Payment Matters: Understanding Payer Perspectives on Laboratory Stewardship

The US healthcare system is complex and includes a number of entities and systems that provide services to patients and to pay for them. While improving health and well-being are accepted goals of healthcare, the 3 stakeholder groups relevant to healthcare-patients, providers, and payers-often have different perspectives on how care should be utilized, performed, and paid for. These differing perspectives are discussed as they relate to clinical laboratory testing.

Patients expect that the laboratory tests performed on them are necessary and covered by their insurance. Providers expect that they will be able to carry out what they believe to be the standard of care for their patients, and they furthermore expect that the systems in place from laboratories and payers will support their efforts without exposing their patients or their practice to financial toxicity. Payers, finally, desire to meet the needs of their customers, who are both patients as well as employers, by providing access to necessary healthcare services at a fair cost. Aligning these desires and perspectives is challenging in a fragmented healthcare system, and in the face of substantial opportunities for secondary gain from disreputable practices such as fraud, waste, and abuse.

Within the constraints of a US healthcare system based on competition and susceptible to misalignment, opportunities nonetheless exist for all relevant stakeholders in the laboratory testing space (patients, providers, and payers) to align and agree on practices that provide reasonably priced, fairly distributed, and medically necessary healthcare.