A Collaborative Climate Fosters Creativity, Boosts Value, and Cuts Costs

On October 1, 2017, Partners HealthCare announced a plan to cut costs by $600 million within three years. The plan (“Partners 2.0”) will more fully integrate the 11 hospitals in its network, which includes Massachusetts General Hospital, Brigham and Women’s Hospital, and Newton-Wellesley Hospital (NWH), a 300-bed community-based teaching hospital with a 14-member pathology group where Michael J. Misialek, MD, FCAP, is associate chair of pathology.

Partners 2.0 envisions collaborative problem solving that reaches across traditional departments, institutions, and administrative levels. The theory is that when more people engage more closely in enterprising ways, one change will lead to another. The outcome should be a more tightly integrated network that makes it easier to share resources of every kind and encourages creative thinking about the best ways to provide economical, efficient, world-class, patient-centered care.

Change at this scale doesn’t drop from the top; it grows from the culture (Or, as Dr. Misialek puts it, “It’s just how we do things here.”) So this story doesn’t begin with the 2017 announcement of Partners 2.0; it begins with a tradition of transparency, teamwork, and flexibility.

A cultural preference for change

Recently, the NWH revenue cycle operations manager, Eugenia Lenz, COC, CT(ASCP), remembered when her boss determined that the complexities of laboratory billing justified a dedicated team. A group of two has since grown to five staff members, who still bill and code but also mine the data for opportunities to refine processes and reduce costs.

When such an opportunity pokes its nose through the mound of metrics, the billing team most often calls Dr. Misialek. He carries the ball on the laboratory side, identifying any clinical drawbacks and talking with his partners about how to approach it. A few examples follow:

• At the start of FY2013, the NWH laboratory billing team added a step in its protocol for managing medical necessity payment denials. When a denial came back, the billing staff would call the ordering physician to ask if there were additional diagnoses for a possible appeal. A year later, medical necessity denial write-offs came in 26% below those in FY2012, saving $900,000.
• When Ms. Lenz’s group proposed that pathologists review orders for send-out tests that cost more than $1,000, it soon became clear that the best way to cut the cost of send-out tests was to think twice before ordering them. That approach worked so well that the triggering price tag for pathologist review gradually dropped to where it is now: $200.
• Norovirus polymerase chain reaction (PCR) testing on stool samples was a costly send-out, and when results are positive, supportive care is the only treatment option. Today, when these orders come in, a member of the laboratory billing team will contact Dr. Misialek, who will reach out to the ordering clinician or ask the appropriate colleague to do so. The two physicians discuss the cost of the test and the nature of treatment when results are positive. The clinician often decides not to pursue testing.
• In FY2016, the high volume, relatively high costs, and often unsuccessful reimbursement for PCR send-out testing for tick-borne diseases anaplasmosis and babesiosis approached the top of the hospital's reference laboratory testing expenses. Pathologists, other laboratory leaders, Ms. Lenz, and members of the information technology department came up with a plan to encourage appropriate utilization and created metrics to gauge progress. Members of the department of infectious diseases and neighboring academic medical centers helped them write a tick-borne disease testing algorithm. In part, the algorithm supported parasite blood smear review as a less costly alternative to PCR testing for babesiosis. Clinicians and departments ordering the highest volume of PCR tests were introduced to the algorithm first via an education campaign where pathologists went to departmental service meetings. The campaign also covered symptomatology, exposure risk, and other laboratory values that help to drive the decision to test, stressing that most asymptomatic patients should not be tested. When pathologists instituted a proactive consultation service for questionable orders based on the test algorithm, unnecessary PCR orders dropped precipitously. These and other interventions translated to an initial 36% drop in PCR utilization.

The laboratory team at Newton-Wellesley has reduced waste, cost, and unnecessary testing by initiating a doctor-to-doctor conversation when testing may not be useful or next steps are unclear. Now, when there are new ideas from the laboratory billing team, Dr. Misialek and his partners call the relevant department and ask if they can come to the next pod meeting so they can talk about it.

Conclusion

Partners 2.0 is about connecting fiscal responsibility to patient care that is humane, purposeful, and scientifically sound. To that end, NWH pathologists have been reporting on ideas from the laboratory at a variety of medical staff meetings and otherwise taking care to see that everyone is in the loop. Good communication will generate more solutions that are efficient, effective, and truly patient centric. Or, as Ms. Lenz would say, sometimes it comes down to asking, “If it won’t impact treatment, then why are we doing it?”

Durable change grows from the culture. It’s just how they do things there.

Postscript

Shortly after interviewing for this article, Ms. Lenz died suddenly. The NWH laboratory team sorely misses her leadership, kindness, and uncanny ability to see the message in the metrics.