We talk a lot about how health reform will place a bigger emphasis on preventative care, managing chronic conditions and paying providers based on the quality of care.  So much of this means providing necessary medical screenings and diagnostic tests to improve the quality of care. But who will be charged with the task of screening us for cancer?  Who will run the CBC (complete blood count) to help a doctor diagnose fatigue or an infection?

Labs. Pathologists. The people in the white coats that shake the test tubes, look under microscopes and mysteriously see things regular people don't see. I spoke at a conference today where more than 1,000 of them were learning about a different mystery -- health reform.

The association that represents clinical labs in Washington (American Clinical Laboratory Association) is fond of saying that lab tests represent only 1.7 percent of Medicare spending but are essential to 70 percent of all clinical decisions. I have no idea if that is an accurate representation, but it is striking what a big player labs are in our health system and yet we only just heard from them recently -- and even then you had to be paying pretty close attention.

Last week, when Senate Finance Committee Chairman Baucus released his health reform proposal, it included a fee for clinical labs in the amount of $750 million a year. The labs launched a serious effort to eliminate it -- and won -- just this past Tuesday. Instead of a fee, the labs' Medicare payment rate schedule will be reduced by 1.75 percent for a few years and be subject to a full productivity adjustment to account for increased efficiencies. This was certainly a hot topic among the participants -- but so was frustration with the unknown about health care reform.

The Lab Institute had a dazzling array of speakers -- Newt Gingrich, House Ways and Means Health Subcommittee Chair Pete Stark, Ceci Connelly -- but I found the audience partly overwhelmed and partly frustrated with the lack of information specifically for labs. And I can't blame them for either, but I am now a little concerned about the latter. Delivery system reforms will cause real disruption in the industry, much of it positive -- but uncertainty is uncomfortable in any event. We don't know how quality measurements will put new pressures on labs to turn around what will probably be an incredible uptick in tests and screenings. We don't know how the new sharing of lab results with enough providers to eliminate unnecessary duplication of tests will affect labs -- will they be penalized directly for repeating a test? How will they be expected to know about the prior lab test that they are not supposed to repeat? How will they be paid if an accountable care organization or medical team is ordering tests -- and how do they fit into a "paying for performance" reimbursement scheme? Comparative effectiveness certainly has them concerned as well -- could a declaration by a comparative effectiveness institute decrease the number of certain types of tests being ordered to such an extent that some labs must substantially change their business model? The lab industry is full of subspecialties, so this seems entirely possible.

My presentation was supposed to describe how President Obama's approach to health care regulation differs from the prior administration's. We all had a good laugh about that...  that was the one obvious topic of the day.

The Lewin Group is releasing a report soon that seems to address this quiet giant in the room: "The Value of Laboratory Screening and Diagnostic Tests for Prevention and Health Care Improvement." We will check in again after we hear more about that.