Q&A: EviCore’s Dr. Lon Castle on Evidence-Based Lab Testing’s Ability to Improve Patient Outcomes & Reduce Costs
Dr. Lon Castle is EviCore’s Chief Medical Officer for Molecular Genetics and Personalized Medicine. He sat down with us to discuss the rapidly evolving, enormously complex world of laboratory testing and why it is so important for patients to get the right lab test to meet their clinical needs.
Why is EviCore’s Laboratory Management solution important?
There are three main issues EviCore is trying to address. First, there are thousands of lab tests on the market, but many of them provide little value to patients. To give you some perspective, there are over 160,000 genetic tests currently available [1], with one or two new tests launched every day. These tests are often made available before the necessary clinical studies have demonstrated how they impact patient care, so we do not know what value they really provide.
Second, even potentially helpful tests are not always used in ways that align with patients’ clinical needs. For example, almost a third of genetic tests ordered do not meet current evidence-based medical guidelines, meaning they are unlikely to benefit patients [2].
Finally, often lab tests are not billed correctly. Around 700 CPT® codes are used to represent the 160,000+ molecular and genomic tests on the market today. Most lab claims include more than one CPT code when billing for these tests, and many of those CPT codes are not transparent about the exact test being performed. Overbilling occurs frequently and can exceed $10,000 for a single test [3]!
Our Laboratory Management solution ensures patients get lab testing that is aligned with the latest medical science, and ensures clients are only paying appropriate claims, which helps to lower premiums and to reduce out-of-pocket costs for everyone.
How do inappropriate lab tests negatively impact patients?
Helping patients get evidence-based lab tests is critical because the results typically inform next steps. Lab tests influence an enormous two-thirds of clinical decisions [4], which means getting the wrong test can lead to a cascade of unnecessary additional tests and referrals, leading to potentially incorrect or even harmful patient care.
The human and financial costs for these low-value tests also add up fast. For example, doctors often order targeted genetic testing to help guide their treatment decisions. However, labs are increasingly marketing more expensive panel testing, which tests several genes at once, including genes and conditions that go beyond what the patient’s doctor needs to evaluate. Often, the report of these extensive panel tests will include “variants of unknown significance” on genes that were not originally targeted. This unhelpful result may lead to patient anxiety, incorrect diagnoses, unnecessary costs and further testing that does not impact the patient’s health outcomes.
How does EviCore make decisions in the Laboratory Management solution?
EviCore wants to focus where it can make the biggest difference, so we use our evidence-based clinical guidelines to determine the appropriateness of a strategic set of highly misused, high-cost tests. Our guidelines are based on information from medical societies like the American College of Medical Genetics and Genomics and the National Comprehensive Cancer Network®, as well as recently published, peer-reviewed medical studies. These guidelines are created and maintained by EviCore specialist physicians and genetic counselors, reviewed by external experts, updated at least annually, and available to anyone on our website.
EviCore also relies on an outstanding clinical team, which includes nearly 500 board-certified physicians. Other experts on our team include genetic counselors and more than 1,200 nurses and additional clinicians with experience across multiple specialties. Only an EviCore physician can make the determination that a request does not meet the evidence-based guidelines. For Laboratory Management, our physicians are board-certified in medical genetics, oncology or pathology.
Here is a quick summary of the various ways EviCore engages with patients, providers, and payers through the Laboratory Management solution:
- Most of the time, the lab—not the ordering provider—initiates any required prior authorization requests. That means there is minimal administrative burden to physicians to ensure their patients get the best possible lab tests to facilitate the correct diagnosis and appropriate treatment.
- For higher-volume, lower-cost lab tests, EviCore uses proprietary, post-service claim edits through our Claims Studio. This process makes sure payers are only paying for appropriate tests. It requires no time from the physician and has no impact on the patient’s speedy access to testing.
- EviCore also has our SmartChoice LabSM solution, which improves the lab testing process for providers and patients. For providers, SmartChoice Lab provides a test database with information on the most used molecular tests, including which tests are available at each lab, health-plan-specific costs, and which labs are in-network for each health plan. For patients, SmartChoice Lab helps guide them to in-network labs, which means lower out-of-pocket costs.
You can learn more about EviCore’s Laboratory Management solution on our website.
Resources:
[1] The Genetic Testing Unit (GTU): A unique identifier for every genetic test, accessible royalty-free by all. Concert Genetics. June 2021, v1.0.
[2] Miller C. Using genetic counselors to decrease errors in test ordering. Clin Lab News. 2012. Confirmed by internal data.
[3] EviCore claims experience
[4] Health Affairs, “The Emerging Use By Commercial Payers Of Third-Party Lab Benefit Managers For Genetic Testing,” 23 Oct. 2019. Accessed 25 Jul 2022. https://www.healthaffairs.org/do/10.1377/forefront.20191021.563154/full/