Tuesday, February 3, 2009
Coupon Cutting in the Coagulation Laboratory
You can't open a newspaper without seeing "in these economic times", or turn on the TV with getting some financial report. People are cutting coupons, not buying expensive coffee, so why not coagulation costs? Okay, personnel is not an issue, there isn't enough of us to go around on a good day! And I am not talking about splitting gauze into pieces. Coagulation testing is expensive- should you "make" or "buy" a test? What about the impact on patient care? All questions that need to be looked at.
Remember when the laboratory used to be a revenue generating center- some of you might not- but tests were done whenever, at a cost set up by the laboratory- no questions asked. With the implementation of Diagnostic Related Groups (DRG's) where ordering tests became relative to diagnosis - ICD-9 codes, the laboratory must have a CPT code for a test in order to charge. For an in-patient laboratory tests are "bundled" for diagnosis- so inpatient testing- if out of the designated scope- the testing the laboratory does is pretty much minimally reimbursed- (trust me this is a watered down version of the complexities of coding etc- it is very intricate)
Therefore the goal is to keep expensive inpatient testing down while not sacrificing patient care - so do more outpatient testing! HOW? restrict inpatient testing- HOW?
make clinicians get approval for coagulation testing- you will eliminate doing factor XIII's when you really have VIII's. Getting a factor V, when they really want an APCR, running factor assays on heparinizned patients,(NOTE: all inpatients that have a factor work-up should get a thrombin time PRIOR to doing that workup to determine if heparin is on board or not. The thrombin time is the best test for residual heparin- and will let you know if you need to cancel that workup, and why your mix didn't correct- save time and money not doing a Lupus workup) or on patients on Direct Thrombin Inhibitors, What about doing factors II, and VII on patients with a prolonged APTT- should I stop here, or my favorite- doing a full thrombophilia workup on an anticoagulated patient or a patient with a clot-
These results are inaccurate- it is a waste- the reality is the patient MUST be treated, so do it- then bring the patient back to find the cause- when the event is over, and the patient can be safely removed from anticoagulation. Okay should we do molecular testing for Factor V Leiden, MTHFR, or Prothtombin mutation? Sure, but not as an inpatient, only as an outpatient. So there, we have not compromised patient care, we have helped to control costs, and given better answers.
Due to the complexity of coagulation testing, interpretaion is very helpful to the clinicians, as well as a great learning experience for the technologists and the residents. This is a coded test, therefore it is billable. Time well spent and everyone profits, patient, students and laboratory.
What about the testing itself- do you make or buy a test? I am very much in favor of having testing in house, available for patient care. Testing should reflect your patient population, maybe slimmed down a bit- for example if you have a coumadin clinic- might want to offer factor II, and VII- less call for V and X. If you want to run one test for thrombophilia- go with APCR, it is the most common disorder. Personnel is always an issue so the best thing is to automate, automate, automate. Tests like ristocetin cofactors, take a long time, but they can be automated. Bleeding times you lose a tech for up to an hour, get an analyzer that screens for primary hemostasis like the PFA 100. It can be coded as you would for a platelet aggregation, and no one has to leave the lab. When you are looking at ELISA based assays see if you can get them on an automated system, or this may be a test that is worth sending out- do your homework.
Batching is also a cost saving measure. Try to accomadate your clinic schedules, this way if certain clinics meet on certain days, their wait time for results will be shorter, so your highest volume will have the quickest turn around time- happy customers- Also, look for mulipurpose controls. Being able to use controls on many analyzers avoids making up different ones, for testing, it is a waste of time and money.
Remember the shortest distance between 2 points is a straight line- so have good testing algorithims. Being able to guide your clinicians on just what should be ordered in what progression will give everyone more bang for their buck!
Better results, shorter response time, direct route, outcome cost savings for everyone.
So look at your spending, use your coagulation coupons and minimze output to maximize your input- everyone wins!
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