CEO SUMMARY: In Florida, obstetricians and gynecologists are complaining about the burdensome nature of the new lab test management system introduced by UnitedHealthcare. In addition to calling for an end to the program, some ob-gyns plan not to use the system, a process that could lead UHC to deny payment to clinical labs. In a letter to UHC, Florida ob-gyns expressed their concerns that use of the BeaconLBS system “may lead to prolonged patient waiting times and patient dissatisfaction.”
OBSTETRICIANS AND GYNECOLOGISTS in Florida are calling on UnitedHealthcare to discontinue its new laboratory benefit management service immediately.
If the lab program, accessed through Beacon Laboratory Benefit Solutions in Florida, is not ended, there is concern that physicians in Florida may not use the service because it is onerous, burdensome, and disruptive to workflow, stated Robert W. Yelverton, M.D., Chair of District XII (Florida) for the American Congress of Obstetricians and Gynecologists.
In a letter sent September 11 to Linda Stewart, vice President of UHC’s national lab program (see letter in sidebar on page 6), Yelverton outlined the research ACOG members have done and the concerns they have about how UHC’s laboratory benefit management program will disrupt physicians’ office workflow and affect patient care. ACOG members have expressed those concerns to UHC, he said, but the health insurer has failed to address their concerns. BeaconLBS is a subsidiary of Laboratory Corporation of America.
“While there are other issues concerning the BeaconLBS program, those highlighted here compel us to request that UHC suspend this test program as a requirement for Florida providers immediately and indefinitely,” Yelverton wrote. “ACOG District XII values its relationship with UHC and recognizes our shared responsibility in improving the quality and efficiency of patient care. However, we view the implementation of the BeaconLBS program, in its current form, as a giant step backward.”
Labs Might Not Get Paid
On October 1, UHC made the program available to physicians in Florida but it rescheduled the date when it would stop paying clinical labs for running tests each time physicians fail to follow the steps required in the BeaconLBS program. In September, UHC said it would move the date back for when it starts to base payment decisions on whether physicians comply with the requirements in BeaconLBS until January 1. (See TDR, September 2, 2014.)
The system so disrupts workflow that some physicians may not use the BeaconLBS, Yelverton said. By not using the system, physicians suspect that UHC or BeaconLBS may not pay clinical labs for the tests they order. Instead, the labs may bill UHC’s patients, a step physicians suspect will cause patients to complain to UHC. UHC forbids in-network labs from balance-billing patients, however.
“BeaconLBS is much more than a headache for physicians,” Yelverton commented. “It’s a migraine,” he said. Ob-gyns are the second physician specialty to complain about the burdens of the new BeaconLBS system. In August, some members of the Florida Association of Family Physicians said they will discontinue their association with UHC rather than use the BeaconLBS system to order lab tests. (See TDR, October 13, 2014.)
On January 1, United will require physicians serving its members in commercial HMOs in Florida to use the BeaconLBS system for ordering any of about 81 clinical laboratory tests. For two of those tests (BRCA1 and BRCA2), BeaconLBS requires physicians to get prior approval before it will approve the test for payment. For the remaining 79 tests, physicians must use the BeaconLBS system to notify it in advance that they are ordering one or more of these tests.
Should a physician fail to get prior approval or give BeaconLBS what UHC calls “advance notification,” neither Beacon nor United will pay the clinical lab that runs that test.
Expert in EHRs, Order Entry
A former chief medical officer for one of the largest ob-gyn groups in Florida, Yelverton is an expert in electronic health record (eHR) systems and computerized physician order entry. In retirement, as Chair of ACOG’s District XII (Florida), he does not see patients.
For several months, Yelverton has talked with ob-gyns who tried to learn the BeaconLBS system. He has explained their frustrations and their concerns about disruptions in patient care to officials from UHC and BeaconLBS. Also, he has had representatives from UHC and BeaconLBS explain the steps needed to order lab tests with the BeaconLBS system. As a result, he is thoroughly familiar with how it works, he said.
Impact on Patients
“Our main concern with BeaconLBS is the functionality of the system and how it affects our patients,” he noted. “The order entry process is very burdensome because it takes us out of our eMR system that we use to order tests and get results bidirectionally. You have to do the BeaconLBS system separately, and that’s not the way it goes when a physician’s office works with any other payer or any other lab.
“To order one of the 81 lab tests, you have to get out of your eMR system and enter the online Beacon system,” stated Yelverton. “Then, it takes what we estimate to be a minimum of six clicks to order a test. But then, if you have to register a new patient, you may need as many as 22 steps to enroll that patient and order the tests on the BeaconLBS list of lab tests.
“That’s our major objection,” continued Yelverton. “But also, BeaconLBS has not developed interfaces with any of the major eHR systems and even when it does, it’s not clear the interfaces will resolve the workflow problems the BeaconLBS system creates.
“From talking with BeaconLBS representatives on numerous occasions, the way I understand it is the interface activity will be capable only of taking the patient’s name and demographic information,” he noted. “If that’s the case, then the [eHR] interfaces they’re developing will not relieve the burdensome nature of the system.”
Last month, in a letter UHC wrote to providers, it said it had developed inter- faces with two eHR systems: Emdeon and Liaison Technologies. The letter also noted that BeaconLBS said it plans to integrate soon with two other eHRs, Aprima and eClinicalWorks.
Few Interfaces with EHRs
“Those two systems, emdeon and Liaison, are minor players and may represent only about 5% percent of the physicians in Florida,” he added. “The fact that they haven’t worked out these interfaces yet tells me a lot about the low level of software capability that BeaconLBS has. How the interfaces work is a major concern to physicians.
“If UHC and BeaconLBS do not support a thorough bidirectional interface, that may mean physicians will need to continually step out of their eHR systems and go to the BeaconLBS website to enter the required information for a lab test order,” noted Yelverton. “Physicians with a bilateral interface, such as exists with the LabCorp test order system, may not have to enter that lab test order twice.
“At the same time, the requirement will remain for physicians to complete the prior authorization and advance notifications processes for those 81 or so tests that require that information,” he added. “As many as three questions must be answered to get the BeaconLBS system to approve the lab test order in some situations.
Answering Clinical Questions
“The BeaconLBS people have said the ordering process is not burdensome and that we could train our staff to answer these clinical questions,” stated Yelverton. “But when a physician looks at the questions the system asks in an attempt to justify the lab test order, these are not the kinds of questions that a medical assistant can answer with any clinical accuracy.
“The physician must stop what he or she is doing to answer those questions in order to obtain the prior notification or prior authorization,” said Yelverton. “That’s for each of those 81 tests, and, frankly, some of the tests listed by UHC are fairly common laboratory tests, such as the prenatal tests.”
Florida Doctors Question Requirement by BeaconLBS to Obtain Pre-Notification for Common Routine Tests
WHY ARE PHYSICIANS REQUIRED to get approval for routine screening tests? That’s a question that puzzles obstetricians and gynecologists, stated Robert W. Yelverton, M.D., Chair of the American Congress of Obstetricians and Gynecologists District XII (Florida).
Starting January 1, UnitedHealthcare (UHC) plans to require physicians to prenotify it or to obtain pre-authorization each time they order any of 81 clinical laboratory tests as a requirement of the UHC laboratory benefit management program. The list includes many tests that are: a) important and routine; and, b) recommended for a substantial number of the patients an ob-gyn would see every day, Yelverton said.
“If a test is routine and if the federal Centers for Disease Control and Prevention recommends such tests, why is advance notification required by UHC?” asked Yelverton. Perhaps notification is required to limit overutilization or to deny payment, he suggested.
“For example, UHC now requires a physician to get approval from BeaconLBS to order the routine screening test for diabetes—yet every pregnant patient has to have that test as part of routine prenatal care,” he said. “That’s just one of several prenatal tests that physicians in a busy office regularly order and now we are required to give advance notification to UHC every time that we order these tests.
Using Beacon for Each Pap
“This is also true of the Pap test,” continued Yelverton. “The physician must go through the BeaconLBS process for each Pap test ordered, and ob-gyns order Pap tests on every patient at least once every three years.
“To require an ob-gyn to go through the advance notification for every Pap test makes no sense at all,” he stated. “We must now do the same for all prenatal lab tests. This includes such routine basic tests as blood type and Rhesus (Rh) test. Getting approval for every Pap test and every prena- tal test simply doesn’t make sense.”
To this point, however, UHC has not provided responses to requests asking why routine lab tests are subject to pre-notification. Nor has UHC provided data that would demonstrate how much inappropriate utilization actually happens when physicians order any of the 81 tests listed by UHC that require pre-notification or pre-authorization.
“UHC is just one payer and that one payer is implementing a burdensome system that takes us out of our normal workflow and impacts patients,” noted Yelverton. “Don’t forget, over the past few years, physicians have worked extremely hard to make that workflow as seamless as possible for the women we serve.
Expert in EHR Systems
“During the day, as an ob-gyn works through each patient, he or she wants to stay on time and keep up with entering data into the electronic health record,” explained Yelverton. “Ob-gyns don’t want anything to interrupt that workflow.”
In the Tampa Bay area, UHC has about 22% of the managed care market, he said. “This means that, in Tampa, a physician could see his or her workflow disrupted on about every fifth patient requiring lab tests,” noted Yelverton. “UHC patients will have a completely different workflow from every other patient.
“UnitedHealthcare says it aims to improve efficiency and quality. But this new lab test ordering process is not improving our efficiency. Whether it improves quality is doubtful,” Yelverton concluded.
UnitedHealthcare provided responses to questions asked by THE DARK REPORT. These responses are published on page 11.
Are Labs and Pathologists ‘Asleep at the Switch?’
IT SEEMS THAT ANYONE WHO UNDERSTANDS medical practice and clinical laboratory testing has legitimate questions about the design and impact of the laboratory benefit management program introduced in Florida last month by UnitedHealthcare.
Several times in recent months, THE DARK REPORT has presented information about the concerns, questions, and objections raised by physicians and their specialty medical associations in Florida concerning aspects of the UHC and BeaconLBs lab program. On one hand, these physicians have legitimate gripes about the disruption to well-established workflow they must endure to meet the pre-notification and pre-authorization requirements of UHC—not to mention the poor design of the BeaconLBS system.
On the other hand, these physicians have equally legitimate questions about the true need for an insurer to question their clinical decisions about which test to order for their patients—particularly since many of the tests on the UHC list are common, have well-established clinical guidelines, and are essential in practicing evidence-based medicine.
So where are pathologists and their specialty colleges and associations in aiding their clinical colleagues in this matter? Pathologists are the experts in appropriate utilization of lab tests. Thus, it would seem that their lab associations would at least make some well-timed and public statements in support of the concerns that Florida physicians have about the requirements of the BeaconLBS program. After all, pathologists and physicians do share the common goal of improving patient outcomes by the proper utilization of the right test at the right time.