Why CMP and BMP should be part of every annual physical.
By Jim Poggi, Principal, Tested Insights
Every once in a while, it pays to consider how certain well-established primary care medical procedures are conducted and, looking through the lens of how point of care lab testing can make a difference, ask ourselves “Can we do better than this? Can lab testing make a difference for the patient and the healthcare system?”
Take, for example, the annual patient physical. Imagine the following typical annual physical for an adult, whether they have known risk factors for diabetes, heart disease or other leading causes of death or not.
The patient checks in and waits to be called to the exam room. The medical assistant takes a weight before escorting the patient to the exam room. Once in the exam room, the medical assistant or nurse asks about any changes in medication, health concerns or life habits with associated health risks (falls, alcohol use, smoking, etc.). The assistant checks blood pressure, pulse, temperature and usually respiration. The information is recorded into the EMR. Once the physician, NP or PA comes in, they greet the patient, scan the information in the EMR and complete the vital signs assessment by listening to the patient’s heart and lungs and give the patient an overall visual assessment. They are looking for any signs of diseases or changes from the last physical.
This sequence has a history and tradition spanning centuries and with modest changes is taught in every medical school around the world. Can you imagine the physician asking “So, how are your alk phos doing? Notice any changes in your bilirubin we need to discuss? Any changes in your calcium since your last visit?”
Obviously, those questions make no sense and the typical patient encounter would likely end pretty quickly if the discussion took this turn. And yet, for millions of Americans, knowing the answers to these lab result questions, and many others, can lead to rapid diagnosis and treatment of the patient BEFORE obvious symptoms present themselves. Either a comprehensive or basic metabolic panel can provide the needed information for the caregiver and patient to understand not just the patient’s obvious physical condition but their metabolic health as well.
Unfortunately, far too many annual physicals end without this information in hand. It is interesting to me that traditional signs and symptoms with centuries of tradition are followed without question, but lab tests that can and do give far more valuable information are not always part of the patient visit process. We see what we see, and miss what’s going on inside.
Sometimes the patient leaves with a lab request slip which may or may not be performed. Even if the tests are performed, there are any number of reasons why follow up is either not timely or simply does not take place.
From my perspective, to have a full picture of the patient’s health, a CMP or BMP should be part of every annual physical in addition to vital signs assessment, especially for patients with any pre-existing chronic condition related to diabetes, heart disease, lipid disorders or kidney disease. Knowing during the patient encounter leads to immediacy, better counseling potential and the ability to initiate or amend a treatment program immediately and prescribing medication as needed.
Which tests are we talking about?
Comprehensive Metabolic Panel (CMP)
The comprehensive metabolic panel contains a total of 14 clinical chemistry tests. These tests include albumin, bilirubin, total calcium, carbon dioxide, chloride, creatinine, glucose, potassium, alkaline phosphatase, total protein, sodium, ALT, AST and BUN. Taken together they assess kidney function, liver function, diabetes, overall metabolic efficiency, and set baselines for important tests that can be tracked and trended over time. Abnormal electrolyte levels (sodium, potassium, chloride and carbon dioxide) are often associated with hypertension.
The CPT code for CMP is 80053 with and without the QW code. The QW code indicates that the test can be performed and billed using a CLIA-waived testing system. Current Medicare reimbursement for the CMP is $10.56. In 2016, Medicare paid for 41.6 million CMP tests, and CMP was the second most commonly performed lab test under the Clinical Lab Fee Schedule. Medicare payments for CMP that year totaled more than $470 million. A reasonable estimate of private pay for CMP would be close to $1 billion.
Basic Metabolic Panel (BMP)
The basic metabolic panel contains eight tests, total calcium, carbon dioxide, chloride, creatinine, glucose, potassium, sodium and BUN. This panel lacks the liver function tests of AST, ALT and alkaline phosphatase included in the CMP. The CPT code for the BMP is 80048 with and without the QW (CLIA waived) modifier. Medicare reimbursement is $8.46. The BMP is intended to assess general metabolic health, kidney function, and test for diabetes. Abnormal electrolyte levels (sodium, potassium, chloride and carbon dioxide) are often associated with hypertension. In 2016, Medicare paid for 13.7 million BMP tests, and BMP was the number nine most commonly performed lab test under the Clinical Lab Fee Schedule. Medicare payments for BMP that year totaled more than $133 million. A reasonable estimate of private pay for BMP would be close to $250 million.
Who could benefit from this information?
The list of Americans subject to chronic diseases including diabetes (30 million diagnosed and another 98 million prediabetics) is compelling all by itself. Add to it the number of Americans at risk for heart disease (47% of all Americans bear risk, or about 157 million Americans) and the number of U.S. hypertensives (120 million) and the overall numbers become overwhelming. Granted, these numbers are NOT additive since many Americans are at risk for multiple serious chronic illnesses.
Even if you take the smallest number, 120 million hypertensives, the number of Americans under risk is no less than 36% of all Americans. The CDC estimates that 90% of the U.S. healthcare spending ($4.1 trillion) is for chronic diseases. Taken together the CDC estimates direct costs and loss of productivity due to diabetes and heart disease costs $543 billion annually. Those are big numbers and represent over 13% of total U.S. healthcare spending. Prevention and early detection can effectively reduce these costs, increase life expectancy and improve quality of life.
What can you do?
As a distributor account manager, you are a vital link to the products, services and information your key customers need to provide the best possible medical care. Your ability to help starts with staying current with the latest information about products for patient care, point-of-care lab testing and maintaining ongoing dialogue with your key suppliers to develop strategies and a compelling customer value proposition that can make a difference in improving patient care. Understanding how annual physicals including CMP and BMP testing can benefit the practice and its patients is one fundamental step you can take to showcase your abilities as a valuable consultant.
An approach that produces the best results begins with dialogue and discussion with your key lab suppliers and strategy development before engaging in customer level discussions. You will find that depending on the number of CMP and BMP tests your customers send out, their current CLIA license and sensitivity to capital and operating budget costs, you will need to work with a fairly wide range of suppliers to meet the needs of the majority of your customers.
Once you understand the range of options you have available, it is always best to begin your customer dialogue by asking questions and carefully listening to their responses. The number of tests sent out and their viewpoint on point of care testing overall set the stage for your value proposition. But you also need to understand the practice dynamics: who makes the decisions? How does the staff feel about adding point of care testing? Have they done it before and abandoned it? If so, why? Thoughtful and comprehensive probing will provide you with the information you need to proceed with a proposed solution, seek more customer or supplier information or to decide the time is just not right for this particular practice.
The more you know, the easier it is to get past a “no” and develop a compelling presentation in the best interests of your customers and their patients. Your business will grow, and your customer satisfaction will also grow. More consulting opportunities are on the horizon for the distributor account manager who can make point-of-care testing a positive and meaningful element of their customers’ practice.