CEO SUMMARY: In this case study, clinical laboratory managers from Bryan Health in Nebraska explain how they expanded their lab outreach program to include direct-to-consumer tests. The project involved researching what tests were most appropriate without the need for a physician’s order and enlisting the help of various business departments within the health system.
FINDING NEW AVENUES OF REVENUE IS IMPERATIVE, particularly for hospital-based clinical labs. Doing so can help the lab meet its budget targets while adding in-house tests that contribute to better inpatient, outpatient, outreach care.
In the case of the laboratory at Bryan Health, a nonprofit healthcare system based in Lincoln, Neb., the lab team did more than generate additional revenue from successfully growing its lab outreach program—including a line of direct-to-consumer (DTC) tests. It also generated thousands of new patients for its parent health system in less than a single year!
These new patients were even more valuable to the health system than the additional lab test orders generated by their physicians. The Bryan Health lab’s story showcases three broad lessons that other laboratory leaders can heed:
- Seek the support of ordering physicians ahead of time before making changes to lab test ordering processes.
- Enlist the help of the marketing and IT departments to bear some of the business burdens associated with new testing programs.
- Think creatively when developing outreach strategies and identifying innovative sales and marketing tactics.
When Bryan Health’s clinical laboratory leaders were asked to develop a new lab outreach service as part of the system’s consumer-focused strategy, they turned to DTC testing to reach people who are uninsured or underinsured.
Serving the New Customer
“We are in a different era, and we had to figure out how to give people what they need,” said Christina Nickel, Director of Clinical Laboratory at Bryan Medical Center. Nickel spoke at April’s Executive War College Conference on Laboratory and Pathology Management, presenting a session called, “Establishing the Hospital Lab Outreach Service of On-Demand Testing for Uninsured and Underinsured.”
From April 2021 to February 2022, the lab outreach effort attracted 6,173 patients, including 3,519 who were new to Bryan Health. During that time, there were 55,000 billable tests and $335,000 in net revenue.
Bryan Health reaches urban, suburban, and rural communities of Nebraska.
It includes six medical centers, a physician network, and cardiac and telemedicine services. The healthcare system earned $1.2 billion in operating revenue in 2021.
Bryan Health was challenged by a competitor that was penetrating the outpatient imaging market. This motivated Bryan’s healthcare leaders to launch low-cost imaging and lab services, starting first with imaging offerings at the new Bryan Imaging and Diagnostic Center at the Pine Lake campus in Lincoln.
“We were losing imaging clients to a freestanding site, and we needed to come up with an imaging and diagnostics center to provide quality for low cost,” Nickel noted. “We had to capture people who are underinsured and uninsured. Hospital administration asked me, ‘How long will it take to build a lab and how much will it cost?’”
Expanding Lab Test Services
The idea for the diagnostic center aligned with the lab’s growth goal to expand services and better meet the community’s needs. However, launching the services fast and during the SARS-CoV-2 outbreak was an unexpected challenge.
“I brought my team together to consider timeline, budget, space needed, staffing, the test menu, and test pricing,” Nickel said.
From the get-go, it was clear test orders from physicians, albeit important, would not be enough to achieve an annual goal of 41,600 tests at the new location. DTC tests, the team decided, could serve the target market while propelling the lab to meet the test volume objective. The team came up with three project phases:
- Phase one: DTC tests.
- Phase two: Pre-employment drug screening tests.
- Phase three: Rapid point-of-care COVID-19 testing offered as DTC.
These new laboratory services debuted in spring 2021 at a patient service center operating under a separate Clinical Laboratory Improvement Amendments of 1988 (CLIA) Certificate of Waiver. Specimens collected at the patient center go to the Bryan Medical Center lab for testing and reporting.
Nickel said Bryan Health consulted with in-house attorneys and a local CLIA inspector before introducing its DTC testing menu. Such tests, regulated at federal and state levels, permit consumers to order them directly from labs without consulting a healthcare provider, according to an American Association for Clinical Chemistry statement, which added that 40 states give consumers direct access to clinical testing. The Dark Report has predicted an expansion of consumer-initiated testing options. (See TDR, “Quest and Walmart to Expand Consumer-Initiated Test Options,” Feb. 22, 2022.)
Still another challenge was educating the public about tests they could order themselves. Bryan Health decided to refer to the offerings as “on-demand tests,” a term people are more familiar with as compared to “direct-to-consumer tests.”
“We had to help the public understand what direct-to-consumer testing was. Marketing staff advised us not to call them DTC tests but to call them on-demand tests, which people know about,” said Jayne Ellenwood, Laboratory Client Services Manager at Bryan Medical Center. Ellenwood also spoke at the Executive War College presentation.
Lab Test Development
“Test development became an important part of the project because that is how we attract consumers. We developed a test menu with over 30 tests available for consumers to order,” Ellenwood added. (See the sidebar below for more details.)
The lab team reviewed reference labs’ DTC test offerings and aimed for tests the Bryan’s laboratory could report on fast.
“We wanted to walk the fine line and keep it to routine lab tests rather than diagnostic. We didn’t want to include tests to the menu that require provider interpretation,” Ellenwood explained. “We want people to take charge of their own health and know they could talk to a doctor about test results if they choose to share those results.”
COVID-19 molecular, antibody, and rapid antigen tests are on the on-demand test menu. “We offered a COVID-19 antibody test because many people wanted to know if they had antibodies after they had COVID-19,” Ellenwood noted. “And a later offering of pre-employment drug screening tests allowed us to capture more new clients and be a collection site for the Department of Transportation.”
Garnering Doctors’ Support
Importantly, an outreach specialist from the Bryan Health lab sought input from physicians: What did doctors want to see on the test menu? How did they envision the patient center serving people?
Bryan’s physician network includes 148 providers in 24 offices. In the Lincoln market, about 70% of them are self-employed and own 20 clinics.
“We would not be successful unless we had physician support,” Nickel said, adding that many of the doctors were focused on COVID-19 patients as the outreach service was in the planning stage.
“They wanted to offer more affordable clinical lab testing to patients, especially those who did not have insurance or who had high-deductible health plans,” Ellenwood added.
Lab results with critical values are shared with patients via Bryan’s telemedicine network. “That helped us bolster support of physicians, because they knew that a provider would address critical values with that consumer. The doctors didn’t have to act on something they didn’t order in an emergent manner,” she observed.
Physicians have Bryan Health forms which allow them to recommend tests to patients without insurance coverage. In those cases, the lab staff confer with patients about forwarding results to physicians.
Online Payment Integration
In addition to physicians, the lab leaders reached out to finance, IT, facilities, and marketing colleagues.
Working with finance, they developed a document that defined expectations. As it turned out, the first year’s annual goal of 41,600 tests was surpassed with 46,961 tests in December 2021. Also, with finance and IT’s help, the online payment system for the tests integrates with Epic Beaker, a lab information system, to capture test revenue.
Consumers register online, choose lab tests, and pay with a credit or debit card. No appointment is needed for specimen collection. Results are posted within four to 12 hours to Epic’s MyChart (a website and application that offers patients access to health information) and the Bryan Health electronic medical record system.
“We wanted this to be a quick experience for people,” Ellenwood said. “We had phlebotomists running this without registration employees to handle cash and balance a drawer at end of the day. We also had an Apple iPad touch screen available for people to use if they walked in. And they could pay right there in person.”
Business from people who prefer to pay with cash or by check may have been lost, she noted. Nickel next acknowledged some of the encounters were made by patients previously seen at a Bryan Medical Center campus. But that was a good thing, she said, because the emergency department was caring for an unprecedented volume of patients during the pandemic.
Gaining New Patients
“We did see a shift, but we also saw many more patients at our Pine Lake campus than we ever would have—a lot of people new to Bryan Health, uninsured patients, or those with high deductibles. That is why we went low on pricing the lab tests,” Nickel observed.
Marketing strategies also were key to attracting new customers. They included a website, electronic and print media interviews, and email and postal promotions.
“Purchase your lab test online and walk in at your convenience,” the website states. Outdoor billboards helped spread the message, with one near the local airport promoting COVID-19 testing: “Am I Cleared for Takeoff? COVID-19 Travel Test, Airline Approved, $50.”
Another billboard on a highway focused on some of the low-priced wellness tests: “On-Demand Lab Tests. No Doctor Order Needed: $7 A1c, $11 Cholesterol, $15 Vitamin D.”
Also, a campaign on Facebook reached 10,700 people (mostly women between age 25 and 44) and produced 48 leads for a cost of $802, Ellenwood said.
Plans for Expansion
Looking ahead, lab leaders plan to extend hours at the patient center to include weekends and expand the test menu. They are considering drive-up testing and streamlining the MyChart sign-up experience.
Contact Christina Nickel at firstname.lastname@example.org and Jayne Ellenwood at email@example.com.
Bryan Health’s On-Demand Lab Tests
BELOW IS A RUNDOWN of the some of the laboratory tests and pricing that Bryan Health offers directly to patients without a physician order:
Popular test panels
- Blood chemistry panel: complete metabolic panel (CMP), lipid, TSH, $38
- Thyroid panel: TSH and Free T4, $22
- Women’s health panel: CMP, complete blood count (CBC), lipid panel, TSH, and HbA1c, $55
- Men’s health panel: CMP, CBC, lipid panel, TSH, HbA1c, PSA, $65
- Immunization status panel; varicella zoster, mumps, rubeola, rubella, hepatitis B, $50
- RT-PCR COVID-19 (for travelers and people with no symptoms), $50
- COVID-19 antibody, $30
- Rapid COVID-19 antigen test, $25
Tests performed individually
- A1c hemoglobin, $7
- Blood type, $7
- CBC, $10
- CMP, $15
- Cortisol, $20
- C-reactive protein, $13
- Free T4, $10
- Glucose, $5
- Hemoglobin and hematocrit, $6
- Pregnancy blood test, $12
- Prostate specific antigen, $10
- Urine drug screening, $67
- Vitamin D, $15
Lab Processes Tiger Tests for a Zoo
ONE OF THE STRANGER ASSIGNMENTS that Bryan Health’s laboratory tackled during the pandemic was to perform SARS-CoV-2 tests for a pair of tigers from Lincoln Children’s Zoo in Lincoln, Neb.
In October 2021, the zoo had an event planned that was to feature two tigers amid human guests. However, one of the tigers was showing symptoms of COVID-19, said Christina Nickel, Director of Clinical Laboratory at Bryan Medical Center.
Because COVID-19 can pass between humans and big cats, the zoo wanted to be sure about the animals’ conditions and asked Bryan Health if it could help. The zoo told the lab that a local veterinary school wouldn’t perform the tests, Nickel said.
The zoo collected the specimens and sent them to Bryan’s lab, which processed the samples quickly. It turned out the tigers did have COVID-19; they later recovered from the illness.
“The zoo actually trained these tigers to have the nasopharyngeal collection,” Nickel noted. “I really wished we could have seen that.”