Volume 5, August 2016

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Toward healthcare integration — How Quest Diagnostics is helping providers respond to healthcare reform
Jay G. Wohlgemuth, MD
Senior Vice President and Chief Medical Officer
Research & Development and Medical
Quest Diagnostics

Healthcare reform in the United States is transforming healthcare delivery. A fragmented, fee-for-service system is being replaced by a more integrated system that rewards quality and improved outcomes.

Dr. Jay Wohlgemuth discusses the impact of the Affordable Care Act (ACA) and reviews how Quest Diagnostics is supporting healthcare integration through its diagnostic information services.

Impact of healthcare reform — toward population health and improved outcomes

“It’s widely recognized that healthcare in the United States is highly fragmented and difficult to navigate,” says Dr. Wohlgemuth. “Testing, treatment, and monitoring have historically been conducted by different providers in different settings, with minimal coordination and little sharing of data.

“In the traditional fee-for-service environment, providers were reimbursed for their services and so would focus on the quantity of specific procedures they were performing, such as cardiac surgeries or colon cancer resections. This focus on procedure volume is not an effective way to target resources. It has led to disproportionate focus on late stages of disease, with insufficient resources directed to prevention.

“The ACA is creating more rational incentives for healthcare providers, linking reimbursement to the quality of the experience and outcomes that go beyond an individual procedure or episode.1 In the new environment, providers are being measured on upstream prevention: are they performing colorectal screening to detect colon cancer at an early stage? Are they performing lipid testing and using statins appropriately to prevent cardiac events? If providers identify a gap in care they will need to close it and thereby reduce the incidence of late-stage disease and its associated costs.

“These new incentives change the game, moving healthcare delivery from an episodic, procedure-based approach to one based on population health and improved outcomes along an entire clinical path. We are now rewarding highly coordinated, high-quality care delivered within a well-functioning, integrated system.”

Quest Diagnostics vision — from test results to integrated solutions

In 2012, Quest Diagnostics redefined its role from being a provider of laboratory testing to a provider of diagnostic information services. “This reflects our commitment to empowering better health through diagnostic insights,” notes Dr. Wohlgemuth. “It is an important shift because we’re moving from delivering a test result in isolation to providing information services to improve health. This approach is aligned with the move toward quality and integrated care driven by the ACA.”

Recognizing that laboratory testing is one component along a diagnostic and care continuum, Quest Diagnostics is now developing products and services that form an integrated offering aligned with a clinical condition or care path. In cardiovascular health, for example, the Cardio IQ® Solution supplements laboratory test results with family history, clinical data, and lifestyle information to provide an 8-year risk assessment for cardiovascular disease or diabetes.

In women’s health, Quest Diagnostics has created integrated offerings that combine a woman’s PAP smear and HPV status with her age and history. This forms the basis for a report that helps assess the risk of cervical cancer and also provides decision support in relation to next steps. “We’re not just providing results,” notes Dr. Wohlgemuth, “but results and clinical implications.”

“We’re essentially providing a solution to a clinical challenge,” continues Dr. Wohlgemuth. “If we define the clinical challenge as cervical cancer detection and prevention, the solution is an integration of clinical assessment, laboratory testing, and decision support. Information technology applications play an important role by providing the physician and the patient access not only to results but also to interpretation and information to guide decision-making. This facilitates good physician practice, consistent with guidelines, as well as patient engagement and compliance.”

In the area of infectious diseases, Quest Diagnostics has developed a comprehensive approach to hepatitis C comprising screening, work-up, and molecular testing to guide precision medicine. “I see this is as an end-to-end solution to support all the steps along a clinical path, including decision support for physicians and patients as they move from screening to treatment to monitoring,” says Dr. Wohlgemuth.

Informatics and information technology — the product

Dr. Wohlgemuth highlights the importance of information technology in enabling greater integration of healthcare delivery. The range of informatics and IT solutions offered by Quest — the Quanum™ suite of solutions — is the “backbone” that supports this move toward greater integration: “These solutions are enhancing integration in numerous ways: decision support for doctors and patients; patient engagement; population health; the use of data to improve healthcare systems. These are all important aspects of a more coherent healthcare system.”

New technology will help bring about more convenient patient testing and monitoring outside the hospital or physician’s office. The collection of medical diagnostic information in a patient service center (PSC) or in a patient’s home is an important area of development for Quest, which will help close gaps in care. “We are looking at new technology that enables a nurse or a visiting phlebotomist to administer tests that would normally be done in a physician’s office, such as an ultrasound or an ear examination, and then integrates the information generated into their system,” notes Dr. Wohlgemuth. “The ubiquitous use of smartphones is changing the way physicians and patients interact with all aspects of their lives including delivering and participating in healthcare.”

The whole field of individual monitoring is evolving rapidly as technology becomes increasingly advanced. Wearable technology will enable glucose levels or blood pressure to be monitored transdermally. “We’re looking closely at how these types of technology can be integrated into our services for home-based or lifestyle-based data collection,” says Dr. Wohlgemuth. “Hypertension is a good example of how this collection of data can change the game. If data for a patient with hypertension can be sent to a physician every couple of days, the doctor can adjust the anti-hypertensive medication as needed. Given that hypertension is the number-one modifiable risk factor for death in the U.S.2,3, improved monitoring of therapeutics could have a significant impact on outcomes. This epitomizes our approach to applying technology to deliver better care and reduce cost to the system.”

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Population health — Working with provider organizations to integrate care delivery and improve outcomes
Gary Bronstein
Director – Business Development
Quest Diagnostics

In response to healthcare reform, providers are organizing themselves to meet quality and financial goals more effectively. There are various evolving models for these provider groups: accountable care organizations (ACOs), independent physician associations (IPAs), management service organizations (MSOs), and integrated delivery networks (IDNs). These organizations provide a framework within which providers can establish best practices and clinical pathways to provide higher quality healthcare at a lower cost, while enhancing the patient experience.

Gary Bronstein reviews how Quest Diagnostics is partnering with ACOs and other provider organizations in developing services and providing actionable data in support of their goals. He describes collaborative approaches to increase compliance with guidelines and parameters established by Medicare and other organizations for colorectal screening and chronic care management.

Sharing savings: CMS and ACOs

The Centers for Medicare and Medicaid Services (CMS) supported the development of ACOs as a means of achieving the Triple Aim whereby care is transformed by pay for performance in quality, effective costs, and patient experience. There are several ACO models, as well as other organized provider arrangements, based on different shared savings approaches. The current established program is the Medicare Shared Savings Program (MSSP), in which approximately 433 ACOs are participating, accounting for 7.7 million assigned beneficiaries.1 Newer models are in process under the Next Gen structure, which launched in 2016 on a pilot basis.

“CMS establishes a benchmark for each ACO based on the total Medicare spend for that ACO’s attributable lives,” explains Mr. Bronstein. “The physician, in most cases the primary care physician, is considered the manager or gatekeeper for patient care and the associated services—office visits, outpatient, inpatient, emergency room—and therefore has significant influence and control with respect to the types of services and the associated expenditure. Medicare shares the savings generated by the ACO with the respective ACO in accordance with a methodology that accounts for the benchmark, as well as the quality performance standards for that particular year. There are 33 quality measures in 4 categories: patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk population.” 1

Working with ACOs to meet quality goals — colorectal screening

“When Quest works with ACOs, we work as a strategic partner to help them achieve their mission,” says Mr. Bronstein. “One way we are doing this is by combining services within clinical franchises aligned with the medical areas on which ACOs are focused. These include cardiovascular, infectious diseases, women’s health, neurology, and cancer. Each ACO or organized provider group may have specific areas of focus based upon their patient requirements.”

“In the area of colorectal cancer, for example, we have developed a program to increase colorectal screening rates and compliance with CMS guidelines. Working with an ACO in New York, we identified 5,000 patients who had not been screened, based on annual health and wellness reviews. We developed a turnkey solution whereby we mailed a package to each of these patients, containing a CMS-approved physician’s letter and fecal globin by immunochemistry kit, which was supplemented by a follow-up letter and a call-center capability. Within 6 weeks of the mailing we achieved a response rate of 17%. Among these completed tests there was a positivity rate of over 16%, indicating a need for physician follow-up with primarily a colonoscopy. This enabled early intervention, and a higher probability of favorable patient outcomes, while eliminating the need for unnecessary colonoscopies in those patients whose tests were negative. The initiative resulted in a 15% point improvement in the ACO’s quality score for colorectal cancer screening.”

Resources to extend care

Extended care is another area of focus, including home-based services and services provided outside the physician’s office or hospital. Quest’s mobile resources extend reach to patients outside traditional care settings, filling gaps in care delivery and enhancing care coordination. Mobile nurses, medical assistants, nurse practitioners, and phlebotomists are available to perform tests, assessments, and vaccinations, and to collect samples in a PSC or in a patient’s home. These healthcare professionals may be able to utilize advanced equipment now available in the marketplace, such as a virtual clinic (Medpod®), which connects patients to practices by means of a telehealth platform. Data from diagnostic devices on this cart system are automatically collected and transmitted both to the physician and the patient’s electronic health record in real-time. Providers can take basic vital signs as well as conduct more advanced diagnostic tests such as electrocardiograms, ultrasounds, and hearing and vision screenings.

“When you stand back and consider our wide range of services, capabilities, and resources, there are multiple ways in which we can help providers achieve the Triple Aim of providing better care, lower costs, and improved health,” concludes Mr. Bronstein. “These services will help us address value-based contracting between providers and payers as well. Integrated care along a clinical path, chronic care management, and extended care are all areas in which we can support their objectives. We are committed to working with ACOs and other provider groups to pilot and deliver new services designed to have a measurable impact on the health of their patient population.”

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Medpod® is a registered trademark of Henry Schein.

From data to information — Harnessing information technology to improve efficiency and quality
Bill Leister
Vice President Informatics, Analytics & Business Intelligence

Healthcare integration is possible only if patient information is available for services and outcomes along a care continuum, and across care settings.

Bill Leister reviews the range of information solutions that Quest Diagnostics has developed to achieve a more integrated approach to healthcare delivery and improve efficiency and outcomes.

New services respond to evolving customer needs

“Our IT strategy reflects the trends in the marketplace,” says Mr. Leister. “The shift to quality-based reimbursement, and the associated regulations and standards of care, are driving our approach to technology. Patients are becoming more involved in their care, while physicians are spending significant amounts of time staying current with guidelines and ensuring they are meeting numerous quality metrics.

“Our response to these changes has been to launch Quanum™, our suite of technology and data-driven solutions. The first aspect of this is a redesign of two of our core products, to enhance the digital experience for our customers. Both Care360®, our primary order entry and resulting platform, and MyQuest by Care360, our patient portal for appointments and test reminder application, are being updated to reflect the evolving needs and workflows of our customers, be they providers, patients, care givers, or health plans.

Solutions to provide insights

The second aspect of Quanum is the launch of a new set of services. In the last year, Quest has introduced new solutions transforming not only how the company engages with customers, but also the nature of the information made available. “We are moving away from being purely a data provider — you send us a specimen and we send back the test results — to being an insight provider,” says Mr. Leister. “This means we are now supplementing data with interpretation and analysis, together with recommended actions to drive down the cost and drive up the quality of care.”

The Quanum Analytics Portal includes a suite of clinical solutions that offer users secure, convenient access to clinical informatics, advanced healthcare analytics, population health management and care coordination, and quality reporting.

Access to laboratory testing data

“The first of these solutions, On Demand Informatics, provides health plans, health systems, and ACOs, with a comprehensive view of the laboratory testing Quest Diagnostics has performed for them,” says Mr. Leister. “It allows them to ‘slice and dice’ that data, and to extract it into their own organization for further analysis. Users can pull test data and results by patient, practice, test, LOINC, diagnosis code, and date of service to create customized reports.”

Information for population management

Population Lab Insights is designed to help healthcare providers better manage their patient population with certain clinical conditions. A diabetes module is currently available and a chronic kidney disease module is being launched in the third quarter of 2016. “Population Lab Insights is essentially a scorecard to help organizations understand how the physicians in their practice or system are managing patients with a specific disease,” says Mr. Leister. “We perform an analysis against clinical guidelines and determine what percentage of that provider’s population is in good control, in borderline control, or out of control. Out of control indicates there are gaps in care: recommended activities that have not been performed for those patients. We allow them to drill down on the data for that patient population to help identify what is missing from the care plan, so they can close those gaps.

“Different scorecard views show physicians how well they’re managing their population compared with their peers in their organization, as well as against national benchmarks derived from our full customer base. It’s a demonstration of how we’re moving to provide a more holistic view of what is occurring with a patient beyond an individual encounter. This longitudinal view of a patient’s care enables providers to identify actions to meet quality benchmarks and improve outcomes.”

Optimizing utilization

Lab Utilization Insights shows whether the right test is being given to the right patient at the right time. “It graphically presents historical and trend information on test utilization: which tests are being ordered within a system, what are the most ordered tests, and what are the costs of those tests,” explains Mr. Leister. “It also allows us to perform a utilization or business review with a health organization, during which we can discuss test ordering for different disease states and possible changes to help lower the cost of care for a patient.”

Spectrum™ Analysis is an additional, customized service to assess utilization. “On request, the Lab Utilization data are reviewed by one of our medical directors, who looks in detail at tests ordered by individual providers for a specific diagnosis or condition,” says Mr. Leister. “Based on their analysis, they prepare a presentation for the customer, showing where there are opportunities for possible improvement in test utilization from a quality or cost perspective. The ultimate objective of this service is to help client organizations improve testing efficiencies and make a more directed choice of tests.”

Comprehensive data to drive efficiency and quality

“Another new service is Data Diagnostics™ from Quanum, which allows us to aggregate data beyond Quest’s own data set. It has the capability to bring in claims data from health plans that have ordered the service, and to integrate clinical feeds from health systems that have agreed to share their data in this process. This allows us to provide information on potential increases in efficiency, quality of care, and clinical history beyond our own services. This is particularly powerful because it is included in our core test compendium, enabling providers to order it at the time the patient is in the care setting and get a real-time response to guide their decisions and care.”

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