seeking to improve results, eliminate errors, and cut costs, he said.

“The people closest to the work know how to fix these problems,” he added. “That’s why labs know they must train their staff to identify problems and then report them up the chain so they can be fixed,” Michel commented. “Labs that are best at listening to their employees are getting very good at identifying problems by measuring results and monitoring and reporting on their own performance.”

Michel identified three principle factors that are disrupting healthcare:

  • The shift from reactive care in which the health system cares for sick patients to proactive care in which the health system aims to keep patients healthy and out of the hospital and other costly sites of care.
  • The transition away from fee-for-service payment that encourages providers to do more for patients, whether more care is needed or not, to value-based payment that aims to reward providers for keeping patients healthy.
  • The consolidation among hospitals, health systems, physicians, and other providers. A trend that requires clinical laboratories to find new partners and new ways to improve lab services and reduce costs.

Informatics Performance Data Help Clinical Laboratories Respond to Change

“The attributes of new and successful labs are that they will have faster workflow and shorter cycle times for clinical lab tests and anatomic pathology specimen results,” Michel explained. “That means that labs will attack non-value-added processes by implementing continuous improvement strategies [such as Lean and Six Sigma] and by the sophisticated use of informatics.”

Making use of performance data enables clinical laboratory directors to make changes in response to disruptions that affect healthcare. “If you have good informatics, then seven or eight of every 10 decisions you make will be good decisions, and with the other two and three decisions, you’ll have time to pull back and adjust,” Michel commented.

The second keynote speaker, Jeremy Schubert, MBA, MPH, Division Vice President of Abbott, reiterated what Michel said about how the health system is moving away from fee-for-service payment. Instead of focusing on caring for sick patients exclusively, he said, health insurers are paying all healthcare providers to keep patients healthy.

“Healthcare today is about the whole life course of the individual,” Schubert explained. “Patients no longer want healthcare only when they’re sick. Instead, they want to be healthy. And health creation is not just about a person’s physical health. It’s about their mental health, their emotional health, and their social wellbeing.

“In fact,” he continued, “you can learn more about a person’s health from their Zip code than from their genetic code.”

That is essentially what TriCore Reference Laboratories (TriCore) has been doing in New Mexico, Schubert added. During his presentation, Michel mentioned TriCore as being one of four clinical laboratories participating in Project Santa Fe, a non-profit organization that promotes the movement from Clinical Lab 1.0 to Clinical Lab 2.0. (See “TriCore Forges Ahead to Help Payers Manage Population Health,” The Dark Report, May 20, 2019.)

“If you want to be a quality engine in healthcare you have to be operating at Lab 2.0. Who is best qualified to interpret information? It’s the lab,” Schubert said. Then he challenged labs to begin pursuing the goal of achieving Lab 3.0, saying “Lab 3.0 is being able to interface with the patient to address each patient’s problems.”

The 13th Annual Lab Quality Confab (LQC) in Atlanta continues through the 17th with post-event workshops in Six Sigma and mastering quality management systems. In attendance are 300 clinical laboratory administrators, managers, and quality team members who are learning a complete array of professional training methods.

To register to attend, click here or enter https://www.labqualityconfab.com/register into your browser, or call 707-829-9485, or e-mail lqcreg@amcnetwork.com.

—Joseph Burns

Related Information:

Clinical Laboratory Improvement Advisory Committee Agenda for meeting Nov. 6

Clinical Laboratory Improvement Advisory Committee Summary Report

TriCore Forges Ahead to Help Payers Manage Population Health

Helping Medical Laboratories Add Value to Health Systems, Providers, and Payers by Moving from Clinical Lab 1.0 to Clinical Lab 2.0

Kaiser Family Foundation Survey Finds Hospitals in West Coast States Incur Highest Daily Expenses when Providing Inpatient Care

US hospitals typically spend $2,424/day to provide inpatient care, according to the KFF report 

How much does the average hospital spend/day to provide inpatient care? The numbers vary widely, but the latest statistics from Kaiser Family Foundation (KFF) State Health Facts show West Coast states incur the highest daily operating and non-operating inpatient costs.

This disparity in spending is unlikely to surprise medical laboratory executives working in hospital settings. They know firsthand that operating costs can vary from state-to-state and by hospital ownership type.

Oregon, California, and Washington are the most expensive three states overall for inpatient hospital care. However, the leaderboard changes when looking specifically at inpatient care at for-profit hospitals.

In the for-profit hospital category:

  • North Dakota, South Dakota, and Alaska rack up the highest expenses/day.
  • Idaho, California, and Oregon top the non-profit hospital segment.

Overall in the US, the average hospital incurs expenses of $2,424/inpatient day, the KFF reports.


While the average US hospital spends $2,424/day to deliver inpatient care, West Coast states have the highest hospital adjusted operating and non-operating expenses/inpatient day, according to a recent report from the Kaiser Family Foundation. Oregon hospitals top the spending list at $3,599/day. (Graphic copyright: Kaiser Family Foundation.)

AMA Annual Survey Rankings

Rankings are based on information from the 1999-2017 American Hospital Association Annual Survey, which includes all operating and non-operating expenses for registered US community hospitals. The figures are an estimate of the expenses incurred by a hospital to provide a day of inpatient care. They have been adjusted higher to reflect an estimate of the volume of outpatient services, according to the KFF. The numbers do not reflect actual charges or reimbursement for the care provided.

Most expensive average expenses/inpatient day:

  • Oregon, $3,599
  • California, $3,441
  • Washington, $3,429
  • Idaho, $3,119
  • District of Columbia, $3,053

Least expensive average expenses/inpatient day:

  • Montana, $1,070
  • Mississippi, $1,349
  • South Dakota, $1,505
  • Wyoming, $1,520
  • Alabama, $1,554

Most expensive non-profit hospitals/inpatient day:

  • Idaho, $4,208
  • California, $3,800
  • Oregon, $3,546
  • Washington, $3,500
  • Colorado, $3,319

Least expensive non-profit hospitals/inpatient day:

  • Mississippi, $1,365
  • South Dakota, $1,519
  • Iowa, $1,564
  • Montana, $1,627
  • Alabama, $1,723

Most expensive for-profit hospitals/inpatient day:

  • North Dakota, $4,701
  • South Dakota, $3,956
  • Alaska, $3,280
  • Nebraska, $3,031
  • Wisconsin, $2,830

Least expensive for-profit hospitals/inpatient day:

  • Maine, $1,055
  • Maryland, $1,207
  • West Virginia, $1,362
  • Iowa, $1,558
  • Arkansas, $1,619

Most expensive state/local government hospitals/inpatient day:

  • Oregon, $4,062
  • Connecticut, $3,979
  • Washington, $3,312
  • California, $3,217
  • Utah, $3,038

Least expensive state/local government hospitals/inpatient day:

  • Montana, $52
  • South Dakota, $442
  • Pennsylvania, $787
  • Nebraska, $906
  • Georgia, $917

Some Regions Pay Much More for Healthcare

The KFF report did not look at whether patients in states where hospitals incur the highest daily operating and non-operating expenses also pay the most for hospital services. Hospital charges vary widely, with many treatments costing far more in some regions than others.

In addition, health bills can vary at different hospitals in the same city or region. According to Healthcare.gov, the average total cost of a three-day hospital stay is about $30,000.

Adding to the confusion is the fact that hospital costs, billed charges, and the amounts paid by patients for services can be distinctly different amounts. Health insurance companies, for example, negotiate lower rates with hospitals and health systems for their plan enrollees. While patients without insurance are billed full price for services based on the hospital’s chargemaster.


Zack Cooper, PhD, Associate Professor of Health Policy and Economics at Yale University, told National Public Radio (NPR) that hospital consolidation is partly to blame for the wide variation in the price of hospital services within states and across the country. He says consolidation has eliminated competition in many markets. “Where one large hospital dominates the markets, that hospital is able to get higher prices,” Cooper maintains. “Hospitals have gotten increasingly powerful over time.” (Photo copyright: Yale University.)

CMS Final Rule Requires Pricing Transparency

As of Jan. 1, 2019, a new Centers for Medicare and Medicaid Services (CMS) rule went into effect aimed at making hospital pricing more transparent. The CMS is now requiring hospitals to publish chargemaster price lists online, rather than release those numbers to patients upon request.

However, healthcare advocates have questioned the rule’s impact on transparency. Posted hospital pricing information is often hard to access and difficult to comprehend. In addition, chargemaster prices typically do not represent the actual costs passed on to consumers.

“[The chargemaster] is the list price. When you go to buy a car, you have a manufacturer’s suggested retail price. This is basically what [the chargemaster] is,” Medical Contributor Natalie Azar, MD, told NBC News.

Meghan Nechrebecki, Founder and CEO of Health Care Transformation, told Debt.org that prevention is the best medicine for lower inpatient hospital bills.

“Prevention comes first,” Nechrebecki suggests. “Utilize the ambulatory care clinics. Go see your doctors and do what they recommend to keep yourself healthy. Eat well and exercise often. You will prevent many surgeries and hospitalizations.”

Sound advice. Nevertheless, clinical laboratories and anatomic pathology groups should take note of the federal government’s ongoing push for price transparency and prepare accordingly.

—Andrea Downing Peck

Related Information:

Hospital Adjusted Expenses/Inpatient Day

Hospital Adjusted Expenses/Inpatient Day by Ownership

HHS Takes New Steps in Secretary Azar’s Value-Based Agenda

Hospital and Surgery Costs

That Surgery Might Cost You a Lot Less in Another Town

Protection from High Medical Costs

Hospitals to List Procedure Prices Under New Law: What You Need to Know

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