Payment Matters: Understanding Payer Perspectives on Laboratory Stewardship.

Area of Science:

• Healthcare Systems Analysis
• Health Economics
• Clinical Laboratory Science

Background:

• The US healthcare system involves complex interactions between patients, providers, and payers.
• Differing perspectives among these stakeholders impact healthcare utilization, performance, and payment.
• Clinical laboratory testing is a key area where these differing perspectives are evident.

Purpose of the Study:

• To explore the divergent perspectives of patients, providers, and payers regarding clinical laboratory testing.
• To identify challenges in aligning stakeholder interests within the US healthcare system.
• To highlight opportunities for improved alignment in laboratory testing practices.

Main Methods:

• Analysis of stakeholder perspectives in the US healthcare system.
• Discussion of challenges related to differing expectations and potential for fraud, waste, and abuse.
• Examination of opportunities for alignment in clinical laboratory testing.

Main Results:

• Patients expect necessary and insured laboratory tests.
• Providers aim for standard of care without financial toxicity for patients or practices.
• Payers seek to balance customer needs with fair healthcare costs.
• Misalignment is exacerbated by opportunities for fraud, waste, and abuse.

Conclusions:

• Despite a fragmented and competitive US healthcare system, alignment among patients, providers, and payers is achievable.
• Opportunities exist to establish practices for reasonably priced, fairly distributed, and medically necessary laboratory testing.
• Collaborative efforts can lead to improved healthcare value and patient outcomes.