There are some well-worn phrases you just don’t hear much of anymore when it comes to the physician office lab.
By Jim Poggi
“Lab is too hard to sell; I’m sticking to med/surg.”
This used to be a daily comment we all heard a few years ago from even seasoned distributor account managers. Back then, when lab was a new adventure for many of us, we all assumed we needed to be technical lab experts. Lab seemed to have its own foreign language, and even the association between lab products and CLIA regulations felt daunting. We were comfortable “going it alone” for med/surg products we had sold for years, but lab was a different animal altogether.
How wrong we were in our assumptions and sales approach! We eventually learned that the key to selling lab was to know enough to “sell the meeting” and that team selling with our key manufacturers and colleagues who had more experience with lab would make all the difference in our success. With that change in our thought process, and the implementation of specialty lab sales forces with many distributors, we have grown the business and learned how to optimize our own personal lab business and revenue.
For many of us, lab is now as comfortable as our daily med/surg products were a few years ago. The effort shows, and we have built stronger customer relationships and a durable source of revenue for us and clinical value for our customers. Our willingness to step out and learn a new skill and provide new ways to improve the customer experience proves that we can grow as consultants and become an even stronger advocate for our physician office customers.
The following is a whimsical look at lab objections and challenges from both the customer and sales account manager perspective. Hopefully, it will rekindle a few memories and elicit a laugh or two as folks realize the number of stumbling blocks we placed in front of ourselves, but conquered anyway.
“Open a lab; you can make a ton of money!”
If this does not sound familiar, you are either a rookie in the lab business, have amnesia or selective memory. Not only do I remember hearing it, I may even remember saying it. The story varied some, but a key advantage of a physician office lab in the pre-CLIA days and up to the introduction of PAMA was the argument that creating a lab was a way for a physician practice to add a revenue stream to their practice. We sometimes discussed the clinical advantages of having a lab on site, but we more often pointed to the ability to capture revenue by bringing in-house several of the most frequently requested send out tests.
While true, this was a pretty narrow value proposition and often did not address the core reason to perform lab tests on site: “to initiate or modify a patient treatment program”. It also led to the possibility that the physician office lab may not live up to the perceived high profitability the customer imagined, creating the possibility of customer dissatisfaction.
PAMA and the increasing sophistication of our customers has helped us and our lab manufacturers to develop a far broader view of the value of lab and far more impactful customer value propositions. Lab is fundamental to the best standards of patient care and our story includes facts to back up this promise readily. Today we can track trends in patient lab values, screen for chronic diseases early enough to improve patient outcomes and even to uncover predispositions to diseases even before they become apparent. We have come a long way, and we continue to improve in this area. As consultants, our value and story has improved significantly over time. While there are challenges associated with PAMA, we can also thank PAMA for helping us to improve.
“CLIA is too confusing; no lab for me.”
I have heard this statement frequently since CLIA ’88 was finally enforced in 1992. Nearly every sales rep in distribution and lab manufacturing heard it, and we also had the same sorts of questions on our minds that we heard from our customers. In the early going, concerns about CLIA and compliance with the new regulations drove many manufacturers and distributors to limit their focus on lab tests. Gradually, as knowledge increased and the interpretation of the regulations became more well known, this trend began to reverse itself.
At the same time, many local lab consultants arrived on the scene to help. National consultants followed and today many distributors have internal resources available to help customers understand and cope with CLIA. Even more recently, cloud-based expert software and lab management solutions have entered the market and can help start up a new lab or assist an existing lab to know, understand and comply with the myriad CLIA regulations on technology, result quality and personnel standards. Check with your colleagues and trusted lab manufacturers to understand the wide range of CLIA help available today. Assistance is far more available than it was in the early going.
“The lab CPT codes are SO confusing!”
That statement was mostly made by the sales and marketing teams of lab manufacturers and distributors, but reflected the state of the payor market before PAMA when nearly every CPT code had a carrier specific payment amount.
Remember before PAMA, the Protecting Access to Medicare Act? Before 2018, when PAMA went into effect, most lab CPT codes were locally determined by each Medicare payor. At that time, there were 57 separate payors and consequently up to 57 different reimbursements for each assay. While many of the more common ones had similar or identical reimbursement across payors, many of them did not. And while some codes were attractive in some markets, other codes for the same test were not. Immunoassay tests and tumor markers stand out as tests whose reimbursement varied significantly from payor to payor and market to market.
One of the benefits of PAMA was that most legacy local reimbursements for lab tests were abolished in favor of national reimbursement limits. Today there are 1991 lab CPT codes, and only 51 local codes. As a result, it is far easier for you, your trusted lab manufacturers and our customers to understand the reimbursement level for most lab tests.
“Pee in the cup and leave it next to the sink.”
Once upon a time, pretty much every annual physical or patient visit with concerns about diabetes or urinary tract infection involved a urinalysis test. Now, not so much. When was the last time you were asked to “pee in the cup” on a routine annual physical? Last time you saw urine cups stacked up in the doctor office rest room? These have ceased to be common sights.
But, as you sell lab and more importantly patient care, urinalysis stands out as the quickest, most comprehensive and non-invasive way to screen for diabetes, urinary tract infection and other organ diseases. Test frequently, diagnose early and save time, money and help patients recover more quickly are all reasons to support increased use of urinalysis.
Fact to share: UTI is one of the more common reasons for the development of sepsis, so urinalysis also supports diagnosis of a potentially life-threatening illness as well as many longer-term chronic diseases. The CPT code for routine urinalysis is 81003. It is national and reimburses $2.25. Urinalysis including a microscopic test is CPT code 81001 and reimburses $3.17 nationally. Remember that toxicology screening is also done on urinalysis as is microalbumin/creatinine testing to assess kidney function. These assays have their own CPT codes and reimbursement. Need more information? Consult your trusted urinalysis lab manufacturer.
“I can diagnose flu; I don’t need to test.”
In the early days of flu testing between the late ’90s and early 2000s, this was a pretty common customer objection. We often heard it with a raised customer eyebrow and the implied suggestion that we were challenging the clinical knowledge of the physician we were talking to. Awkward.
But, in studies published by the Centers for Disease Control and Prevention (CDC), the data shows that many respiratory illnesses mimic influenza symptoms and we can focus on the clinical story, not how good the physician is at respiratory pathogen diagnosis. In any given year, the number of influenza tests that correlate with the disease is under 40% and with the advent of COVID-19, the numbers continue to drop. For the past season, only 16% of all influenza tests reported to CDC were positive. The end result: to be sure, your customers need to test. There is a wide variety of respiratory pathogens and many have similar symptoms.
“Every long-term care facility vaccinates patients; no need to test the patients.”
I personally fell for this one a few years ago. When you first hear it, it seems to make sense. Then once you do a little thinking, it no longer does. The latest data suggests that only 27% of elder Americans have a sufficient response to the flu vaccine to be protected. So, just because every patient in a long-term care facility gets a flu shot does not mean that flu will not take hold and circulate throughout the facility.
The most effective way to avoid spreading the flu throughout the facility is to test patients with symptoms, and then isolate those who are positive for flu. This also applies to COVID-19 and RSV. Elder patients typically have more severe symptoms from any of these respiratory pathogens and run the risk of contracting pneumonia as a complication of the underlying disease. This progression can be serious and even life threatening.
“We can’t find the patient record in the files.”
Setting the issue aside of how much a customer likes their EMR, paper files and their issues (misfiles, lost files, “borrowed files” that never return) are in the past. Your efforts along with government subsidies and the development of a robust suite of EMR products have finally brought us into the 21st century. EMR in addition to other technologies I will discuss later in this column have made data more timely, accurate and accessible. At-home testing seems to be the last hold out, but there is technology in development to integrate at-home testing into EMR. Still clunky, but effort is there to plug this gap.
“The patient called looking for their lab results.”
For the most part, the never-ending round of phone calls from the physician office to the patient and back again has been made a thing of the past due to EMR and patient portals. At one point, I calculated that before EMR and patient portals it took an average of seven calls back and forth for the physician office to get lab test results to working adults. EMR and patient portals have made a patient’s confidential data easy to access safely and shows result history clearly and in a way that is easy to understand. Portals I am familiar with also show test result trends over time, which results are abnormal, permit asking questions and making appointments online and significantly streamline the back office process both for caregivers and patients alike.
“We can figure this out without too much training.”
This is the surest way I know of to fail when switching from a waived lab solution to a moderate complexity solution. Limited training for a new chemistry or hematology system can lead to several adverse outcomes from inaccurate results to no results at all. Building a strong implementation program with your lab manufacturer and sticking to the program is the surest way to make this transition successful. Have a formal plan, get it in front of the customer, your lab manufacturers and any other parties helping with the implementation including consultants to get the job done right. Overplanning beats underplanning every time. If you don’t believe me, try both and let me know how it goes.
“Medicare is the lowest cost payor; we do not accept Medicare.”
I have seen versions of the “we do not accept Medicare” sign at any number of physician offices in my career. At one point, probably more than 20 years ago, Medicare and Medicaid paid less than commercial insurance for lab tests. But the whole premise behind PAMA was to align Medicare with the lower costs being paid by private insurance for lab tests. And that premise was confirmed by the Office of the Inspector General’s reporting. PAMA has taken some halting steps to align with private insurance and after some legislative delays, 2025 will see what the next round of proposed cuts will look like. Medicare has the authority to lower reimbursement for tests that have higher reimbursement than private insurance by up to 15% in 2025. The data is being collected and analyzed this year and the next Clinical Lab Fee Schedule, due in December of 2024, will show what the current gap looks like. Don’t be surprised to see some further cuts for the coming year.
“The doctor will see you now.”
A time long ago, before the clinical staff included Nurse Practitioners and Physician Assistants, this usually meant you were going to see your primary care physician, and they would be looking at you, not a laptop screen. For many practices, this situation now means you will see a member of the physician’s staff, and your vitals will be taken by a medical assistant. This is not necessarily a bad thing, but it does reflect changes to both staffing and the cost of managing a clinical practice that are increasing.
As a sales consultant, we need to be mindful that many practices now have a broader variety of influencers, and as a result, we need to take the time to understand the dynamics of decision making in the practice. Whether the practice has an existing lab or you are working with them to have them consider implementing a lab, you need to know each decision maker, their role and their attitude toward lab and its impact on patient care. The savvy consultant knows and understands each influencer in the practice and actively works with them on current and future practice opportunities.
“Lab testing is way too complicated; my staff will never figure it out.”
Once upon a time, before most lab chemistry reagents were liquid ready to use, lab instrument systems had built-in help and we even had the first CLIA waived hematology or molecular systems, this statement was truer than not. With lab technology becoming ever easier and the trickle down of highly sophisticated technology (PCR and other molecular tests in particular), those days are over.
The well-equipped physician office lab today can perform chemistry, immunoassay, hematology and molecular tests that even large-scale hospital labs found challenging to implement just a few years ago. The progress of technology, along with more sophisticated training methods and help via the internet has leveled the playing field to a large extent where lab testing is concerned. Systems are smaller, smarter, faster, easier to use and have more fail-safe mechanisms to prevent errors than ever before. Add in your consulting efforts along with your lab equipment manufacturers and your commitment to customer satisfaction, and lab testing has never been easier or more accessible from a technical viewpoint.
I see the future as bright for easier to use microbiology systems to enter the market in the next few years. They will probably be powered by molecular systems similar to those in use today, and the range of available assays will also grow. I wonder when and if the most exciting developments in cancer diagnosis and monitoring will make it to the physician office lab. Liquid biopsy and other cellular detection methods are becoming more frequently used in tertiary care centers and I believe it is only a matter of time before they make it to the physician office lab. In combination with large scale data sets and expert system analytical tools, there is a revolution happening that is sure to come our way. I wonder what the next version of “things you don’t hear much anymore” will include. Watch this space and we will learn together.