How labs are taming test utilization

Anne Paxton

June 2013—It might be a legacy of the economic downturn. Perhaps it is the prospect of increased capitation under health care reform. Or it could be the stunning price tags of some new tests on the clinical laboratory test menu. Whatever the cause, health systems across the country are increasingly moving beyond education and retrospective review to more specific, targeted, prospective controls on test utilization.

One of the most dramatic factors driving the trend is the number of new proprietary and genetic tests with four-figure prices. The $60 to $70 billion cost of clinical and anatomic pathology laboratory tests—which makes up four percent of the total U.S. health care tab—is on pace to double in three or four years. And ballooning molecular and genetic testing outlays are a major reason.
Partly as a result, traditionally modest laboratory costs are collectively starting to form a flashing amber light on the health care system dashboard, drawing the same kind of attention to test ordering that radiologists have long known in diagnostic imaging. “When a test costs $200, it’s a different scenario than when a test costs $5,000,” says Curtis A. Hanson, MD, professor of laboratory medicine and pathology at Mayo Clinic, Rochester, Minn.

At Mayo, for example, pressure from above and below recently made test utilization management a priority, Dr. Hanson says. “In hematopathology, starting three or four years ago, we were seeing a lot of requests for testing from clinicians that just didn’t make sense. It reflected both a gap in knowledge and a problem with our processes that didn’t encourage the right kind of testing.”

Then, about two years ago, Mayo as a whole started grappling with finding that sweet spot of controlling expenses and providing quality care, he says, and asking how it could use all its resources most effectively. “Mayo started questioning whether physicians were ordering the right tests, and were we really getting the right clinical return from our laboratory testing dollars.” Test utilization became part of a general program of “practice optimization.”

His Department of Laboratory Medicine and Pathology chose to pursue a four-pronged approach to test utilization. “One is developing a test formulary. The second is reducing unnecessary testing in hospital patients. Third, implementing algorithm and guideline testing across the practice, whether that be low-volume, high-cost tests that can be honed by pathologists or genetic counselors, or algorithms for cascade testing that a clinician may order on a higher scale. And finally, reducing blood product utilization, obviously a high-cost area for all kinds of practices.”

Mayo shies from using the term “formulary,” but is now forming a committee to categorize tests according to whether they need review, Dr. Hanson says. Algorithm or guideline testing, however, has already had a measurable impact on utilization in hematopathology, where the emphasis has been on chromosome analysis, FISH testing, and a variety of molecular testing. (“Lab teams up to curb unneeded testing,” CAP TODAY, December 2012.)

“We’re finding the algorithms are helping, most definitely.” Having pathologists who are willing and able to work with their clinical colleagues in establishing the algorithm and guideline approaches has been an important feature of Mayo’s test utilization program, he adds.

But there is still an art to medicine, Dr. Hanson cautions, and when one of his clinical colleagues at Mayo wants a test, in certain situations the laboratory will still agree to it even if it’s thought to be unnecessary. “I think standardization attempts have typically failed when people follow algorithms and guidelines like standard operating procedures that must be followed every single time. Standardization must be considered all the time, but not necessarily used all the time. In medicine, you really need to think about the usual patient versus the special patient. For the most part, the usual or routine patient accounts for 80 percent of what we do. Physicians tend to remember the 20 percent because that’s where 80 percent of their effort goes. But standardization needs to focus on the 80 percent—the usual.”

“It’s easy to point fingers at clinicians and say why are you ordering all this stuff?” But it’s impossible for clinicians to know all the performance and clinical characteristics of all the tests they are going to order, Dr. Hanson notes. “When clinicians see a patient, they have a differential list of possible diagnoses in their head and they think diagnosis A is the most likely, but they feel compelled to do the testing to rule out diseases B, C, and D in this process.”

“They may have to draw blood at that point in time because it may be the only time they have the opportunity. They can’t go back once they start treating or if the patient doesn’t come back to the office, so if they don’t order all the testing then, they may have missed their chance.” Clinicians may have no choice but to order excess testing, if the lab doesn’t have a process in place that allows sequential testing. So laboratories are part of the “problem”—and the solution.

There is another important benefit to test utilization management, in Dr. Hanson’s view. “Our genetic and molecular tests are growing rapidly and we need to keep our hands around that kind of expense. But that overall cost is still a small percent of the total. What I’ve seen by doing this utilization management in the lab is that it helps lead the change of culture across the entire practice of how you can practice more effective and efficient medicine.”

As the health care system gets more into value-based payment, he adds, “If we can’t show value for what we do, then labs will just get further commoditized. And we’ll be the last person around the table to get reimbursed. When you start pushing habits of effectively choosing the right test for patients in institutions, it begins to raise more global questions as far as utilization of other health care resources. And that’s how we can provide leadership within our practices.”

Based on research at his institution, Seattle Children’s Hospital, Michael Astion, MD, PhD, says utilization is a central problem in laboratory medicine. “In practice, you come to realize that the biggest errors in laboratory medicine that harm patients are doctors ordering the wrong tests, doctors misinterpreting laboratory results, and doctors failing to retrieve lab tests they’ve ordered,” says Dr. Astion, division chief of laboratory medicine at Seattle Children’s and professor of laboratory medicine at the University of Washington.

In research funded by the insurance industry, Seattle Children’s has looked at databases of millions of people who have had lab tests. “We’ve been able to analyze what tests they’ve had, how frequently, the medical necessity codes attached. And there are certain things you can see very easily,” he says. There are seven domains of abuse—some easy to detect, others not so easy.

For example, some clinicians order IgG allergy testing, a test with no evidence base to justify it but with CPT codes listed for it and some insurers paying for it. “That’s the low hanging fruit, where there is complete waste.” Other tests may be ordered flatly against guidelines, such as a PSA test for 90-year-olds on a well-patient screen, or an ANA test on 2.5 percent of patients in a database, even though lupus and related systemic rheumatic diseases occur in maybe five people in a thousand.

“So there is a lot of testing for low-prevalence disease,” Dr. Astion says. In part, patients themselves drive this over-testing because they Google their symptoms and many different diseases, both common and uncommon, come up. “That’s why thyroid testing is so overdone now. It’s one of the most popular tests in America because every conceivable symptom is related to thyroid.”

Fee-for-service medical labs still have tremendous incentives to promote over-testing in ambulatory patients because more testing equals more money, and many physicians simply think more is better. “Some [labs] try to offer these gigantic panels as part of the special services they provide. For example, physicians are supposed to screen for cardiovascular disease risk, right? But some get talked into ordering much larger panels, 10 times the price of a standard lipid panel, and the labs make it part of their marketing strategy that they do much more comprehensive testing.”

Similarly, instead of a focused workup after taking a detailed exposure history of six, 10, or 12 allergens, a doctor may order 25 to 100 allergens—most of which will be meaningless and some of which will produce false-positives.

Because of reimbursement through DRGs, “we’ve had a big motivation to decrease testing in the inpatient setting for a long time,” Dr. Astion notes. Most places have eliminated the use of CK-MB for myocardial infarction except in special cases, for example, and use troponin instead. But various techniques are available for managing utilization apart from just taking a test off the menu.

“You can make something hard to order, say, by requiring three or four button clicks for CK-MB while troponin pops right up. You can just not allow people to order a test, or you can put it under management and require active review by a pathologist or specialist. For example, you can restrict the privileges of primary care practitioners so they can’t order special very expensive genetic tests; only a geneticist would be allowed to order them.”

Utilization “report cards” can also be useful, Dr. Astion says. “You can give feedback to physicians about their orders relative to their peers and relative to guidelines. That’s very effective. And with electronic reminders on the CPOE [computerized physician order entry], when you order certain things you might get a message saying, ‘That’s an unusual order. Here’s what is recommended.’”

The test-ordering system can include decision support options, which the physician can click to receive an ICU template, or care pathway, for a condition or disease. “In our system we call them ‘power plans,’ where you click on a few buttons and the template includes all the orders commonly needed. Then you can see how if it’s not on that plan, it’s not likely to get ordered.”

Generally, Dr. Astion says, “you make it hard to order things you don’t want, and easy to order things you do want. You make it easy to turn off standing orders on patients and hard to turn them on, because they’re rarely useful. You put in detection systems to detect duplicate orders.”

Seattle Children’s program may be best known for putting genetic tests under a utilization management plan, he says. “Any genetic test above $1,000 has to be reviewed and approved, and we have a process for that. It’s screened by a genetic counselor, an employee of the laboratory, for medical necessity, and that counselor works with the clinicians to move the order forward or modify it, usually in a downward direction. We find 25 percent of the time under this system, either the doctor cancels or modifies it downward.”

The system was developed because of patient complaints about their out-of-pocket expenses for genetic tests, Dr. Astion adds. “In the old days, when tests were less expensive and insurance coverage was better, you just ordered tests and patients usually did not speak up about the costs. Now, the physician may say, ‘I don’t think this test is going to change the child’s diagnosis or treatment but it may give you an answer on exactly the genetic problem your kid has,’ and the parent can make a more informed decision. If, because of limited insurance coverage, it’s going to cost $1,000 out-of-pocket, do they really want that test?”

Evidence-based medicine has steadily become a much more routine part of practice, Dr. Astion says. “There is a change happening. With standard clinical care pathways, when a patient comes in with a known syndrome or relatively uncomplicated cases of most common problems—for example, a patient admitted for diabetic ketoacidosis—they’re put on a care pathway that everybody agrees to. They get certain tests, certain imaging, certain medication protocols or admission to the CICU, whatever it is, but all doctors have to follow that care pathway, and if they’re going off it, there has to be good reason for it.”

Paradoxically, a remarkable outcome of doing standard work is that you gather less data, he says. “Essentially there have never been more lab tests available, for example, and there have never been fewer recommended for screening. Twenty-five years ago, you were going to a doctor and they would do a big chemistry panel for sure, but not now. We used to image the majority of patients with back pain and now we image very few. It’s the quality of information that the clinical standard work makes you focus on. “