1. © The Children's Mercy Hospital, 2016 A Children’s Hospital Perspective Lee Zellmer, MS, CGC Senior Laboratory Genetic Counselor Children’s Mercy Hospital Genetic Test Utilization Management

2. Children’s Mercy Hospital   Not-for-profit pediatric institution   Seven Kansas City metropolitan locations in Missouri and Kansas, as well as nine towns outside the metropolitan area   >14,000 annual inpatient admissions   >200,000 annual outpatient specialty visits   50% of patients are covered by Medicaid   CMH Laboratory billed >1M procedures FY2015, >$140M gross revenue 2

3. CMH Clinical Genetics Laboratories   Five subsections: Cytogenetics, Microarray, Molecular, Genome, and Genetic Sendouts   FY 2015 – –Molecular, Genome, and Genetic Send-outs processed >11K samples – –$7.4M gross revenue.   FY2012 – –Laboratory Genetic Counselor position was created to manage utilization and improve workflow 3

4. Utilization Management (UM)   Multifaceted Approach – –Genetic Counselor Review and Modification of Orders   Identify errors in test ordering   Guide providers toward most appropriate test   Design customized panels 4

5. CY 2015 Average Cost/Test 5

6. Multifaceted approach to UM   Algorithm development – –Previous successes in CMH General Lab (i.e., thyroid, celiac) – –First Genetic testing algorithm - new autism diagnosis   Eliminated high resolution chromosome analysis   Step 1 - Microarray (SNP+oligo) as first step   Step 2 - Reflex to Fragile X only if above is negative   Step 3 - NGS panel to be implemented 6

7. Multifaceted approach to UM   EMR test display – test name followed by $s relative to price – –Not effective in reducing ordering   Software solutions – –Online ordering/resulting reduces employee time and errors – –Use online tools to compare tests and prices across reference labs – –Utilization tracking 7

8. UM Case Example 8

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10. Multifaceted approach to UM   Borrow successful ideas from your friends – –PLUGS (Pediatric Lab Utilization Guidance Service) – –NSGC Test Utilization Management Special Interest Sub-Group   Reference Lab Service Agreements – –Discounted pricing and free shipping   Preauthorization   Reference lab direct billing when available and appropriate 10

11. Using Reference Lab billing wisely 11

12. Multifaceted approach to UM   Provider report cards – –Reports to individual providers with volume and cost – –Summary report to department Chief – –“Interesting” but no major changes to ordering 12

13. Collaboration   Periodic Review of Send-out Tests – –Committee of Lab Directors and Administrators meet quarterly – –Review test volumes, cost/test and test methodologies annually – –Some tests brought in-house. Others moved to a different reference laboratory, primarily for cost-saving purposes.   Hospital Utilization Committee – –Lab Directors, hospital physicians and Quality Improvement employees meet monthly with goal to identify opportunities which will improve test utilization. 13

14. Lessons learned   There is no one-size-fits-all approach to every lab or institution (but a Lab GC is always a good start)   It will almost always take more than one approach   Don’t be afraid to try something new   Use available tools/software to streamline your processes   Collaborate with both internal and external groups 14

15. Acknowledgements   CMH Clinical Laboratories and Clinical Genetics Laboratories – –Toni Sheffer, MBA, MT(ASCP), Administrative Director Laboratory Services – –Debra Faller, MBA, MT(ASCP), Operations Manager, CPGM – –Carol Saunders, PhD, FACMG, Clinical Director, CPGM   NextGxDx – –Dan Kaupke, Director of Customer Operations – –Cheryl Hess, MS, CGC 15