Paying for Lab Services Based on Effectiveness

In recent years we have heard a lot about evidence-based medicine (EBM). Many physicians practice medicine out of habit; doing what is familiar or what they have been taught. Evidence-based medicine, however, is based on doing what the research shows is most efficacious; despite popular or conventional wisdom. In reality, EBM has been practiced in various ways, such as instituting care maps whereby for example a  patient with chest pain is always given aspirin or clot busters on arrival at the ED, is given an EKG, has cardiac enzymes drawn stat and repeated every 6 hours, starts cardiac rehabilitation within 48 hours of admission and so on.

Laboratory tests have been an integral part of EBM from the beginning (consider HBA1C for all diabetics, using PTT and INR to guide anticoagulant dosages, for example). However, not much has been done in terms of investigating the efficacy of laboratory tests.

With major payers like managed care plans and Medicare trying to reduce cost at every turn, it is no wonder that they are starting to suggest that reimbursement should be tied to the proven efficacy of lab tests.

Congress is considering several bills that may result in an increase in federal funding for what is termed comparative effectiveness research (CER). If passed, this could have huge implications for how lab testing is used and reimbursed.

CER is an evidenced-based research tool, which compares different health services or treatment options for the same condition, so healthcare professionals can personalize patient care.

The possible upside is successful CER studies may well provide laboratories with important information for assessing tests and improving test selection. In addition, these studies may provide needed data for new guideline development. However, there are also potential pitfalls associated with CER, such as how payers use the data. Will they use it to restrict coverage or reduce payments for certain tests? If insurers choose this route, what will it mean for clinical laboratories and test developers?