By - August 08, 2023
When the Pathology Services team at University Health in San Antonio recognized that even the health system’s most specialized and experienced healthcare providers struggled to keep pace with the rapidly evolving role of genetics in medicine, they saw an opportunity for change. Understanding that a genetic counselor can play a vital role in streamlining laboratory services, Pathology Services added one to their team. Soon, the laboratory began seeing a solid return on their investment. It wasn’t long before Pathology Services saw the need to create an entirely new division: Genetics Specialty Services.
The laboratory genetic counselors don’t replace current laboratory professionals, and they don’t encroach on the work that laboratory professionals do. Instead, they work alongside pathology laboratories, helping ensure any genetic testing ordered is optimal for both the patient and the lab. The infusion of their subject matter expertise optimizes patient care, increases laboratory professionals’ productivity, and reduces the number of denied claims a laboratory faces. In the case of University Health in San Antonio, the team was so successful that they now advise other laboratories on how genetic counselors can help them too.
Critical Values spoke with Stephanie Whitehead, MBA, MPH, MLS (ASCP), Executive Director of Pathology Services at University Health and Megan Maxwell, MS, LCGC, Lead Laboratory Genetic Counselor of Pathology Services’ Genetics Specialty Services division at University Health. Mrs. Whitehead and Ms. Maxwell shared how they launched their genetic counseling division and the benefits that the program is already bringing to University Health.
Understanding that optimizing genetic test utilization would likely result in higher quality patient care and more effective use of laboratory resources, Pathology Services made the decision to invest in a laboratory genetic counselor.
Mrs. Whitehead recalls, “As the number of genetic test orders started to increase and become more complicated, the challenge of managing constant insurance denials and appeals became increasingly more challenging. So, we decided that investing in a laboratory-based genetic counselor would be an asset.”
Laboratory genetic counselors work closely with non-geneticist physicians, consulting on tests and reference laboratory selection, Mrs. Whitehead says. The genetics division also helps with insurance approvals and appeals.
University Health’s Genetics Specialty Services division helps keep genetic testing requests on track.
“All genetic test requests in the health system, both inpatient and outpatient, are funneled to us (i.e., the laboratory genetic counselors) for review,” Ms. Maxwell explains. “We then perform a thorough chart review to assess medical necessity, appropriateness, clinical utility, accuracy, etc. After our review, we collaborate with the ordering providers on test selection. Sometimes this can be as simple as introducing our preferred vendors’ version of the desired test. Other times we may recommend a more strategic alternative or superior methodology or another test altogether. On occasion, cancellation is the most appropriate recommendation. In other words, we work to ensure that the right test is performed for the right patient at the right time and for the right reasons.”
After test selection, Ms. Maxwell explains, the laboratory genetic counselors’ dedicated support staff, known as Genetics Operations Support Specialists, then handle most of the remaining logistics, such as:
Facilitating insurance authorization approvals
Scheduling patients for phlebotomies, buccal swabs, or skin biopsies as needed
Sometimes collecting specimens, particularly with inpatients
Completing test requisitions
Ensuring specimens are directed to intended labs and arrive safely
Monitoring for test complications or delayed results
Serving as liaisons for providers’ and reference laboratories’ non-clinical inquiries
Once tests results are available, the laboratory genetic counselors reenter the process to provide interpretation assistance to clinicians if pathogenic variants or variants of uncertain clinical significance are reported, or to reengage clinicians to recommend more testing if results are negative, per Ms. Maxwell.
When they started the division, Ms. Maxwell was the sole operator for the first two years. But as demand increased, so did their need to expand.
“Physicians started to trust, and ultimately, rely on Megan,” Mrs. Whitehead recalls. “So much so, that the volume became too much for one person.”
They brought on a support specialist to assist Ms. Maxwell. But it wasn’t long before they needed to expand even more.
“In June of last year (2022) we doubled in size, hiring a junior genetic counselor and a second Genetics Operations Support Specialist,” Ms. Maxwell says.
The group evolved into an official division of Pathology Services called Genetics Specialty Services. While “Genetic Counseling Services” may seem like a more intuitive title, unlike traditional genetic counseling which is performed in the clinical setting, genetic counseling in the laboratory setting does not involve patient contact or patient-provider counseling sessions.
“It was important to me to keep the word ‘counseling’ out of the title, because I didn’t want to further the misconception that we provide direct patient care, particularly since it’s such a common misconception,” Ms. Maxwell explains.
Hear from Ms. Maxwell and Mrs. Whitehead on adding a genetic counselor to University Health's laboratory services
The division has paid off many times over since its inception.
“Within the first year of hiring Megan, our data showed a drastic reduction in healthcare costs, improved patient care, and higher efficiency,” Mrs. Whitehead says.
When Ms. Maxwell was first brought on, Pathology Services was transitioning to a different EMR system, which helped make her changes easier to implement.
“This allowed me to build a utilization management workflow directly into it,” Ms. Maxwell says.
Mrs. Whitehead notes: “This really gave us an opportunity to build a solid and successful infrastructure that infuses the laboratory genetic services into the ordering process for clinicians.”
Since the implementation of this EMR-integrated approach, Ms. Maxwell has collected and presented data at national scientific meetings demonstrating that her utilization management workflow has tripled the health system’s diagnostic yield when compared to genetic testing outcomes prior to her hire.
“This means that more patients and families are walking away with meaningful answers and important information that often directly impact their own medical management or that of a family member,” Ms. Maxwell notes.
If your laboratory wants to start a similar division, be intentional during the hiring process
The initial hiring process was difficult to navigate because Pathology Services had never had a division like this before. But they learned a lot of lessons along the way.
“Because the health system had no real infrastructure…for something like this (which is not unusual), it would have to be built from the ground up,” Ms. Maxwell recalls. “That is quite a big ask—especially in a health system this size with so many moving parts—and would require extensive, highly specialized experience, even more niche than genetic counseling experience itself.”
This specialization isn’t something taught in school.
“Its success would be contingent on a working knowledge of things that just aren’t taught in grad school, like insurance capitation, institutional billing, medical coding, RFPs, compliance, cost recovery, cost avoidance, DRG payment, laboratory exclusivity, tiered pricing, business acumen, etc.” Ms. Maxwell says. “So, I can imagine that such a prospect may have been overwhelming for a number of applicants.”
Most of the people they interviewed wanted a patient-facing job, while this position was a non-patient support role, Mrs. Whitehead says.
While Ms. Maxwell was perfect for the job, she does have advice for other laboratories wanting to do the same. She suggests posting job openings on genetic counseling specific sites, like the National Society of Genetic Counselors, or a state chapter like the Texas Society of Genetic Counselors.
Another task was to introduce these new concepts to the system’s physicians and other allied health professionals in such a way as to foster trust and drive culture change. They first addressed this paradigm shift by giving Ms. Maxwell a retrospective role where she reviewed practices. Then they phased her into a more prospective role, Mrs. Whitehead says.
“The first year was an adjustment period, since the practitioners had historically operated totally independently,” Ms. Maxwell recalls. “Also, there’s just the general stigma that ‘utilization management’ is a more diplomatic way to say ‘obstructionist barrier.’ So, it took a little while to earn their trust. I found that the more diagnoses we helped make by increasing access and contributing our expertise—diagnoses that would not otherwise have been made—the more they truly believed that we were on the same team, and now many of them think of us as an indispensable resource to their practice.”
The future is bright for this field.
“The era of genomic medicine is here and it’s here to stay. Genetic tests will only become more complex, the number of genetic factors attributed to human disease will only continue to increase, and navigating these dynamics without the guidance of a trained genetics professional will become near impossible,” Ms. Maxwell says.
Ms. Maxwell considers the division to be an invaluable resource given the current shortage of people qualified to render clinical genetic counseling services.
“I view what we’ve accomplished here to be a sort of alternative service delivery model through which genetic counseling expertise can be extended to support more providers and touch more patients than would be achievable in a conventional clinical setting,” she says.
In many cases, Mrs. Whitehead would indeed recommend that other laboratories launch a similar service.
“Depending on your lab’s size, adding this service is worth the investment in the staff,” Mrs. Whitehead says.