Document: Health Care Reform
Classification: Position Paper
Date: June 1995
Status: Approved by ASCLS House of Delegates July, 1995
In the absence of comprehensive national health care reform, Congress and state legislative bodies will take incremental actions to deal with inequitable access to health care and to reduce health care costs. The American Society for Clinical Laboratory Science (ASCLS) espouses "excellent, accessible, cost-effective laboratory services for consumers of health care" in its vision statement and supports the tenets of health care reform delineated in this document.
Health care reform became a major public policy issue due to the rapidly escalating costs of health care and the growing number of citizens not having access to quality, affordable care. Medicare expenditures constitute an ever-expanding portion of the federal budget. Both federal and state governments consistently struggle to fund their portions of Medicaid allotments. As more people have become unable to afford private insurance, the increased uninsured/underinsured population has caused cost-shifting, thus inflating private insurers' expenditures even more.
The United States health care delivery system is exceedingly complex, and proposed solutions to remedy the identified problems may well have ramifications elsewhere in the economy. The 103rd Congress was unable to reach a consensus on the comprehensive changes needed. The 104th Congress is likely to consider separate and incremental actions. At the same time, the market place is reforming itself with the rapid onset of managed care, and states are implementing their own health care reform programs. While ASCLS supports the cost-effective, appropriate delivery of laboratory services, the Society asserts the following positions at both the state and federal levels to ensure that legislative initiatives do not undercut the provision of high quality laboratory services.
As the health care focus continues to shift toward wellness, ASCLS supports preventive care such as early intervention, immunization and screening programs. ASCLS supports direct access to clinical laboratory services for screening tests, tests used for monitoring purposes, and tests that do not require consultation. Direct access can greatly increase the availability and usage of preventive services. Furthermore, substantial cost savings can be achieved by eliminating office visits and prior approval of appropriate, preventive laboratory services.
Despite today's emphasis on primary care, citizens in rural and underserved areas frequently lack adequate access to health care services, often related to a local shortage of health care professionals. To increase the number of professionals in those areas, to expand educational enrollment in allied health professions with the greatest shortages, and to develop innovative curricula meeting current needs, ASCLS supports continued funding of the Allied Health Project Grants under Title VII of the Public Health Service Act.
The Clinical Laboratory Improvement Amendments (CLIA) of 1988 must be implemented equitably in all sites so that citizens are assured of an accurate laboratory result whether in a hospital, independentlaboratory, physician office, nursing home, or other site. We believe reasonable and appropriate regulatory standards for laboratory operation and personnel are necessary in all sites to ensure reliable results.
Health care reform legislative initiatives must include a mechanism for quality monitoring. When incentives exist to reduce expenditures, provisions must consistently be made to ensure quality is not compromised as a result.
Medicare reimbursement significantly impacts the quality of clinical laboratory services provided to the American public, as well as access to those services. The laboratory community has already experienced disproportionate cuts in reimbursement. From 1984 until 1996, Medicare fee caps for clinical laboratory testing shrank from 115% to 76% of the median. While reimbursement must be reasonable, additional significant decreases will reduce access to and adversely affect the quality of laboratory services.
ASCLS supports all-payor direct billing and/or anti-mark-up (beyond costs justified by specimen handling) legislation as a means to contain costs and control inappropriate test utilization. When providers are allowed to significantly mark-up the costs charged to patients for tests performed at another laboratory, incentives exist to order an excessive number of laboratory tests.
ASCLS opposes a 20% Medicare copayment for outpatient laboratory services. In many instances, the cost of billing the patient's portion could exceed the amount of the copayment. Yet laboratories electing to save costs by not billing for copayment would be subject to fraud and abuse penalties. In essence, copayment represents a substantial decrease in Medicare reimbursement. Also, the additional out-of-pocket expense to the patient can decrease access to laboratory services.
ASCLS opposes mandated competitive bidding for outpatient laboratory services, particularly versions with a "winner-take-all" provision. The "winner-take-all" provision could jeopardize the ability of all other laboratories to survive. Competitive bidding has strong incentives for laboratories to submit unrealistically low bids to become the exclusive supplier. With so much emphasis on cost reduction, quality will be compromised. Previous federal armed forces' experience with competitive bidding in health care proved unsatisfactory and compromised quality of care. ASCLS particularly opposes the automatic 10% reduction in reimbursement that would occur if Medicare does not save 10% in laboratory payments. This percentage is arbitrary and without justification.
ASCLS supports continuation of programs to detect fraud and abuse in laboratory reimbursement and emphasizes that regulatory bodies must provide clear guidelines for providers as to legally acceptable practices.
In order to control costs, laboratory service must be delivered in an efficient and cost-effective manner. To that end, we support mechanisms such as administrative simplification to reduce unnecessary paperwork. Laboratory benchmarking is an effective tool to compare costs, detect waste, and develop more efficient processes. Outcomes measurement must occur so that laboratories can determine the effect of a particular intervention on total patient care. The clinical laboratory scientist clearly has the expertise and must contribute to these endeavors.
Appropriately trained, competent laboratory professionals are essential for cost-effective, as well as quality, laboratory services. Unqualified testing personnel unnecessarily increase the cost of health care through errors in testing, repeat testing, false diagnosis due to false-positive test results, and undiagnosed conditions due to false-negative test results.
A 1994 Congressional Office of Technology Assessment study reports a small proportion, "certainly less than 8 percent," of diagnostic procedures are likely to be caused by malpractice liability concerns, a finding which greatly undercuts the "defensive medicine" rationale for excessive ordering. Thus, appropriate test utilization is key to cost-effective delivery of care as inappropriate testing adds significantly to the cost of health care. Clinical laboratory scientists must increase their dialogue with those who order laboratory tests as to the most beneficial tests in a given situation. Practice guidelines, patient cae paths, test ordering algorithms are all effective in reducing unnecessary testing; however, it is imperative that the clinical laboratory be involved in these processes if they are to succeed.
ASCLS also supports extending the ban on physician self-referral of clinical laboratory services to include all payers. Again, the reimbursement incentive with self-referral encourages excessive ordering and inappropriate utilization of laboratory tests.