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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.
Physician Management Companies Exploding, Will Transform Healthcare
CEO SUMMARY: Consolidation and integration of healthcare services will be the dominant trend during the next five years. It happened to commercial laboratories from 1985-95. Widespread hospital consolidation began around 1990 and continues today. Now consolidation is coming to physicians….
Another Portent Of Change
How many laboratory executives and pathologists consider themselves futurists? Probably not many, because healthcare’s traditional fee-for-service arrangements provided little financial incentive to alter the status quo. Yet I would argue that the radical restructuring of healthcare currently unde…
Cigna Buys HealthSource, Inc., Increases Managed Care Clout
CEO SUMMARY: Consolidation continues among managed care companies. Cigna’s acquisition is an effort to boost its managed care business. Healthsource’s market coverage complements areas where Cigna can use the additional market strength to negotiate more favorable contracts with provid…
LabCorp Seeks $500 Million Through Public Stock Offering
CEO SUMMARY: After a financially difficult year in 1996, LabCorp enters 1997 with plans to raise $500 million. Despite the laboratory industry’s poor prospects, LabCorp will probably succeed in raising capital. After this infusion of capital, will LabCorp’s new management team have wi…
Unilab Pushes Insurers To Increase Cap Rates
CEO SUMMARY: California’s financially destructive capitation rates plunged two more laboratories into bankruptcy. Unilab’s actions indicate that even the largest laboratory company in the state can no longer survive without reimbursement relief. The question remains as to whether mana…
It Can’t Happen Here
Here is another issue of THE DARK REPORT with stories about radical changes to laboratory organizations. When Canada’s Alberta Province whacked almost 40% out of the healthcare budget over two years, laboratories …
Lab Services In Canada Undergo Radical Changes
CEO SUMMARY: Canada’s single-payer healthcare system is undergoing transformation. Rising costs now compel individual provinces to re-engineer their existing healthcare arrangements. In Alberta, commercial laboratories were forced to merge and cooperate with hospital-based laboratories….
CURRENT ISSUE
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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