IT’S OFFICIAL! A YEAR-LONG COLLABORATION involving a health insurer, a clinical laboratory, and an analytics company showed that insurers and physicians can use clinically-actionable intelligence developed from medical lab test data to improve patient outcomes.
This important accomplishment in patient care comes with another significant milestone: The health insurer is paying the lab outside of the clinical laboratory fee schedule to develop useful information from lab test results. The three organizations are TriCore Reference Laboratories and its software company subsidiary Rhodes Group, and Blue Cross and Blue Shield of New Mexico.
In a news release on Aug. 2, the three organizations explained that the Rhodes’ clinical analytics program uses algorithms to analyze TriCore’s clinical pathology laboratory test data. From the data, TriCore and Rhodes Group produced insights that BCBSNM uses to improve the health of members in the state’s Medicaid program (Centennial Care) who are pregnant or who have such conditions as diabetes or hepatitis C.
The announcement signifies that the health insurer, BCBSNM, is paying Rhodes Group for this information. This is different than paying for a simple lab test result, even a high-quality result reported within an acceptable turnaround time, as clinical labs have done for decades.
TriCore, through Rhodes Group, is believed to be among the first clinical laboratories to collaborate with a health insurer using a Clinical Lab 2.0 model.
Clinical Lab 2.0 describes the attributes that medical laboratories need to succeed in a value-based healthcare environment. TriCore and other members of Project Santa Fe Foundation, the nonprofit organization that promotes the Clinical Lab 2.0 movement, supports the idea that clinical labs need to prove that laboratories can do more than deliver diagnostic test results. Labs can activate timely care, and even prevent complications or hospitalizations by helping health insurers and health systems identify and close gaps of care.
Labs as Equal Providers
Michael Crossey, MD, TriCore’s CEO and Chief Medical Officer, acknowledged the role that BCBSNM played in helping Rhodes and TriCore develop a different approach to using lab-test data, and to educate TriCore on what the insurer needed from its lab and data analytics partners. “Clinical Lab 2.0 requires laboratory professionals to act as equal partners and clinical colleagues with payers and care providers to achieve the Triple Aim and improve medical care,” he said. The Institute for Healthcare Improvement describes the Triple Aim as improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of care.
The announcement from TriCore, Rhodes, and BCBSNM reflects the next step in the evolution of laboratory medicine because TriCore is, “putting the medicine back into laboratory medicine,” as one expert said. TriCore and Rhodes have developed a way to translate laboratory testing into information BCBSNM can use to manage a population effectively and efficiently by identifying patients in need of care before their conditions become acute and costly.
“These insights assist BCBSNM in risk stratifying their Centennial Care population, thus identifying members who need care or may be at risk due to comorbidity,” the three organizations said in the news release. Using TriCore’s data and Rhodes’ analytics, BCBSNM can target its care coordination efforts effectively, leading to better patient outcomes. (See, “TriCore Forges Ahead to Help Payers Manage Population Health,” TDR, May 20, 2019.)
For more than a year, BCBSNM worked with Rhodes and TriCore to refine and confirm the algorithms to produce information that care coordinators could use to do outreach to members and connect those members to physicians. “The product has really helped us understand member needs and work more effectively in integrating patients into care,” said Eugene Sun, MD, BCBSNM’s Chief Medical Officer.
Keeping Score with HEDIS
One way to measure the effectiveness of TriCore’s lab test data, and Rhodes’ analytics on that data, are HEDIS reports from the state’s Human Services Department. Those reports show that BCBSNM was rated as the top performer in prenatal and postpartum care last year. HEDIS is the Healthcare Effectiveness Data and Information Set, a data-collection system the National Committee for Quality Assurance developed in the early 1990s to measure health plan performance. New Mexico’s Centennial Care plan uses HEDIS measures to direct performance improvement incentives among insurers.
Demonstrating Value of Lab Data Insights
FOR YEARS, CLINICAL LABORATORY DIRECTORS HAVE PREDICTED that health insurers would pay for insights into patient care based on clinical lab data and data analytics. Now that day has come.
On Aug. 2, Rhodes Group, TriCore Reference Laboratories, and Blue Cross Blue Shield of New Mexico announced that the three partners are using medical lab test data to deliver clinically-useful information to payers and to physicians in their provider networks, according to Rick VanNess, Rhodes Group’s Director of Product Management.
During a presentation at the Executive War College in May, VanNess outlined how TriCore and Rhodes combined clinical lab test data and data analytics to help health insurers improve patient care, fill gaps in care, and manage population health. Over the previous three years, health insurers had been interested in paying for the data analytics that TriCore and Rhodes had sent to BCBSNM.
VanNess is optimistic that—based on the performance that the three partners produced with this proof-of-concept—more insurers may be willing to share savings with their lab partners when collaborating in value-based and shared-savings arrangements. If and when they share such savings, the analytics that TriCore and Rhodes provide would generate new sources of revenue in addition to the fee-for-service payments the clinical laboratory gets for the testing it does.
“Other insurers have signed on to the platform or are actively negotiating,” VanNess said. “We are changing the perception of the clinical laboratory.”
TriCore, through its subsidiary software company, Rhodes Group, is believed to be one of the earliest clinical labs in the United States to collaborate with health insurers in ways that meet the Clinical Lab 2.0 business model.
Contact Rick VanNess at Rick.VanNess@tricore.org.