Lab Benefit Management Bill Advances in FL Senate

Senate bill would set some restrictions on use of clinical decision support systems for lab orders

CEO SUMMARY: To date, a bill to restrict how health insurers use lab benefit management systems such as UnitedHealthcare’s BeaconLBS, has been favorably received in the Florida Senate. But the bill may face opposition when presented to the Senate’s Appropriations Committee. In a report, the state Office of Insurance Regulation said that restricting the use of clinical decision support and laboratory benefit management programs could raise costs to the state Medicaid program.

IN RECENT WEEKS, TWO COMMITTEES in the Florida Senate gave favorable votes to a bill to restrict the use of clinical decision support and lab benefit management programs.

Hearings on the bill were conducted by the Banking and Insurance Committee on January 20 and the Health Policy Committee on February 1.

Supporting the bill have been such state physician associations as the Florida Society of Pathologists, the Florida Society of Rheumatology, and the Florida Medical Association. FSP is working with lobbyist Amy Young of Ballard Partners, according to FSP President Margaret Neal, MD, FCAP, of KWB Pathology Associates in Tallahassee.

As currently written, the bill would limit how clinical decision support systems and laboratory benefit management programs—such as the program UnitedHealthcare introduced in Florida— can be used. On April 15, 2015, UHC required physicians serving its commercial HMO patients to use the Beacon Laboratory Benefit Solutions system when ordering any one of about 80 clinical lab tests. BeaconLBS is a business division of Laboratory Corporation of America.

Physicians must use BeaconLBS when ordering certain tests and wait for an authorization from BeaconLBS before sending lab test requisitions to one of 20 “labs of choice” that UHC and BeaconLBS designated as in-network labs. LabCorp owns eight of those 20 labs. (See TDRs, July 21 and November 3, 2014, and January 5 and March 9, 2015.)

Concern about Costs

Supporters of the bill may face opposition when SB 1084 is presented to the Senate’s Appropriations Committee in the coming weeks. The Department of Management Services in the state Office of Insurance Regulation, Division of State Group Insurance, has said that restricting the use of clinical decision support and laboratory benefit management programs could raise costs to the state Medicaid program.

In a report on this matter, the DMS wrote, “Further, the DMS states that the provision in the bill that prohibits HMOs from requiring healthcare providers to use a clinical decision support system or a laboratory benefits management program, to direct or limit provider’s decision-making ability could affect the state group health insurance program. Changes to current medical management procedures that cause an HMO’s medical costs to increase would result in higher negotiated premiums for the state-contracted HMOs.”

This report is titled: “Senate Bill 1084 Fiscal Analysis (January 14, 2016).” It is on file with the Senate Committee on Banking and Insurance.

Two Committee hearings

During two committee hearings, no opposition has been raised and no support has been introduced regarding the section of the bill that would limit how health insurers can limit the use of decision support or lab benefit management systems. To date, all of the debate has focused on another section of the bill that addresses the protocols health plans use to manage physicians prescribing prescription drugs.

State Sen. William Gaetz, who introduced SB 1084, said he expects the decision support and lab benefit management portions of the bill to be debated and he expects opposition from health plans. The Senate’s Appropriations Committee will be next to consider the bill, but no date was set as of press time.

Robert W. Levin, MD, a rheumatologist in Dunedin, Florida, is prepared to defend the bill if there is any opposition. As the President-Elect of the Florida Society of Rheumatology, Levin is a staunch opponent of BeaconLBS.

“Rheumatologists are very much affected by the BeaconLBS system because the tests we order are needed for many reasons,” he said. “The most ridiculous example from the BeaconLBS program is the requirement to get authorization for testing for lupus, specifically, ANA testing.

“The diagnosis of lupus is very hard to make,” observed Levin. “It combines lab criteria with the patient’s signs and symptoms from a physical exam. I’ve been trained to do this diagnosis through medical school, internship, residency, and a rheumatology fellowship, and I can’t figure out how a computer or a decision support system would trump my clinical impression of whether the patient needs a workup for lupus. This diagnosis requires an objective evaluation combined with an expert opinion and there is no way a computer can do that. It’s absolutely insulting!

Diagnosing Lupus

“I understand that insurers will say there is some inappropriate ANA testing,” he continued. “The truth is that ANA testing is not appropriate for every elderly patient who comes in with degenerative arthritis. There is no reason to do an ANA on those patients. But for a patient you suspect has lupus, then an ANA test is the most helpful lab study we can do.

“In addition, we also need to do the follow up lab testing—which is called an ANA profile—to see if you can confirm the diagnosis,” explained Levin. “There’s no way a computer can do that. It’s impossible because the diagnosis is not an automatic ‘yes’ or ‘no’ answer to a list of questions from a computer. Yet, that is required by the BeaconLBS system and it’s a total waste of time for physicians.

“Physicians also need to use the BeaconLBS system to order vitamin D tests as well,” he said. “Vitamin D deficiency has been associated with bone disease, such as osteoporosis, general malaise, and fatigue.

Infringing on patient Care

“Many patients have low levels of vitamin D and when you test and have them take vitamin D every day, about half the time it solves the problem,” stated Levin. “If the system doesn’t allow vitamin D level testing, those patients are at risk of harm, and a large proportion of patients are vitamin D deficient.”

A significant proportion of Florida physicians believe the use of a decision support system as designed by Unitedhealthcare infringes on a physician’s medical judgment. This issue is likely to be among the arguments proponents of SB 1084 make.

Levin added that another issue ordering physicians complain about is the requirement to use the BeaconLBS system in addition to their own electronic health record system.

No EHR–Beacon Interface

“In our office, the BeaconLBS decision support system doesn’t interface with the computer system we use,” he said. “Thus, we must go into a totally different computer screen to enter all of the patient’s demographic information and then answer the questions needed to get an authorization that will allow the lab to draw the blood. It’s another impediment to getting things done on behalf of our patients.”

Recently, Levin had a patient who had to wait two to three hours to see if the BeaconLBS system would authorize Levin’s request for ANA and vitamin D testing. “We just wanted to draw her blood so we could start the testing, and yet the authorization took all afternoon,” he said. “That’s ridiculous.

“Another concept to consider involves the issue of the obstacles going up against patients who need care,” Levin added. “The insurers have put so many prior authorization hurdles in front of physicians and patients, that both physicians and patients have become extremely frustrated by these roadblocks to care.

“What happens is that physicians and patients simply give up trying to fight the system,” he explained. “Therefore, appropriate and needed diagnostic testing and treatments are never authorized. When that happens, patients end up being the big losers.

“But physicians also lose with this system because we need to spend so much time and effort to get authorizations for things that we know are reasonable and medically necessary,” Levin concluded.

Interesting Battlelines

The proposed bill creates interesting battlelines. Florida physicians are encouraging passage of a law that would restrict the ways that health insurers can require physicians to use clinical decision support systems and laboratory benefit management programs.

Will the health insurance industry decide to oppose this bill with great vigor? Or might health insurers decide to save their lobbying clout in the Florida Legislature for issues that are of greater importance to them? However this plays out, clinical labs and pathology groups in Florida will follow these events with great interest.

Contact Robert Levin, MD, at 727-734- 6631 or rwlevin@msn.com.

There Is Plenty of Resistance to UHC, BeaconLBS System

FROM THE FIRST ANNOUNCEMENT by UnitedHealthcare in early 2014 that it would require Florida physicians serving beneficiaries enrolled in UHC’s commercial HMO to follow the requirements of its laboratory benefit management program, there has been much dissatisfaction and outright opposition.

Several of Florida’s specialty medical associations wrote to UnitedHealthcare describing their objections to the program, including: Florida Society of Pathologists, Florida Society of Rheumatology, Florida Medical Association, and the Congress of Obstetricians and Gynecologists, District Xll (Florida).

Even COLA took objection because it was excluded as a laboratory accreditation organization for UHC’s laboratories of choice network.

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