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Fee-for-service
Fee-for-service has long been the primary payment model for clinical laboratories and pathology groups. Fee-for-service (FFS) is a payment model in which services are paid for as itemized in the provider’s invoice. It gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, patients are incentivized to welcome any medical service that might not be necessary. Insurance companies shield themselves against ruin by setting cover limits for every beneficiary.
FFS raises costs, discourages the efficiencies of integrated care, and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence (such as moving towards bundled payments and capitation).
Medicare Parts A (hospital insurance) and B (optional insurance that covers physician, outpatient hospital, home health, laboratory tests, durable medical equipment, designated therapy, outpatient prescription drugs, and other services not covered by Part A) are FFS programs. Medicare processes over one billion FFS claims per year.
As part of the ongoing drive to cut healthcare costs, this model is gradually being phased out by payers and healthcare organizations in favor of value-based payment models, such as pay-for-performance programs and accountable care organizations that are intended to cap costs and spread financial risk among providers, while encouraging coordination of care, disease prevention and better management of chronic conditions. This is seen as a threat to the survival of clinical labs, which expect to see far fewer tests ordered by healthcare providers.
The Clinical Laboratory Management Association is working to help labs navigate these changes. “As fee-for-service reimbursement gives way to bundled reimbursement and per-member-per-month payment, labs will only be successful if they add value to physicians by helping them diagnose disease earlier and more accurately,” says CLMA President Paul Epner.
CLMA has named this program “Increasing Clinical Effectiveness,” or ICE. THE DARK REPORT is one of CLMA’s partners in this effort.
“Our hope is that ICE is a catalyst that helps lab administrators, pathologists, and medical laboratory scientists broaden the focus of their laboratory beyond operational efficiency to include measurable impact on positive patient outcomes,” says Epner.
CEO Describes Characteristics Of the Clinical Lab 2.0 Model
CEO SUMMARY: Moving away from volume-based care will not be easy for clinical labs. After all, high volume sustains labs. But labs seeking to transition away from fee-for-service to value-based care must have a seat at the table where decisions are made, said a lab CEO who is part of Proj…
More Hospitals Consider Options for Their Labs
CEO SUMMARY: Is it a new sign of the times? After decades of reluctance to sell their lab outreach businesses or enter into inpatient lab management agreements with commercial lab companies, a surprising number of hospitals and health systems are taking that step. Since the first of the y…
Value-Based Care Is One Goal Of WHCN-Sonic Lab JV
CEO SUMMARY: Announced last month, the new laboratory joint-venture partnership with Sonic Healthcare’s Sunrise Clinical Laboratories will allow WCHN to compete with other health systems and prepare to respond to health insurers’ requests that hospital systems offer lower rates in val…
Sonic, Western Connecticut Health Network Announce New Laboratory Joint Venture
CEO SUMMARY: To prepare for the transition from fee-for-service to value-based payment, Western Connecticut Health Network, a three-hospital health system, announced a laboratory joint venture with Sonic Healthcare. Benefits will include lower test costs, more competitive prices, and the …
Clinical Labs Bidding Up Lab Director Salaries
CEO SUMMARY: There’s great news for pathologists and PhDs with expertise in molecular and genetic testing. Salaries are on the rise as more clinical labs build up their molecular and genetic testing programs and need talent to implement and supervise this activity. One experienced medic…
Ending ‘Lab Tests as a Commodity’
WITH HEALTHCARE POISED TO MAKE FUNDAMENTAL CHANGES in both the delivery of care (think integration, ACOs, medical homes) and how providers are paid (less fee-for-service, more budgeted payment metho…
Lab Innovators Advocate Need for Clinical Lab 2.0
CEO SUMMARY: It is generally recognized that the clinical lab industry faces a financial squeeze of unprecedented dimensions. Lab test prices are falling steadily and more major cuts are coming to Medicare Part B fees in just 11 months. At the same time, obtaining favorable coverage and r…
California’s Lab Price Data Collection Project Cuts Lab Test Prices by 10.5%
COLLECTING LAB TEST PRICE DATA is not limited to PAMA and the federal Centers for Medicare & Medicaid Services. California’s Medi-Cal program is in its second year of requiring clinical labs to submit private payer lab test price data. However, in both the fir…
Medicare Part B Lab Test Prices Versus Budgeted Payment
THERE IS AN IMPORTANT QUESTION THAT lab industry magazines and news sources have failed to address: How many years are left before Medicare officials drop fee-for-service payment for clinical lab testing? On January 26, 2015, the Department of Health and Human Services (HHS) issued a press rele…
10% PAMA Fee Cut Would Lower Medicare Pay to Laboratories by $400 Million
CEO SUMMARY: Just eight weeks remain before certain clinical laboratories must begin submitting private payer lab test price data to the federal Centers for Medicare & Medicaid Services. A new report …
CURRENT ISSUE
Volume XXXI, No. 16 – November 25, 2024
Two different federal lawsuits that challenge the authority of the federal Food and Drug Administration (FDA) to regulate laboratory developed tests (LDTs) will be combined. Plaintiffs and the government in both cases agreed to move forward on this basis.
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