Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep109: Point-of-care testing with Daniel Krajcik, D.O., MBA
Transcript
- 0:00 Than if I can diagnose them with covid or flu rapidly and get them started on a medicine to help reduce their risk of severe disease or hospitalization, that's something I want to do. Welcome to 0:21 off the chart a business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latrell. I'm the assistant editor at medical economics, and I'd like to thank you for joining us today. Today we're talking about something that every primary care practice wrestles with sooner or later, and that's point of care testing, what's worth offering, what actually improves care, and how do you navigate the costs and other challenges that come along with bringing testing in house to dig into all of that. Medical economics Managing Editor Todd schryock sat down with Dr Daniel krasick, a primary care physician with the Cleveland Clinic who works closely with rapid testing. Every day. They talk about what tests make the most sense for small practices, how to evaluate your patient population, what the real costs and time commitments look like, and how rapid testing can change the way that you manage chronic disease, urgent complaints and overall patient satisfaction. Dr krajiek, thank you for being here. Let's get into the episode you 1:23 All right, so doc for a primary care practice that doesn't do any point of care testing, is there certain tests you would recommend them look at implementing, and how should they evaluate? You know what tests are worth offering based on your patient population and visit types? 1:41 Yeah, I mean, that's really good question. So I think it comes down to what does your patient population look like, and also, what does your patient location look like, or your practice location look like? So think if it would depend heavily on like, if you're seeing adults kids, both adults and kids, maybe just kids, once in a while, as some primary care practices do, so thinking about your demographics, because that will determine, help you determine, you know, what type of tests you want to implement. I think like a few basic tests that everyone can consider starting up front would be urine test strips, for example, is a very low, cost, effective test. You can use urine test trips without buying expensive machinery, and have a way to be able to diagnose urinary tract infections, diagnose glucose in the urine for people who might have, you know, be at risk for diabetes, so they could tell you a lot without having a lot of upfront costs. Similarly, I think that having a glucose meter in your office is a very good idea because diabetes is extremely prevalent, and we'll talk about that more here in a bit, but having a simple glucometer could be a very helpful tool in your office to help you treat your patients. But also sometimes medical emergencies happen in the office, as we know, and so it's good to have one of those on hand. 3:05 So my understanding is a lot of these tests require a CLIA waiver. Talk to me a little bit about what's involved in getting that CLIA certificate, and if there are mistakes to avoid or anything else a practice would need to know about that process. 3:22 Yeah, I've never applied for a CLIA waiver myself, so the but I know about the Clinical Laboratory Improvement Amendment, and so every lab has to comply with federal, state and local regulations when it comes to their point of care testing. And the CLIA waiver is part of the federal program. The form you could find, it's very clear and easy to fill out. I think it's on the CDC website. You can also find it on the CMS Centers for Medicare website. And so it's a form where you fill in you know a lot about your practice, and then the intended test you plan to implement, and then you would submit that to CMS or, you know, Center for Medicaid services. To do that, you can apply for a waiver for various tests, especially if they're tests that could be run at home. And so tests that are run at home or have very low risk, you know, maybe something such as like a rapid viral test for flu or covid, maybe it's a urine drug screen that we use for opiates or other controlled substances or illegal drugs. These are things that people can use in their houses, and so you can obtain waivers to also do them in your office. 4:37 So for these rapid tests, talk to me a little bit about the level of documentation that's required and how much staff time is going to be involved in that. Yeah. 4:47 I mean, there's a very wide range of rapid testing that a primary care office can consider. So just to name off a bunch of them, you know, you can consider your infectious tests, such as your rapid top, your rapid strep. Tests. If you're in an area where you know STDs might be a higher prevalence, then you can get rapid HIV or gonorrhea, gonorrhea or chlamydia. There's also urine pregnancy tests, which are very common and also a low cost option. But if you have patients that are older, if you're taking care of a large Medicare population, for example, many of them are going to be on blood thinners. So having something like a point of care INR could be really valuable. Having a point of care a 1c test could be really valuable. And so some of these tests that we that are, you know, more specific to blood tests, those can definitely cost more money up front, just because they're going to require, oftentimes, that, you know, some sort of, you know, machine to be bought. A lot of these runoff machines, but some of them are simple, like just urine dip tests, which are quite easy to do. So it's important to think about, you know, as with buying anything, there's fixed and variable costs. So if you it's always important to think about the costs of your test, both for the fixed which is your upfront cost of buying a point of care machine, but then your variable costs, such as all the supplies needed to keep to actually run that machine. And other variable costs would include things like the materials to run the tests, the maintenance of the machine, training personnel to manage that test. And so there's a lot of different variable things you have to consider when implementing a point of care test. 6:27 You mentioned training, is there somebody specific on the care team that should be trained to be doing these tests? 6:33 Yeah, definitely. To get a waiver, you're going to have to from from CLIA, you're going to have to have a point person for the test. And so, you know, in our our clinic, for example, like the the charge nurse or the HUD RN nurse manager, whatever you want to call them, they will be often in charge of, you know, monitoring the test and man, like making sure that it's in a it's meeting all the regulations. Whereas, then, you know, individual medical assistants or LPNs might be the ones who are actually running the test on a regular basis, and so they would need training to do. So the tests are often very easy to do. And so luckily these the training can be done, usually in just maybe a one hour session with just refreshers, depending on what the regulations are in your local or state area. But it's always good to have someone who's in charge, who's making sure that everything is in within regulations for both the state, local and national guidelines. 7:36 So offering rapid testing. How does it impact the clinical workflow, is it lengthening a patient visit, or is it actually improving efficiency? Because maybe you're eliminating a future visit, 7:49 that's good question. I think it depends. You know, I think in that moment, it probably lengthens your visit, right? Because it takes a few minutes to run that test. But that's okay, because exactly as you said it could be that if you're able to get a point of care a 1c on someone with diabetes, you're able to make a lot of medication adjustments at that time based on if their a 1c is that goal or not, whereas, if you had to send them off to a lab, and then you get that lab a day or two later, well, you're often have to bring them back to discuss The risks and benefits of tight training medicines, or starting new medicines, or even decreasing medicines based on what it is. So I think overall, it definitely improves our ability to care for patients. It improves our ability to offer a service that enhances patient satisfaction. You know, offices, although it does take a little bit more time, offices can bill for it, and so it can help increase your revenue by collecting point of care testing. 8:50 And I would think it would be a nice customer service aspect. I know I like when the doctor says, oh, we need to run this test, and we're going to do it right now, instead of a go to this location on another date. So I would think there's a customer service benefit as well, 9:05 definitely, especially if you're in an area where there might be multiple primary care practices, or there's so many freestanding urgent care practices around now that have lots of point of care testing, right? They're part of their value proposition in the market is to offer lots of rapid testing for people who are sick and want a quick answer. And so if your office can offer rapid strep testing, maybe rapid flu or covid testing, patients are going to want to come to you and have that testing done. But if they know that you don't offer those tests, it's obviously understandable that they're going to want to go to a place such as an external urgent care center that might offer those tests. 9:54 Hey there. Keith Reynolds here and welcome to the p2 management minute, in just 60 seconds, we deliver proven real. World tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow, hack, an employee engagement win, or a lesson learned the hard way. I want to feature it. Shoot me an email at K Reynolds at mjh life sciences.com with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next p2 management minute. 10:42 You are 10:48 there any legal or documentation requirements as far as what you tell a patient about a test or its accuracy limitations or anything like that? 10:59 I wouldn't say, Well, I think that that is very dependent on, again, your practice location. It's hard to comment on that now, because although there's a minimal set of Federal Regulations, there's definitely a lot of variability state by state, so it's definitely important to check your state's regulations for that. But I think that is also just ethical if you know that a test is not as good as a point of care test to make sure patients know that. You know, we always talk about shared decision making, and it's definitely worthwhile to take the time to say, hey, this test might not be quite as perfect as a if we did a blood test or if we sent a swab off to the lab to check a PCR, that is something that you should discuss. And so it is important for clinicians to understand the sensitivity and specificity of their point of care testing and how that might compare to a test that's run in an actual laboratory, you know. So for example, you know, I, I do lots of diabetes care, so I use lots of hemoglobin, a 1c examples. And so a point of care hemoglobin a 1c which tells us a patient's three month average of their glucose. Those tests are getting really good, but the standard of error is still within, you know, point two to point 3% in either direction, whereas a blood test is within, you know, point one or point 2% in either direction. And so that doesn't make a huge difference clinically, but sometimes, if patients are really borderline, that could be the difference between them feeling really accomplished, of having an A, 1c less than seven, or feel like that, they're still sitting above, you know, a recommended goal, and then that could affect your medication adherence. So it is important that patients understand that point of care tests, although they're definitely getting better, they are not perfect in any sense. 12:53 What about when it comes to, like, tracking your your test kit, inventory, expiration dates, lot numbers things like that. Is that a big time consumption? Is it fairly easy to do all of that? 13:09 Yeah, it depends on how much you're offering, and it depends how, I guess, how responsible your nurse manager may be. I guess, you know. So I work for a very large healthcare system, and a lot of this is just very standardized. And our nurses, luckily, they're able to follow a protocol. They're able to check on the inventory, see if things are expiring. Are we ordering too much, too little? Where we get most of our supplies for more of a central supply type place, but if you're a standalone, small practice, that is something that your nurse is going to have to take more time to fact check and to also think critically about, well, how much do we actually have to order from the manufacturer? Because if you order a test and it goes to waste, that's lost revenue for a practice like that. 13:56 Are the new molecular rapid tests, such as those for covid, flu or STIs are those changing the capabilities of a typical primary care practice, 14:06 I would say so in the sense that, you know, for example, there's a lot of clinics, you know, throughout the country that might focus on maybe LGBT, LGBTQ populations. They might focus on a more, you know, lower socio lower socioeconomic status area, where, in either of these locations, there might be more a higher prevalence of sexually transmitted diseases. And so it's important for these clinics to offer these type of rapid tests, because when it's when you're in a community, or if you have a patient population that seeks you out for a specific type of service, it's important to have those tests. And I think that in those type of areas, it is very important to have, you know, and definitely with covid and flu, you know, for high risk patients, you know, I think of my clinic, which has all ages, but. But I have lots of high risk older adults, and if I can diagnose them with covid or flu rapidly and get them started on a medicine to help reduce their risk of severe disease or hospitalization, that's something I want to do, as 15:15 you expect more reimbursement or value based care incentives for point of care diagnostics in the coming years, 15:23 I think so. You know, I not all institutions are part of value based contracts yet, but I know our organization is becoming very heavily involved in value based contracts, and I know that our reimbursement there's lots of opportunities for, you know, cost sharing and revenue sharing based on this. And so I think when it comes to having patients that are very well controlled for chronic conditions, diabetes, hypertension, there's a really good opportunity. You know, the easier you can, you know, collect someone's a 1c in their office, the more aggressive you're able to be to say, No, we need to continue thinking about lifestyle and medications to get this down. So I think overall, that's going to really help your value based reimbursements. When you're able to get more data on your patients. And there might be, you know, I think that because value based arrangements happen throughout different states and different ways that there might be opportunities for cost sharing and then revenue sharing based on the point of care testing, 16:28 okay, if you were advising a small practice that kind of feels overwhelmed by this, like, Wow, it sounds like, you know, there's a lot to do, a lot to keep track of what advice would you give them? 16:40 I would say, you know, I would start with, I would, I would look really closely at your patient population, and maybe look at all of the different diagnoses you make throughout a day. And if you're able to pull it out of an EHR, I would look and see what are the things that are most important to you. And I would start with one, you know, I think it's obviously, it could seem very intimidating, but, you know, it'd be easier to submit one, you know, CLI, a waiver, as opposed to 10 at once. And so what I would say is, I would go for one that you think best serves your patient population. And if, once you are able to do that, you learn the process. Your nurse feels comfortable managing the test, your team feels comfortable using the tests, then I'd look into what the next one is, and so forth and so forth from there. 17:29 Is there anything else about rapid testing that you'd like to mention that we haven't talked about, 17:34 an important thing to consider when determining if you need to offer rapid tests is also determining Do you have the ability to collect that test in a laboratory or in a radiology suite otherwise nearby? So for example, I work in a very large outpatient building, and we have a lab in our office, so patients are able to stop on the first floor on the way out to get their labs drawn. And so I feel comfortable that they're able to stop and get these things drawn same day, if I don't think it's a life threatening emergency, whereas, if you're in a rural location or just somewhere where there might not be a lab close by, then you do need to consider, you know, the higher value for point of care testing, right? Because if your patients aren't going to be able to make it to a lab. Maybe the closest lab is an hour away. Well, then, you know, asking patients to drive out there for these tests is definitely very different than asking them to stop on the first floor before they exit the door to have these things done. So I think that that would also have a large impact on wanting to have more or less point of care tests. In that sense, I also think that, like your practice, size can make a really big difference. So obviously, if you're a solo practice, you might have one or two practitioners. You know, paying for these things might not be feasible all the time for point of care testing. But if you're in an office that has 10, 1215, primary care doctors, such as a setting where I work in the volume we see is quite high. So we offer a lot of point of care testing, because we know that on any given day we're going to have a baby from one day old up to anybody 100 years old. And so we really got to offer that full gamut of testing to because we have such a high volume in such a wide variety of patients. 19:23 Yeah, I've never understood primary care. Seems to have to know the most about everything that gets paid the least and never makes sense to me. 19:32 In order talk, we can do another interview that day about that, if you want. Right, right? I think, luckily, I think the healthcare system is realizing the importance of prevention and really strong primary care. So I do see improvements in primary care reimbursements across the country, because I think that, as we know, you know, when you keep people healthy, that that's what reduces costs and also just improves lives of your community over time. 19:57 Very good. Any other thoughts i. 20:00 I don't think so great. Well. 20:03 Thank you so much. I really appreciate it. Once 20:14 again, that was a conversation between medical economics Managing Editor Todd schryock and Dr Daniel krajiek, a primary care physician with the Cleveland Clinic. My name is Lawson Latrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart, wherever you get your podcasts. Also, if you like the best stories that medical and physicians practice published delivered straight to your email six days of the week, subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin the trail. Medical economics and physicians practice are both members of the mjh Life Sciences family. Thank you. You.