Special Report: Infection Control and Managed Care

Labs perform more tests under managed care

Survey raises concerns over quality

In a "striking" finding that underscores that the jury is still out on the impact of managed care on clinical practice, 66% of the respondents to a national survey of microbiology laboratories reported increased levels of testing over the last five years.¹

The finding was surprising in light of widely held concerns that managed care-driven pressures to reduce costs would result in a reduction in such clinical services, reported the Lewin Group in Fairfax, VA.

"These results are striking, as they contradict generally held fears about the future of microbiology," the report stated. "It is possible that managed care’s emphasis on cost-effective care may actually produce a greater level of testing volume than a fee-for-service system."

Increased testing over the period was reported for such purposes as determining antimicrobial susceptibility, infectious disease serologies, blood cultures, and molecular tests.

The survey, commissioned by the American Society for Microbiology in Washington, DC, netted responses from 351 clinical microbiology laboratory directors or administrators in 231 institutions. Overall, 84% of the respondents were hospital-based, with the remainder based in independent reference labs or public-health labs.

Cost and time per test decreased

"However, it should be noted that test volume is only one dimension of laboratory activity — the survey provides clear evidence that costs per test are decreasing, and that time spent per test is decreasing," the report continues. "Although these results may be taken in part as positive productivity gains, it is also clear that managed care and health system changes are driving a shift away from costlier — and potentially more rigorous — laboratory services."

In addition, there appears to be evidence of downsizing in microbiology labs, as many more survey respondents reported a decrease rather than an increase in the number of midlevel positions. In general, the changes reported at the labs reflect dramatic fluctuations throughout the health care delivery system.

"Nearly 90% of survey respondents reported that their laboratory had experienced at least one of the following during the past five years — had acquired another organization, had been acquired, had merged, had downsized, or had increased partnerships or affiliations with other laboratories," the report states.

Efficiency reportedly improved

All the while, the survey cited increased use of quality assurance mechanisms, such as ongoing assessment of the competency of laboratory personnel and efforts to eliminate medically unnecessary testing. Though respondents were not asked specifically whether quality of laboratory services had improved or had a positive impact on patient care, such quality assurance mechanisms are generally associated with improvements in service, the report concludes. Likewise, survey respondents reported improvements in efficiency and productivity, which also may translate into improved service.

The survey also found that laboratories have initiated cost-control and revenue-enhancement activities in response to health care system cost pressure.

"Many survey respondents reported that their laboratories acquired new technologies to increase efficiency or decrease cost, and implemented utilization review, outsourcing of costly, low volume tests, and prior authorization requirements," the report states. "Laboratories also expanded into new areas such as overall outreach testing, molecular/ PCR testing, diagnostic/pharmaceutical trials, and nursing home testing."

Reference

1. The Lewin Group. The Impact of Managed Care and Health System Change on Clinical Microbiology: A Survey Analysis. Fairfax, VA; 1998