Lab Soft News

Amazon Pays Costs for Its Employees to Seek Specialized, Early Cancer Care

Employers are becoming increasingly active in providing special health services to their employees. Such an employee/employer cohort is being called a a Smart Health Community, the activities of which are beneficial to both parties (see: Smart health communities and the future of health). Now comes news that Amazon is assisting its employees in getting high quality cancer care from a specified cancer hospital (see: Amazon Joins Trend of Sending Workers Away for Health Care). Below is an excerpt from the article:

Employers are increasingly going the distance to control health spending, paying to send workers across the country to get medical care and bypassing local health-care providers. One of the latest is Amazon...which will pay travel costs for workers diagnosed with cancer who choose to see doctors at City of Hope, a Los Angeles-area health system. More than 380,000 of the Seattle-based company’s employees and families across the U.S. are eligible for the travel benefit....Proponents say companies can get competitive prices and employees get better care—such as avoiding unnecessary treatment—by shopping around the country instead of always relying on local providers. Employer health plans, which cover roughly 153 million people in the U.S., struggle to command competitive prices and quality controls in some markets as health-care providers have consolidated and gained leverage in negotiations....By paying employees’ way to travel for medical care, Amazon hopes to increase workers’ choices and curb health spending by getting workers to top specialists and reducing the chance of the wrong diagnosis or treatment....Workers who travel to City of Hope meet with specialists who review local doctors’ records and might seek additional information, such as genetic testing, to make treatment recommendations.

A critical element in cancer care is that a top flight oncologist should be consulted early in the diagnosis and treatment process. As noted above, this decreases the chances of an incorrect diagnosis or treatment which has both quality and cost implications. In addition to employing high quality and specialized oncologists, cancer centers can also provide state-of-the art imaging and molecular testing. I made this same point in a note way back in January 2009 (see: Some Tips for Selecting a "Good" Doctor and a "Good" Hospital). Below is an excerpt from the note:

If I were personally seeking care for cancer, I would get myself to a specialized cancer hospital or clinic, even if it involved some travel. In my personal opinion, there are four criteria to keep in mind when seeking the best cancer treatment: (1) physicians and staff at the facility should treat many patients per week with the same or similar diagnosis as yours; (2) the physicians should pride themselves on being up-to-date on the latest research and treatment of your disease as well as available clinical trials; (3) there should be little or no direct connection between the treatment being offered to you and the salary of the treating physicians, and (4) your treatment plan should be developed by a multi-specialty panel of physicians working in the facility, resulting in a more nuanced and balanced approach.

This Amazon program resembles Walmart's Centers of Excellence program whereby company employees who are candidates for particular surgical procedures are directed to distant, high quality hospitals such as Mayo, Cleveland Clinic, and Geisinger for evaluation and a second opinion (see: Reducing Healthcare Costs; Surgery at a Selected Hospital and Pharma Tourism). The Walmart experience has been that sometimes the need for surgery is reversed in this process. This may not often be the case for cancer patients but I suspect the recommended therapy may be altered or the patient may be offered access to a clinic trial. 

Using AI to Ensure Follow-Up of Suspicious Nodules in Radiology Reports

Nearly every day exciting articles are published about how AI is being used in pathology and radiology to improve the quality of reporting and the follow-up of salient findings. A recent article discussed such AI software (see: How University of Rochester uses AI to reduce risk of failed follow-up). Below is an excerpt from it:

The University of Rochester Medical Center needed a better way to ensure that its many patients with incidental radiology findings received their recommended follow-up care in a timely manner. Failure to follow up happens for a number of reasons, including inconsistent communications during care transitions, not notifying patients of actionable test results, and inadequate systems for managing and tracking incidental findings.....In 2015, the provider organization piloted a recommendation tracking system it calls “Backstop”....The goal of the system was to serve as a safety net for patients for whom clinicians had identified a potential malignancy or aneurysm and offered an actionable recommendation....[However,] the manual process required to flag recommendations was a significant barrier to widespread adoption of the program. The Backstop program depended on the radiologist manually adding patient cases to a central database for tracking at the time of dictation.

....Backstop needed to take advantage of recent advances in natural language processing algorithms to help identify and track more of the recommendations coming out of the department (see: A Backstop that reduces risk of delayed diagnosis).....[The radiology department] partnered with Nuance to integrate mPower, their NLP-based clinical analytics solution, into...[the] Backstop system. mPower [a Nuance product,] contains radiologist-designed and -validated algorithms that automatically identify actionable recommendations from unstructured radiology report text. Without disruption to the provider organization’s radiologists’ workflow, the NLP-based clinical analytics provided another layer of protection for patients.

To summarize, the University of Rochester radiology department is using their Backstop program with added Nuance software to ensure that actionable recommendations for follow-up in its reports are being attended to. Such followup recommendations relate mainly to "possible" malignancies or aneurysms. Nuance natural language programming (NLP) was added to Backstop program to avoid the necessity of manually adding cases to a central database that includes followup recommendations. Instead, such follow-up recommendations are now extracted from the natural language in the radiology report.

Until recently, recommendations for followup in radiology and pathology reports would have been covered by case coding by the pathologist and radiologist. This would allow such recommendations to be identified in the future but, of course, such cases would need to be identified by running the relevant search program. It may be possible in the near future for coding of pathology reports to be totally avoided by the use of ever more sophisticated NLP software. In fact, automating this coding process has the potential to be accurate than the dictated codes for a case. This is part of the ongoing process of removing manual steps from diagnostic report generation and thus improvising pathologist and radiologist work efficiency.

Medical Community Braces for Algorithm to Reduce Unnecessary Imaging Orders

Eventually, algorithms will be broadly used to assess the appropriateness of diagnostic imaging orders by clinicians, but not by January 2020. That's the date CMS has mandated that such algorithms will be deployed as part of PAMA (Protecting Access to Medicare Act). This topic was discussed in a recent article (see: Docs Brace for Medicare 'Appropriate' Imaging Rule). It's long so link to it if you are vitally interested. Below is a short excerpt from it:

As the medical community braces for implementation of the Protecting Access to Medicare Act (PAMA) by the Jan. 1, 2020 deadline, some wonder if it's even feasible or if another program delay is on the horizon. The policy, aimed at reducing unnecessary testing, mandates that all advanced diagnostic imaging orders go through an algorithm that provides key confirmation codes required when Medicare is billed later on for the service. Dubbed a "clinical decision support mechanism" (CDSM), this software processes each CT, MRI, nuclear medicine, and PET order before spitting out its verdict to the ordering professional: "appropriate," "maybe appropriate," or "rarely appropriate".... Eventually, Medicare will not pay claims or advanced imaging without these codes. The program has been delayed several times, and the 2020 deadline equates to a "soft launch," as improper imaging claims won't be rejected until the following year, with no firm deadline for additional penalties beyond that. Still, many physician organizations have raised concerns about the policy...."The way PAMA requires AUC [Appropriate Use Criteria] to be implemented is very prescriptive, very limiting to physicians, with the potential for unintended consequences" [according to a physicians' spokesperson].[Physician groups are] asking that the Centers for Medicare and Medicaid Services (CMS) postpone PAMA implementation "until we come up with an alternative way to apply AUC and practice value-based imaging."

The article correctly identifies an algorithm to identify a priori inappropriate imaging orders as a type of clinical decision support mechanism (CDSM). The mandatory use of the algorithm should reduce healthcare costs for CMS. I have recently blogged about clinical decision support software (see, for example: PCPs Responsible for Allocating About 90% of Total Hospital Costs). This proposed algorithmic software could also be classified as an example of diagnostic/predictive analytics (see: Diagnostic and Predictive Analytics and Their Possible Link to the Future of the LIS). The broad use of predictive and diagnostic algorithms is surely on the horizon and will be the basis for algorithmic medicine (see: What’s In The Box? Issues In Algorithmic Medical Care). However, the chance that CMS could internally develop and release such an algorithm in the proposed time frame is near zero. The chance that it could successfully outsource the development of such a tool to a medical software company is also close to zero.

So what does the future hold for this plan? Possibility #1 is that the release of the software will be postponed but the discussion of the possibility of the future release of the software may have the desired effect of proactively causing radiologists and clinicians to be more cautious about ordering advanced imaging studies in questionable cases. Possibility #2 is that CMS will release, perhaps on a delayed basis, such an algorithm that functions as blunt tool to achieve the desired goal, denying confirmation based on obvious criteria. However, it could exclude the most obvious cases of inappropriate imaging orders. The experience with such software could also form the basis for the release of a more sophisticated tool in the upcoming years based on the real world experience that would be gained.

Some Hospitals Now Offering Price Estimates; More Transparency for "Shoppable" Services

It has been frequently stated that healthcare needs to be more consumer friendly (see: Making Hospital-Based Labs More Consumer Friendly). This applies partly to the pricing of hospital services. In prior blog notes, I have stated that a bill for an inpatient stay has little bearing on the cost of the services for the hospital (see, for example: Coding for Hospital Services; One Reason for the High Cost of Healthcare; Patients' Out-of-Pocket Healthcare Costs Rising; Expect More Consumer Backlash). A recent article indicated that some hospitals are beginning to offer price estimates to help ameliorate consumer dissatisfaction (see: Some hospitals are already offering price estimates). This is a beginning of the process of making hospital billing more understandable and perhaps lower the cost of care by increasing competition. It's a long article so follow the link for more details if you are interested. Below is an excerpt from it:

The CMS...[has] issued several proposed rules that, among other changes, would require hospitals to publish payer-negotiated prices for various services alongside standard gross charges. The goal is to make it easier for patients to understand the cost of a hospital service before accessing care, according to agency leadership. Starting in January 2019, the CMS began requiring hospitals to publish their list of retail charges for healthcare services—a move that's been roundly criticized since patients rarely pay those rates. But under the latest Medicare Outpatient Prospective Payment System proposed rule, the CMS would go a step further by requiring hospitals to publish the negotiated price by specific payer and plan for "shoppable services." The agency defines those as procedures that patients can book in advance, including X-rays, outpatient visits and lab tests as well as bundled services like a cesarean delivery....

Some hospitals and health systems are already offering patients estimates of their out-of-pocket costs, often providing individualized cost projections while masking these negotiated rates. In August 2018, UCHealth launched a tool within its patient portal where patients can view cost estimates for more than 350 procedures and services. At the time, the Aurora, Colo.-based health system didn't think the agency's focus on chargemasters went far enough for providing price transparency....The price estimates tool provides a breakdown of the patient's expected out-of-pocket liability based on the typical cost of the service and a real-time eligibility check with their benefit plan, including identifying how much of the patient's deductible has been met for the year. To get around possible issues with publishing payer-negotiated rates, UCHealth....masks these rates by combining its contractual discount and the insurance payment as a single line in the price breakdown.

It's become quite clear that the publication of hospital chargemaster data will yield few benefits from the perspective of hospital price transparency (see: Hospitals vary in publishing CMS chargemaster prices). I very much like the UCHealth idea referenced above of placing a tool on the patient portal to provide "a breakdown of the patient's expected out-of-pocket liability based on the typical cost of the service and a real-time eligibility check with their benefit plan, including identifying how much of the patient's deductible has been met for the year." After years of hospital CEOs saying that it would be extremely difficult to decipher their bills or predict what services will cost, some of them at least seem to be willing to develop a tool to do just that.

Of even greater interest to me as a pathologist is the CMS plan in the wings to require disclosure of the negotiated price by payer and plan for shoppable services like lab tests and imaging. Historically, test prices have often been greatly inflated to offset hospital losses in areas that are less automated like critical care units and operating rooms. If this proposed plan is executed, healthcare consumers who pay attention to such matters cold potentially choose to order direct-to-consumer (DTC) tests on the web (see: New Definition for DTC Lab Testing Prompted by EverlyWell Business Model). The prices for such tests will always be priced at a lower level than hospital lab testing. In fact, it's possible that some some hospital labs may be permitted to offer DTC tests to consumers in the community. For consumers with high-deductible plans, this may be a perfect way to save money without sacrificing quality.

A New Way to Gain Additional Diagnostic Information from Radiology Images

I had previously thought that I had a good grasp of the term biomarker when I posted a note about it more than thirteen years ago (see: Use of Term Biomarker vs. Analyte). The definition that I used  at that time was: any molecular species found to provide correlation to a particular phenotype or perturbation of a biological system. Unstated at that time was that the molecular species was found in a biologic fluids like blood, serum, or urine. Now comes an article that upsets this definition but that makes a persuasive argument for doing so (see: U-M startup analyzes data from patient imaging files to help cure what ails them). Below is an excerpt from it:

Digital medical image files such as X-rays, MRIs and CT scans fill roughly half of all existing electronic storage around the world. And a University of Michigan startup has figured out how to mine and analyze this Big Data with technology that could make treatment choices incredibly precise for each patient...Applied Morphomics Inc. is a biomarker technology and development company that assesses body factors essential for delivering precision medicine....A patient’s body is their biological medical record and contains a tremendous amount of information that clinicians to date have not been able to comprehend. The [company's] technology extracts thousands of digital biomarkers from a patient’s medical imaging files. From this data, physicians can pinpoint a patient’s condition, the state of their disease and the kind of treatments that might be most helpful....A patient’s body is their biological medical record and contains a tremendous amount of information that clinicians to date have not been able to comprehend.

[The founder] and his team began by closely analyzing millions of digital images from CT and other imaging scans of more than 100,000 patients over an almost 20-year period. From this, they were able to define baseline information about gender, age and fitness....The deep analysis of the variety and often less apparent nuances of our physical structure that have been developed by the Morphomics project is a phenomenally deep and sophisticated benchmarking reference....Muscle mass is important because it’s predictive of overall health. For example, by measuring the amount and quality of a patient’s core muscle, AMI can predict how well someone will recover from a major surgery. If the muscles are small and infiltrated with fat compared to an age- and gender-matched reference population, they can recommend a two-week routine of walking to build up the muscle and improve the patient’s rate of recovery. 

The scientists at Applied Morphomics have developed a technology based on the idea of using the myriad data points in an MRI and CT scans as biomarkers. This makes perfect sense if we redefine the term biomarker as a measurable molecular substance or data points in a living organism. On this basis, the company is extracting new information from images that characterize, for example, a patient's muscle or adipose tissue. A physician would not order an MRI for any reason other than to diagnose a disease but this new technique can provide additional benefits from preexisting images. In this sense, these new measurements remind me of so-called incidentalomas whereby a new diagnosis is discovered in an image not anticipated when the study was ordered (see: Introducing the Incidentaloma; Implications of Whole Genome Scanning). I suspect that the company will be able, in time and using computerized image analysis, to assess the shape and mass of body organs such as the heart or lungs. In so doing, they can determine to what extent they deviate from the normal, taking into consideration the age and sex of the patient. An organ may be hypertrophic or hyperplastic, which is to say larger, smaller, or even misshapen on the basis of a disease. Radiologists make such judgements today but these new tools will enable far earlier assessment of diseases based on newly defined radiology biomarkers. 

Cash is the Best Incentive for Health Plan Members to Shop for Services

For many years, health plans have been searching for ways to incentivize their members to search for lower priced services such as imaging and surgical procedures like total hip replacement. I believe that the best incentive for this searching and cost-saving behavior is some sort of benefit like cash. A recent article covered this topic (see: How employers save money by paying employees to shop for healthcare) and below is an excerpt from it:

 According to a new RAND Corp. study published in Health Affairs, paying employees between $25 and $500 for using a transparency tool, and encouraging them to select a lower-cost provider for certain elective healthcare services, can result in modest savings of about 2.1 percent over the course of a year.....The research looked at insurer Health Care Service Corp's rewards program, which 29 employers have offered to roughly 270,000 workers enrolled in PPO plans in 2017.....[T]he program encouraged employers to pay workers $25 to $500, depending on the service and its cost, with the use of a price transparency tool (or a rewards advice line) a prerequisite for eligibility. Slightly more than 8 percent of workers used a price transparency tool, and about 23 percent of those patients were given a reward payment for going with a lower-priced option. Among patients in PPO plans, 1.9 percent received the reward payment. As patients switched from higher- to lower-cost providers, employers saved about $8 per member -- translating to about $2.3 million in savings overall. There weren't big changes in the prices of surgical procedures or CT scans, but MRI prices dipped about 4.7 percent, ultrasounds 2.5 percent, and mammograms 1.7 percent. Employers who shopped around saved big: 78 percent on ultrasounds, 33 percent on mammograms, and 25 percent on MRIs. 

While great savings were not realized in this study, it did demonstrate one of major ways for health plans to reduce their costs. Note that the healthcare consumers in the study were required to use a price transparency tool or rewards advice line. However, such tools may be difficult to understand because of the complexity of the healthcare system. Moreover, consumers' loyalty to their current and known providers may win the day (see: Refining Price Transparency Tools to Increase Patient Use, Cut Costs). With regard to a consumer's choice of a physician and surgeon, the critical nature of the service may be such that many will stay with the known and familiar. Hence, the high quality measures for an alternative provider or service must be described in a way that the consumers can understand and believe.

It should come as no surprise that most of the savings gained in the study were on the basis of alternative radiology procedures like MRIs and ultrasound. In this particular case, I suspect that many consumers think that all MRIs are equivalent in terms of technical aspects and don't understand or minimize quality differences in the interpretation of such images. Secondly, free-standing radiology centers are becoming increasingly common (see: Health Systems Putting Imaging Services, Such As MRIs, In Strip Malls and Shopping Centers). They will generally provide imaging services at lower cost than hospital-based services.

Radiology is a cash-cow for hospitals with high margins that are set to offset financial losses incurred in services like the ICU which are labor intensive. Health systems understand the trend of increasing completion for imaging and are thus opening their own free-standing radiology centers (see: Health Systems Putting Imaging Services, Such As MRIs, In Strip Malls and Shopping Centers). However, the revenue from such centers will be about half that of hospital-based imaging services per procedure (see: Freestanding imaging strategy: The good, the bad—and what it means for you). Here is a quote from this article:

Freestanding centers bill at a lower rate than HOPDs (hospital-based outpatient departments) . And you probably can't get around this if your imaging center is affiliated with a health system: Site-neutral payment (SNP) regulations stipulate that any new, relocated, or remodeled HOPDs will have to bill at half of the Hospital Outpatient Prospective Payment System (HOPPS) rate.

Pathology and Radiology Collaborate with a Concordance Conference

The University Hospitals Cleveland Medical Center (UHCMC) is in the process of deploying a digital pathology system and therefore exploring ways to educate and prepare their pathologists for this new technology (see: Digital Pathology Pilot Predicts Prosperity: Pondering Pathology’s Pivot). As part of the process, a pilot study was undertaken with a focus on frozen sections. In the study, pathologists’ diagnoses using digitized slide images were compared with diagnoses using standard microscopy. Frozen sections were chosen as the focus of this study because digital pathology allows remote access by a specialized pathologist if necessary. The results showed an average overall concordance rate of 95% for the two methods across 11 organ systems.

In the article referenced above, brief mention was made about a routine rad-path conference in the hospital that was greatly improved by the use of digital images. The article went on to discuss the purpose of this rad-path concordance conference: to resolve issues of concordance between imaging findings and the microscopic findings to also determine whether or not patients need additional surgical intervention or can be followed with imaging. In the support of this goal, it was deemed necessary for all conference participants to examine both the radiologic images and the microscopic images. 

In October, 2006, I first proposed close collaboration (or even, shockingly, merger) of the two medical specialties of pathology and radiology into a new one called "diagnostic medicine" (see: Ten Reasons for Merging Pathology/Lab Medicine with Radiology). I think that a concurrence conference similar to the one at the UHCMC would be an important first step in promoting collaboration between radiology and pathology in any hospital. One major goal that could be accomplished by such a conference would be to determine whether reports generated for a particular patient by both departments were in agreement and/or consistent with each other.

To put the matter more bluntly, the continuing goal of the conference would be to determine whether a significant pathologic finding by one group of diagnostic specialists was overlooked or deemphasized by the other group. Another important goal would be for pathologists and radiologists to better understand the reporting conventions and medical vocabulary of the other group and, in so doing, promote better concurrence in the future. In this same spirit, it would be possible to determine which pathologic changes in an image or specimen noted by one group would prompt a telephone call to to the other group rather than communicating solely by "formal" reports that may not always highlight subtleties or uncertainties.

Retail Drug Stores Emerging as Healthcare Hubs for First-Tier Primary Care

Two recent articles provide additional evidence that a new type of first-tier, healthcare hub is emerging. It consists of the following: (1) a retail drug store like CVS or Walgreens; (2) a walk-in healthcare clinic like MinuteClinic; (3) direct organizational and financial ties to a major health insurance company like Aetna; and (4) a reference laboratory patient service center (PSC) for blood draws provided by a company like LabCorp. Here's the first of the two articles (see: CVS Health and Aetna $69 Billion Merger Is Approved With Conditions) with an excerpt is below:

The Justice Department’s approval of the $69 billion merger between CVS Health and Aetna on Wednesday caps a wave of consolidation among giant health care players that could leave American consumers with less control over their medical care and prescription drugs....As the last major free-standing pharmacy manager, CVS Health had revenues of about $185 billion last year, and provided prescription plans to roughly 94 million customers. Aetna, one of the nation’s largest insurers with about $60 billion in revenue last year, covers 22 million people in its health plans....“The combination of CVS and Aetna creates an enormous market force that we haven’t seen before,” [a commentator] said.....[S]tate regulators and consumer groups have also raised other concerns about the impact of the merger, saying that the lack of large pharmacy managers that aren’t affiliated with insurers could make it difficult for smaller competitors in either sector.....Much of the enthusiasm over CVS’s acquisition of Aetna has focused on the insurer’s addition of a retail component and the potential use of CVS’s 10,000 pharmacies and 1,100 retail clinics to deliver care, particularly to Aetna customers. Imagine a single hub where someone can go to get care for everything from a sore throat to their diabetes. CVS stores could become places to get blood tests for monitoring chronic conditions, not just toothpaste or prescription refills.

Here's the second of the two articles, this one addressing as new relationship between Walgreens and LabCorp, a large national reference lab (see: Walgreens, LabCorp To Open 600 Diagnostic Test Centers). Below is an excerpt from it:

Walgreens Boots Alliance Wednesday said it will expand a collaboration with diagnostic testing firm LabCorp. to open at least 600 patient service centers at Walgreens stores over the next four years....“LabCorp’s strong partnership on this joint initiative, coupled with the enthusiastic consumer feedback we’ve received, allows us to undertake an exciting expansion of our collaboration together,” Walgreens executive vice chairman and CEO Stefano Pessina said. ....Walgreens’ effort to provide lab-testing services in its stores is part of an ongoing transformation into becoming more of a healthcare services company than a retailer. Walgreens tried to bring diagnostic tests to its stores in Arizona via its Theranos partnership, but that deal ended following investigations into the accuracy of Theranos blood tests. Walgreens has said the lab testing services with LabCorp will complement its pharmacy and healthcare clinics. The centers will be branded “LabCorp at Walgreens” and offer specimen collection services for LabCorp testing, the companies said.

Below are some of the possible features and services of the first-tier, healthcare hubs that are emerging:

• They may ultimately number in the thousands and will be in close proximity to the majority of healthcare consumers in the U.S.
• The companies owning, managing, and participating in these hubs will each be worth multiple billions of dollars and have access to abundant development capital.
• Hub personnel will have much stronger business incentives to emphasize wellness than many health systems. Such a perspective will be viewed favorably by younger healthcare consumers. 
• Because of economies of scale and sophisticated logistics, the national reference labs integrated into these hubs can perform lab testing less expensively than most hospital labs or theoretically deploy POCT testing on site for rapid result TAT.
• By deploying Epic's EHR software, these hubs will have medical record interoperability with any large health systems running Epic EHRs for referrals and record transfers for patients.
• The hubs will be able to provide physician consultations for patients with chronic diseases by outsourcing telemedicine contracts to health systems anywhere in the U.S. Such contracts will be looked upon favorably by those health systems with telemedicine expertise because they do not require expansion of bricks-and-mortar facilities. 
• As the number of patents with chronic diseases seen in these hubs increases, hub personnel will exercise greater influence over referrals to in-network physicians, hospitals, and stand-alone imaging centers. 

Hospitals Cry Foul Over Anthem's Radiology Reimbursement Policy

In a previous post, I noted that health insurance company Anthem was refusing to pay the hospital rate for outpatient MRIs and CT scans, dictating that their insurance holders receive outpatient imaging services from less expensive free-standing radiology centers (see: Anthem Won't Pay for Outpatient MRIs and CT Scans in Hospitals). Hospitals are fighting back and taking Anthem to court over this policy (see: Hospitals cry foul and sue Anthem over new policies). Below is an excerpt from this article:

County courtrooms are no strangers to contract disputes between local hospitals and insurers. Lately, though, they've had some big cases dropped in their laps as hospitals owned by HCA Healthcare, Sentara Healthcare and Piedmont Healthcare take health insurance giant Anthem to court over its new policies that restrict outpatient imaging and emergency department reimbursement.....The hospitals argue their contracts with Anthem, through its Blue Cross and Blue Shield affiliates, require all parties to agree to such material changes to the policies. They also say the imaging policy isn't really about medical necessity, as Anthem has said, because the insurer allegedly granted exemptions for hospitals that agreed to accept lower rates. The Anthem spokeswoman said the company does not comment on pending litigation.....Some legal experts say the hospitals are standing on solid ground, while others argue Anthem's policies are an important opening salvo to changing healthcare's traditional business model....[T]he underlying issue is the fact that the same services cost more when delivered in inpatient settings than in outpatient settings.....Anthem's cost-shifting strategy aligns with the migration of many healthcare services over the years to cheaper outpatient settings....In every instance, hospitals have resisted the cuts to their revenue....That's what happened when doctors years ago began performing cataract surgeries in outpatient offices, for example.

....[H]ospitals argue that the imaging policy takes away physicians' ability to use their clinical judgment to determine medical necessity, and instead makes it about the site of service.....From the payer standpoint, services covered under hospital-based contracts tend to cost two to three times more than the same ones performed at free-standing clinics, he said.....Part of the reason Anthem's policies in particular are making such a splash is because they're targeting providers themselves. Other carriers have focused on "educating" patients about less-expensive options, a tactic that doesn't get as much attention....UnitedHealthcare...charges higher co-pays for MRI scans performed at hospitals compared with outpatient facilities....Hospitals' legal arguments against Anthem's imaging policy makes material changes to contracts with hospitals without giving proper notice and receiving approval from hospitals.

I have the following observations about this news:

• The hospital strategy of increasing their revenue from profitable lines of business like radiology and the labs to offset losses in others units like ICUs is probably outdated and may not survive various legal challenges such as the one described in this article (see: Identifying the Gap Between Hospital and Free-Standing Prices).
• Hospitals need to directly compete against surgicenters or freestanding radiology centers (see: Tug of War between Hospitals and Surgicenters for Knee Replacements). One of the ways for doing so will be to launch or purchase such businesses (see: How Hospitals Are Rethinking Imaging).
• Meanwhile, health insurance companies like Aetna and UnitedHealthcare are increasingly engaged in direct patient care. I have discussed the merger of CVS with Aetna with the former providing walk-in MinuteClinics in drug stores (see: Details about CVS' MinuteClinic POCT Strategy; Merged CVS and Aetna Will Move Toward a Community-Based Healthcare Model). Meanwhile, UnitedHealthcare has purchased a large physician group so the lines are blurring between health insurance companies and providers (see: UnitedHealth Buys Large Doctors Group as Lines Blur in Health Care).
• The article above points out that health insurance companies have traditionally "educated" their policy holders about how to seek less expensive services (see: CMS Requires Hospitals to Post Prices for Medicare Patients; Useful Step?). Such an approach may now be a thing of the past with direct competition more of the norm for the health insurance companies. 

Making Surgical Pathology and Radiology Reports More Patient-Friendly

To restate the obvious, surgical pathology reports have a new audience -- patients. Some of them are accessing their reports via patient portals (see, for example: Patients Often Lukewarm about Patient Portals; Problems with Training?; Could Apple Be Trying to Develop a "Patient Portal" for the iPhone?). Traditionally, pathologists have dictated these reports with the understanding that they were communicating primarily with the physicians who submitted the tissue for diagnosis. An important question these days is whether the language of these reports needs to be altered in any way now that patients are reading them. A recent article discussed a radiologist-developed "platform" that tweaks radiology reports so that they can be better understood by patients (see: New platform creates patient-friendly radiology reports). Below is an excerpt from it:

Patients may soon have a much easier time understanding the details of their own radiology reports, thanks to a platform presented by Seong Oh, MD....The platform, called Patient-Oriented ReporTER (PORTER), was designed as a response to the increasing prevalence of online patient portals and various online medical resources. Patients are being asked to access their own information from home, Oh and his colleagues recognized, but radiology reports are still being written as if they’ll only ever be read by someone with a medical background....PORTER takes the radiologist’s findings and helps translate it so that patients with no medical knowledge can fully understanding the information. Key words are underlined, and users can hover their cursor over those words to make the definition pop up. Click “axial,” for instance, and PORTER will say, “An anatomical plane that divides the body into head and feet portions.” Visual aids are also provided, including charts, graphics and a photograph of the radiologist completing the report....One of the biggest advantages to patients understanding their own radiology reports, Oh said, is that it empowers patients to ask the right questions when they meet with their referring physicians.....Oh said PORTER is still in the early stages, but a prototype has been fully developed to be used with knee MRI reports at Penn Medicine. In the near future, patients will be asked to use PORTER at home to review their own reports and then complete a detailed survey about their experience.

In a blog note posted almost two years ago, I presented some criteria that pathologists and radiologists could follow to make their reports clearer to other healthcare professionals (see: Avoiding Qualifiers, Exceptions, and Hedges in Radiology and Pathology Reports). I list them below:

• Speak to the referring clinician whenever there is ambiguity or extreme complexity of a case.
• In reports, avoid a vague rambling discourse as well as qualifiers, conditions, and exceptions.
• Whenever possible, arrive at a reasonable and actionable conclusion in the report to guide the clinician.

The major thrust of this current note is different from my previous note. The question is now being asked whether pathologists should seek to achieve greater clarity with their reports and also perhaps take steps to make them more understandable by patients. I have a feeling that the "PORTER platform" described in the excerpt above may be unacceptable for many radiologists because of the possibility that the software might malfunction and introduce mistakes or misunderstandings into a report when viewed by patients. So what action should be taken to make surgical pathology reports better understood by patients? Given that the primary audience for such reports will continue to be the physicians ordering them, I am not sure that an app like PORTER would be suitable. However, it might be appropriate on patient portals to post a glossary of medical terms used by pathologists and radiologists in their reports that could be used by patients to better understand their reports.