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Chapter 7 : The Changing Healthcare Environment

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Abstract:

This chapter provides a historical overview of reimbursement for laboratory services from 1969 to the present. It presents an outline of healthcare reform and its impact on the industry stakeholders. Value-based healthcare models share the following common elements: management of distinct patient populations; delivery of coordinated care through integrated networks of providers; focus on patient outcomes using evidence-based practices; use of health information technology for measuring, managing, and reporting quality; and focus on costs of providing healthcare. The chapter helps the reader to learn about special issues related to contracting for managed care, including prospective payment, capitation, and providing service with payment caps, learn the risks related to each of these challenges, and discuss the challenges ahead as the industry responds to healthcare reform. It aims to provide an understanding of the impact of educated and informed consumers, patients, providers, insurers, and employers on the delivery of healthcare, and to learn about how consumer-driven healthcare impacts the industry. The chapter also helps the reader to understand the impact of technological advances, home health devices, and genetic information, and learn how technology is driving personalized medicine, and to understand how society is becoming increasingly litigious. To succeed in the future, hospital administration, employees, and physicians must develop an appreciation for each other’s culture, values, beliefs, language, and goals. Finally, the chapter facilitates in learning about how consolidation among providers and vendors is driving reengineering and restructuring, and in understanding how healthcare reform is fueling consolidation among all stakeholders.

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7

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Figure 7.1

Elements of meaningful use. Eligible professionals will receive incentives if they can demonstrate and provide data for three of these required elements. doi:10.1128/9781555817282.ch7.fl

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Figure 7.2

Evolution toward regional laboratory system. In a network model, independent laboratories affiliate under a network organization without any consolidation. In a consolidation model, two or more laboratories consolidate core operations to one primary site operating rapid access operations in remote sites. In a regional laboratory system, a hybrid operation is formed with participants from academic medical center laboratories, a commercial laboratory partner, and participating consolidated hospital laboratory models. (Reprinted with permission from reference .) doi:10.1128/9781555817282.ch7.f2

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Figure 7.3

Bottom-up customer focus: the inverted paradigm. In the new business paradigm, the customer as king maintains the position of influence at the top of the chart. Employees are empowered and trained to provide exceptional customer service, exceeding the customers expectation. The management teams within the organization must lead by example, building trust among the staff, doi: 10.1128/9781555817282.ch7.f 3

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Tables

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Table 7.1a

Legislation and regulation concerning healthcare and clinical laboratories

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.1b

Legislation and regulation concerning healthcare and clinical laboratories

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.2

Traditional indemnity versus managed-care insurance: a comparison

C. Haller, presented at the Executive War College, New Orleans, 1997

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.3

Types of managed-care organizations and services

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.4

Key features of bundled payment models

See reference

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.5

High-deductible health plan (HDHP) deductibles and annual limits

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.6

Changes in code sets

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.7

HEDIS performance criteria developed by the NCQA for rating MCOs

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.8

Quality management tools used by MCOs

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.9

Clinical pathways

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.10

The evolution of the educated consumer

See reference

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.11

Internet stakeholders: the barriers and benefits to healthcare

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.12

Advantages and disadvantages of point-of-care testing

See reference

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.13

Genetic mapping techniques

See reference

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.14

Eligible professionals (EPs)

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7
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Table 7.15

Providers

Citation: Harris A, Wilkinson D. 2014. The Changing Healthcare Environment, p 164-216. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch7

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