MULTIPLE TRENDS ARE UNFOLDING that mutually reinforce the need for pathologists and PhDs to be experts and consultants in how physicians order and follow up on molecular diagnostics assays and genetic tests.
“Healthcare in the United States is approaching a tipping point that can greatly favor pathologists and PhDs as specialist consultants,” observed Katherine Tynan, Ph.D., President of Tynan Consulting LLC, in San Francisco, California. “Today, treating physicians are being overwhelmed by the rapid advances in genomics and molecular medicine. They cannot stay up with all the changes to the state-of-the-art diagnostic tools in their specialty.”
Tynan is a strategic consultant for diagnostics companies. She is engaged in developing the evidence needed to demonstrate the clinical utility of new molecular and genetic tests to physicians and payers.
“At the moment, payers are struggling to decide whether to cover these tests and how much to pay for them,” noted Tynan. “At the same time, both physicians and patients are aware of these new diagnostic tests and they want information to guide clinical decisions.
“All of this is happening as the U.S. healthcare system is moving away from fee-for-service reimbursement,” she continued. “The emerging new reimbursement models are centered around rewarding providers for value, bundled payments, and capitated or per-member- per-month payment—all based on outcomes rather than process steps.
“Thus, there is urgency for the laboratory medicine profession to step up and assert its role as the expert and the consultant in how diagnostics tests are ordered and used by clinicians,” stated Tynan. “Pathologists and PhDs have a compelling argument to make that they are best-qualified to be consultants to physicians—and that the healthcare system needs to compensate them for this consultative role.”
Tynan is not the first to make this argument. Pathologists have regularly asserted this point. But Tynan said that the time of opportunity for pathologists and PhDs to successfully make their case will be a short one, noting that “pathologists should take some cues from how other cognitive specialist physicians are establishing their value propositions as consultants who should be rewarded for that expertise with Medicare, private health insurers, healthcare administrators, and other physicians.
Explaining Value to Payers
“For example, infectious disease specialists are in a similar situation in that they too— like pathologists and PhDs—are working to explain the value of their work to payers, patients, and other providers,” explained Tynan. “Pathologists and infectious disease (ID) doctors consult with other providers and so they are unlike proceduralists who get paid for each procedure they do.
“Last fall, I attended ID Week in San Francisco, which is a joint meeting for ID physicians, pharmacists, and others in the field,” she said. “The Infectious Diseases Society of America (IDSA) recently retained consultants to help develop health economic arguments to justify their services. The results of the study give the IDs an opportunity to get politically active within their institutions.
“The activity-based payment system currently used in the United States healthcare system rewards physicians doing procedures disproportionally relative to those who are cognitive specialists, such as those in endocrinology and infectious disease,” continued Tynan. “Recognizing the need for data that would demonstrate their value proposition as cognitive specialists, the IDSA undertook a project to obtain objective data about the value ID physicians bring to patient care.
“The results of the study will be useful for the IDSA and for the infectious disease physicians themselves for years to come,” she noted. “By contrast, pathologists and the PhDs running molecular and genetic testing laboratories have not yet come together to fund and conduct a comparable study that would provide data that supports their value as cognitive specialists.
“Yes, there are some diagnostic testing companies, such as Clarient and Genoptics, that communicate effectively the value of their professional services, but they do this as an integrated part of their differentiated service offerings,” explained Tynan. “These are the right discussions to have in laboratory medicine, but not enough of them are happening, at least not yet.
“The challenge is that pathologists have always measured themselves on revenue, which works in an activity-based payment system,” Tynan explained. “But it doesn’t work in the new healthcare world into which we are evolving.
“Last year we saw what happened when the Medicare program introduced the new molecular CPT-codes system and that turned into a test by test coverage discussion with the payers,” she added. “Now, molecular labs are being paid even less than they were under the old system and for far fewer tests.
“So, in conclusion, my recommendation to those pathologists and molecular geneticists who see the writing on the wall, is to work internally on the value of molecular testing,” urged Tynan. “The profession of laboratory medicine must get hard data in front of physicians, administrators, and payers because healthcare today is data-driven.”
ID Study Presented Value of Cognitive Specialists
ACCORDING TO KATHERINE TYNAN, PH.D., a strategic consultant for diagnostics companies, to demonstrate their value as cognitive specialists, pathologists and PhDs should borrow a page from the infectious disease physicians.
Initiated by the Infectious Diseases Society of America (IDSA), a study designed to show the value of infectious disease (ID) physicians was published last year in Clinical Infectious Disease.
“Using administrative fee-for-service Medicare claims data, the researchers identified Medicare patients who were hospitalized in 2008 and 2009 and who had at least one of 11 infections,” said Tynan, President of Tynan Consulting LLC. “This was a large study in which the researchers identified 101,991 inpatient stays with ID interventions and 170,336 stays without ID interventions.
“When the ID physicians intervened in these cases, the patients had significantly lower mortality and readmissions compared with those cases in which there was no ID physician intervention,” she said. “The researchers reported improved patient outcomes when ID specialists intervened, and early interventions were associated with reduced costs for beneficiaries with certain infections.”
The journal, Clinical Infectious Disease, published an article on the study, “Infectious Diseases Specialty Intervention Is Associated with Decreased Mortality and Lower Healthcare Costs,” online September 25, 2013 (doi:10.1093/cid/cit610).