Issues & Answers:
Point Of Care Testing
by Dr. Sheila Dunn
The decision to perform "near-patient"
testing involves both clinical and economic issuesand, there are no"one
size fits all" answers. Point of care tests (POCT) generally cost
more than tests designed for huge assembly-line type testing facilities.
Can your customers afford to do them? Will managed care plans pay for them?
Does a rapid test result provide better patient care?
The Cost Factor
POCTs are often more expensive to perform on a cost-per-test basis due
to built-in checks and balances for error-free operation. These new bells
and whistles reduce test errors but do not come without a price. Despite
a greater initial cost, there are many valid reasons why these tests are,
in fact, more cost effective when performed at the point of care.
Real cost savings has little to do with decreasing the
cost/test from, for example, $25 to $5. Rather, economic benefit comes
from lower hospital admissions, fewer emergency room visits, and correct
treatment plans. Financial differences in managing patient care in various
settings are substantial: $1000-$1500/day in an acute care facility vs
$48-$80/patient encounter in an ambulatory care setting.
For example, due to a delay in receipt of test results,
patients receive inappropriate or delayed therapy which costs the health
care system additional dollars, not only for the medication, but also for
repeat visits to health care providers, emergency facilities or hospitals.
Such gains offset any increased, marginal cost of reagents for performing
The benefits of POCT can be divided into three general
categories, all of which result in real savings to the health care system:
1. Psychosocial benefits (i.e., patients are more satisfied
with their healthcare experience and understand and comply with provider
2. More accurate results for some tests (delays and specimen
deterioration contribute to unreliable test results); and
3. Clinical benefits (i.e., patients get better faster
and return to work).
The Managed Care Obstacle
A major challenge for POCT
is the fact that some managed care organizations (MCOs) require that all
testing be referred to a mega-facility with whom the health plan has negotiated
rock-bottom test pricing. The probable reasons for MCO test referral stipulations
are given in Table 1.
To add insult to injury, different MCOs have a variety
of referral facilities to which tests must be sent. Doctors then become
confused by differences in test results and take this into account before
making a diagnosis or treating a patient.
For example, in-office glucose test devices are performed
on whole blood whereas glucose tests performed in referral laboratories
use serum or plasma specimens. Not only are there differences in the "normal"
reference ranges for tests performed on different types of specimens, but
different instruments do not provide data that is interchangeable. Also,
referral facilities have different ordering procedures, sample collection
and handling requirements, and result reporting methods. For medical management
purposes, POCT is clearly superior.
In response to managed care restrictions, many doctors
individually negotiate payment to retain their office-based testing for
three main reasons: it clearly improves physicians' clinical efficiency,
(i.e., they can see more patients), it provides better patient satisfaction,
and it improves clinical outcomes.
Help Is On The Way
The Health Industry Distributors Association (HIDA) will soon publish APOCTA
Cost-Benefit Analysis which petitions MCOs to recognize the value of POCT
and revise existing policies to ensure fair and appropriate reimbursement
for these tests. Specifically, it seeks to convince MCOs who contract with
regional or national testing vendors to:
1. Reverse policies which prohibit testing at the point
of patient care;
2. Allow individual medical practices to determine which
APOCT are appropriate for the patients encountered at that location;
3. Reimburse providers who wish to perform APOCT at fair
market value; and
4. Participate with manufacturers and providers in long
term studies to prove the overall cost-effectiveness of certain APOCT.
The study includes case management examples from physicians
and other health care providers using real patient data to demonstrate
the clinical, economic, and psychosocial benefits of APOCT to the healthcare
customer, the patient.
POCT restriction by MCOs is clearly an instance of contractually
obligating providers to reduce service levels as well as the quality of
care. Perhaps, in the future, when the economy of POCT has been documented,
MCOs will actually encourage - and reward- physicians for performing it.
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Table 1: Why MCOs Require Referral Testing
| Reason For Referral Stipulation
| Referral testing is less expensive
|| Referral testing is actually more expensive in the long term
due to dissatisfied patients, dissatisfied providers, poorer patient outcomes,
inaccurate results due to specimen deterioration, increased referrals or
hospital admissions, decreased employee productivity, and improper expensive
| Providers will test excessively if a financial incentive
|| Providers who view testing only as a way to generate revenue
are a minority of total providers. MCOs should reimburse for POCT based
on the Medicare fee limitations under which only reasonable profits are
available, certainly not enough to be an impetus to test more than is medically
| A national or regional contract is in place. Exceptions cannot
be made for individual providers.
|| Revise the national referral contract and encourage/ reimburse
those providers who rely on POCT. Work with manufacturers, providers, etc.
to generate outcomes and customer satisfaction data to quantitate the value
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