Value-Based Care Meets Patient-Centered Care for Lab Testing

July Webinar

Avalon Healthcare Solutions hosted a webinar on federal policy news and laboratory trends. Julie Barnes, the Principal of Maverick Health Policy, interviewed Michael Bagel, the Director of Public Policy for Alliance Community Health Plans. The webinar covered:

Breaking News

  • July 1: Transparency in Coverage Rule went into effect—plans must post machine-readable files with prices for all covered services.
  • July 8: President Biden issued an Executive Order to protect access to contraceptive and abortion services post-Roe v. Wade overturning. The impact of Roe v. Wade overturning is significant on health plans. Many health plans were unprepared. 
  • July 8: CBO said legislation allowing Medicare to negotiate prescription drug prices would save $290 billion over 10 years.
  • July 15: Biden Administration extended the public health emergency another 90 days for COVID-19. 
  • Moving forward: The Federal Trade Commission is investigating the six largest pharmaceutical benefit managers. Also, congressional action is forthcoming on the reconciliation package. 

How the PHE Affected Lab Testing 
The public health emergency has impacted the healthcare environment in innumerable ways. The federal government and private entities are cognizant that COVID-19 tests resulted in increased federal spending. A record $1.5 billion dollars was spent on tests. Currently, federal legislation requiring insurers to cover COVID-19 testing is still in place. Additionally, several labs have been prosecuted for price gouging and fraud. 

Four issues rise to the forefront:

  • Deferred care continues to impact the system.
  • The rise in high and previously unseen costs in lab testing during COVID-19.
  • Facility fees for testing are an ongoing issue.
  • At-home lab tests lack continuity of care and tracking of results.

Where Patients Get Lab Services Will Matter
According to the No Surprises Act, hospital labs cannot balance bill, but when a doctor-office orders labs, they can balance bill. This affects how and where patients will go for lab services and is another issue to watch.

Future Lab Testing Issues for Plans
The new frontier is discretionary lab tests. For example, Medicare spending has risen exponentially. In 2015 the total spend was $289 million. By 2019 it was over $1 billion. 

Specific issues:

  • Molecular oncology tests have seen a rise in sales tactics and direct marketing. 
  • Consumers are well-versed in options and interested in having a choice.
  • Insurers will need to be proactive in positioning coverage.
  • E-prior authorization is on the horizon but not without considerable back-and-forth between providers and health plans on the implications.

Bill Kerr, M.D., Avalon’s CEO, closed the session by discussing the importance of planning for 2023. He talked about the consequences of unit price on price transparency, the tight labor market, and the high rate of inflation—all of which will factor into industry calculations. 

Register for the September Webinar

Tuesday, September 17
2 – 3 p.m. EDT

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