Just What The Doctor Ordered:
Outpatient Anticoagulation Services
by Dr. Sheila Dunn
Reprinted with Permission from Physicians Marketplace
Talk about not being able
to leave work at the office? Well, during our first attempt at gardening
this year my neighbor Henry, a cardiologist, popped open a cold one, leaned
his head across the fence, and asked for my help. At Henry's Friday afternoon
staff meeting, the senior physician of his large group practice asked all
seven physicians to come up with a way to either save significant resources
or generate additional revenue.
Like most other medical practice in America, Henry's cardiology
practice has been hit hard by managed care payment reductions. In fact,
their largest managed care plan cut the group's bonus significantly due
to patient satisfaction issues and, to a smaller extent, because of patient
outcome issues. The senior physician wanted one suggestion from each physician
by the next weekly staff meeting. All Henry had managed to come up with
was to cut costs by removing non-physician employee insurance benefits.
I replied: Let me get this straight. You need to come
up with a service or product that your practice can implement to save money
or generate revenue. Right? I already had a great idea but wanted to make
sure it would be appropriate for his practice.
Do you have patients on warfarin (Coumadin) therapy? I
asked. Henry explained that he had several such patients, so I asked him
if his practice had anticoagulation testing services.
No, we send patients to the hospital for testing, he said.
Although our hospital is only a 10 minute drive from the cardiology practice,
parking is a nightmare and patients have to walk several hundred yards
to reach the drawing center.
I was amazed that such an intelligent person didn't make
the connection between these circumstances and patient satisfaction. Imagine
taking your car in for a tune up and having the mechanic tell you that,
in order to finish the job, you needed to run down to the auto supply store,
wait in line, hope the part was in stock, and bring it back for installation!
To add insult to injury, your car won't be ready for 2 days!
Only a small portion of the medical industry has fully
embraced the idea of customer service. In fact, some physicians become
downright hostile when their patients are referred to as 'customers.' But,
medical practices that take into consideration their patient's time and
non-medical concerns are coming out ahead in today''s managed health care
environment. For some practices, a way to show your concern for patients''
medical and non-medical needs involves providing a one-stop shop for anticoagulation
If your practice can answer "yes" to the following
3 questions, you should consider offering on-site anticoagulation testing:
- Do you have patients who are on long term Coumadin therapy?
- Do you see newly-anticoagulated patients whose drug levels
are not yet stable?
- How about those who take Coumadin for a limited amount
of time, such as prophylactically following hospital discharge for orthopedic
If you've answered "yes" to any of the above,
also consider patients who:
- Have poor venous access. Whole blood fingerstick samples
are more comfortable for these patients.
- Do not have easy access to laboratory services and require
- Have had their blood samples misplaced or mixed up by
the referral laboratory.
More than 3 million patients in the US take long-term
anticoagulants and must routinely monitor their prothrombin time (PT),
but there are many patients who should be on the drug but aren't. Dr. Jack
Ansell, a pioneer researcher in this field, estimates that only about 40%
of atrial fibrillation patients take Coumadin.
Lab Testing? No Way...
At this point Henry was shaking his head. "No way we're getting into
lab testing." "We used to have a whole lab about 10 years ago,
but closed it down when CLIA regulations came about."
I explained that these instruments are CLIA-waived, meaning
that all they had to do was get a CLIA license ($150 every two years) and
follow the instructions for the test. Unknown proficiency testing samples
will not be sent and no federal agents will come calling, thank you very
"Listen Sheila, you know that monitoring Coumadin
levels is serious stuff. It's not like we're talking about a urine dipstick.
Can you really trust those things?"
Are Whole Blood Fingerstick PT Instruments Accurate?
The Coagucheck (Roche Diagnostics)
provides results comparable to standard plasma prothrombin time determinations. (see Note 1) Several studies have demonstrated that
anticoagulation testing performed by this fingerstick method is less variable
than routine laboratory methods. In fact, the Coagucheck is both easy to
use and accurate and provides a prothrombin time-international normalized
ratio (PT-INR) result from a single drop of blood in about two minutes.
At this point, my Henry mentioned a few patients (an elderly
couple who came in once a week and a young woman who took time from work
for frequent testing) who could benefit from on-site testing. But can this
type of testing program generate revenue? he needed to know.
Will It Generate Revenue?
I explained that, after an initial investment of about $1500, he could
expect to generate revenue in the following ways:
1. Keep your patients coming back. Patients may change
doctors or healthcare facilities if they hear that routine testing is available
more conveniently elsewhere. The cost of one lost patient over the lifetime
of a practice is estimated to be over $200,000!
2. Provide better outcomes. Faster results often contribute
to more stable drug dosages. More stable INR's coupled with better patient
compliance with therapy avoid negative outcomes. HMO bonus checks will
increase when patient complications decrease.
3. Free up your support staff to do clinical duties; nurses
can spend less time on paperwork and telephone calls and concentrate on
revenue generating activities. Nurses and physicians' time is the most
valuable asset of any medical practice. Why waste it playing telephone
4. Generate revenue. It costs about
$7.00 per coumadin-related encounter when testing is performed at a remote
location (encounter for this purpose is defined as pulling the chart for
appointments, entries, coping, reviews or insertions). Although it costs
slightly more $11.00 for each patient encounter when testing is performed
in-house, reimbursement averages about $21.00 (See Note
5. Save time and increase efficiency by explaining dosage
changes in person and going over any lifestyle issues with the patient.
Immediate feedback really improves patients' understanding and results
in fewer repeat calls.
"So here you have it, Henry. Put yourself in your
patients' shoes. There's no way you would wait in line at the parts store
rather than doing business with a company that provides one-stop shopping.
Do you really think your patients want to drive, park, walk, wait, walk,
drive and then wait a few days for a test result? Making your office a
one-stop shop also gives you an edge up on the local competition."
I'm not sending Henry a bill this time, but next time,
the "cold one" is on him.
1. Douketis, James D. et al. Accuracy
of a portable international normalization ratio monitor in outpatients
receiving long-term oral anticoagulant therapy: comparison with a laboratory
reference standard using clinically relevant criteria for agreement. Thrombosis
Research. 1998; Vol. 92:11-17. (Return to text.)
2. Williams, James R. Reengineering
Practices For Oral Anticoagulation Monitoring. Health Care Innovations,
The Journal of the Association of Managed Healthcare Organizations. March/April
1997 Vol. 7 No.2. (Return to text.)
3. The Physician's Guide to preventing
strokes and lowering health risks in patients with atrial fibrillation.
Northwestern University Medical School, Chicago, IL. Chapter 5,6. (Return to text.)
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