Now more than ever, it's crucial to eliminate waste, inefficiency, and unnecessary spending in healthcare wherever they occur.
One way to achieve this is by resolving misalignment among health plans, providers, patients, and government health programs on various issues. Although these four stakeholders share the goal of affordable, accessible, high-quality healthcare, their ideas about what that entails, how to achieve it, and who should bear the costs differ significantly. Aligning them remains a continuing and very challenging task, but it is essential if healthcare in this country is to endure the pressures it faces.
The problem of misalignment
Clinical lab testing exemplifies this competitive misalignment. It affects all four stakeholders, and although lab testing accounts for only a small portion of total healthcare spending, it remains crucial to clinical decision-making, care coordination, and cost management.
Consider stakeholders' varying expectations of lab testing:
- Patients want their tests to be medically necessary, accurate and paid for by insurance.
- Providers want to order tests they consider necessary without interference from plans and to be reimbursed for them.
- Plans require tests to be clinically appropriate and accurate while managing costs.
- The government aims to control costs, prevent waste, fraud, and abuse, and often gets involved in private sector healthcare regarding issues like mandated testing, reimbursement, prior authorization, and more.
Not all worthy goals are mutually exclusive, but aligning all stakeholders on how to achieve them is challenging. It requires an approach that balances everyone's interests while maintaining fiscal responsibility and quality control. It also demands lab stewardship.
The need for lab stewardship
Lab stewardship is a practice that promotes the correct use of tests, aligns clinical and financial outcomes, and ensures compliance with evolving payer policies. It has five goals:
- Access to testing
- Correct test ordering
- Accurate and timely test result retrieval
- Correct result interpretation
- Financial alignment between patients, laboratories, and payers
Implemented correctly, it can do much to improve lab testing by:
- Ensuring proper test use and reimbursement
- Reducing unnecessary tests and costs
- Improving patient safety and diagnostic accuracy
- Integrating into governance, analytics, and clinician education
A health plan or lab benefits manager working for the plan enforces stewardship through a comprehensive solution:
laboratory benefits management (LBM) involves using evidence-based laboratory policies and pre-authorization tools to reduce unnecessary tests and ensure that the right patients receive the right tests at the right time.
In addition, leveraging diagnostic intelligence capabilities that transform complex diagnostic data to provide predictive health insights, identify risks early, and guide interventions. This includes analyzing test volumes and patterns and preventing fraud, waste, and abuse.
Lab stewardship is not only a good policy; it's also required by law. In 2023, the HHS Office of Inspector General (OIG) issued a statement reminding the industry that lab stewardship is a regulatory requirement, and failure to comply can result in civil and criminal penalties.
What lab stewardship looks like
An effective lab stewardship program includes these critical components:
- Enforcement driven by science. Lab stewardship is effective only when its programs are firmly grounded in scientific principles. That foundation guides optimal outcomes and is defensible to all parties. Policies based on science improve compliance by ensuring appropriate test ordering, enhancing quality, and reducing costs.
- Preventive care integration. Policies should follow evidence-based practices and national guidelines, such as those from OIG, Choosing Wisely, and the American Society for Clinical Pathology, to ensure that testing is clinically appropriate.
- Full transparency. Policies should be reviewed and regularly updated by an independent clinical advisory board. Meanwhile, health plans should retain complete control over the adoption and modification of policies, including any variances. This includes detailed information on specific billing procedures (procedure codes, edit types, fixed criteria) and a clear narrative of explicit conditions that align with policy compliance.
- Provider education. Lab stewardship should include supporting clinicians and lab providers through real-time decision support, education, policy transparency, and justifiable evidence-based edits. The plan's policies determine denials.
Increased savings and better outcomes
A robust lab stewardship program using an LBM can lower outpatient lab costs by 10% to 18% and reduce unnecessary lab expenses by $1.75 to $2.35 per member each month.
Additionally, leveraging diagnostic insights can significantly contribute to population health and value-based care efforts by helping to identify members with certain conditions that might otherwise go undiagnosed, enabling earlier interventions.
Furthermore, the rising demand for genetic testing and personalized medicine is increasing the volume and diversity of laboratory tests, emphasizing the need for coordination among all stakeholders to ensure testing is performed effectively and produces the best possible results for everyone involved.
By aligning the goals and interests of all stakeholders within an evidence-based program, lab stewardship can advance the shared aim of affordable, accessible, high-quality healthcare.
