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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.
HMO Decline Predicted As PPOs Gain Enrollment
CEO SUMMARY: Managed care analyst Michael Casey believes HMO enrollment will peak, possibly in 2000. PPOs (preferred provider organizations) are gaining members at an increasing rate. Within California, the provider revolt over deficient reimbursement levels is escalating. Orange County…
Insurers Dropping Medicare HMO Programs in Various Regions
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ProxyMed, MedePass, Cigna, Aetna
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CEO SUMMARY: Texas demonstrates that, where providers have political clout, some of the more onerous aspects of managed care can be changed. The Texas Attorney General sued Aetna and five other HMOs in 1998 about the way physicians were given incentives to stay within budget numbers for t…
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CARESIDE POC Solution in entirety, the traditional way of performing tests in the To Alter Lab Organization
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Finally: Respect for Cytyc As Aetna OKs ThinPrep®
CEO SUMMARY: Here’s an important development in the battle to get the healthcare community to accept new technology for the preparation of Pap smears. Aetna/U.S. Healthcare announced that it would cover the monolayer preparation tests offered by Cytyc and AutoCyte. Aetna’s decision ma…
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Volume XXXII, No. 6 – April 21, 2025
Now that a federal judge has vacated the FDA’s LDT rule, The Dark Report analyzes the judgement and notes the various steps the FDA could take in response. Also, lab testing at pharmacies is proving to be less successful than was once anticipated.
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