Vol. 24 • Issue 6 • Page 16
Going forward, healthcare organizations will be paid as a whole for keeping people healthy-for being effective in providing prompt and accurate diagnoses and for proactively monitoring and managing high-cost diseases. Rather than a focus on reimbursement per lab test, the lab’s future role lies in the support of a rapid, accurate diagnosis that becomes a part of the overall cost of doing business in healthcare. Therefore, if laboratories are no longer paid per test, but are a necessary function of getting proper and effective care, they must perform as efficiently and effectively as possible. As we continue to make positive changes in our healthcare delivery system, one of the most effective ways to do this is by eliminating waste and making sure the right tests are ordered-which is the goal of test utilization programs.
3 Areas of Focus
In focusing on test utilization, there are three main areas to think about and a multitude of reasons why laboratory tests are “misordered,” ranging from “that’s the way it’s always been done” to pressure from patients to order tests simply because they read about the test on the Internet. In a fee-for-service (FFS) environment, ðproviders are trained to order any and all tests and have been incentivized to order this way. In the new value-based models, ordering the right test at the right time will be the new framework for reimbursement.
Because of misaligned FFS incentives, our healthcare system is riddled with overutilization and unnecessary services. In a recent study undertaken by a group of neurosurgery residents at the University of California, San Francisco Medical Center, they found that by reducing five common lab tests by approximately 50 percentr. They saved more than $2 million dollars and saw no negative effects on patient care or safety. They determined that, whether the results of these tests were normal or abnormal, it made no difference in the patients’ care plan.1
Interestingly, according to a study performed at Beth Israel Deaconess Medical Center, they found that underutilization was just as prevalent as overutilization. In the study, 33 percent of tests were underutilized, meaning tests that would have benefited the patients should have been ordered, but were not.2 A vital component of early chronic disease care is the increased utilization of preventive screening tests to predict chronic conditions earlier, leading to better patient outcomes and reduction of healthcare costs associated with long term chronic disease.
Influence Order Selection
There is clear evidence that the way in which test options are presented can have an influence on which tests are selected. With the push toward Meaningful Use of certified EHRs, most facilities now have computerized provider order entry (CPOE) in place. By far, the best time to intervene and offer guidance toward best test orders is at the time the order is placed. Many EHRs have capabilities that support CPOE enhancement.
It Takes a Committee
Most facilities with in-depth test utilization efforts involve the use of laboratory utilization committees that include staff from various members of the healthcare team. The team shares the collective goal of promoting the highest quality, most cost-effective testing patterns. Any successful test utilization program will require input from multiple departments and effective collaboration with ordering clinicians. With committee support, the lab should be comfortable questioning test orders, suggesting more appropriate test choices and canceling inappropriate tests. Laboratorians have the knowledge and skill set to be instrumental in promoting better test utilization.
Unnecessary Test Combinations
Discuss with your ordering clinicians or test utilization committee scenarios where it does not make clinical sense to order two specific tests together. For example, it may not be necessary to order a particular test until you know the results of the initial test, creating an opportunity to offer a reflex testing option (e.g., TSH reflexing to FT4, GGT reflexing to ALKP). For certain diagnoses, there are tests that offer greater diagnostic accuracy, such as the CRP instead of the ESR for inflammation or the Troponin instead of the CK-MB for myocardial infarction. Or, testing may only be recommended for ðspecific diagnoses (e.g., 1,25-Dihydroxy vitamin D for renal failure patients).3
Laboratory-driven algorithms, where clinicians order a testing cascade and initial ðlaboratory results drive subsequent test selection, allow the laboratory to handle the entire cascade process with no further input from the provider. Proper implementation of testing algorithms that proceed through a logical testing sequence based on initial results can eliminate providers having to choose from an overwhelming menu of hundreds of available tests and can be instrumental in making sure that only the appropriate tests are ordered.4 Take, for example, a thyroid cascade that starts with a TSH. If the TSH is abnormal, a FT4 is ordered, then based on the FT4 result, a reflex FT3 or anti-TPO is ordered, ensuring that only necessary tests are being performed.
One data tool that can benefit a test utilization plan is an internal ordering variation analysis, in which provider ordering patterns by diagnosis are reviewed in comparison to recommended testing, with an eye on associated costs and outcomes. It is not meant to point out that any specific provider is ordering incorrectly, but simply to reveal outliers that can be looked at as an area for improvement. For example, review your individual physician ordering patterns for diabetes, comparing ordering patterns among the group and with recommendations for diabetic monitoring from the American Diabetes Association. Once the analysis is performed and shared, providers and laboratorians can use published, recommended guidelines to establish and promote their internal best laboratory practice order sets for specific diagnoses and incorporate these into their CPOE process to make the recommendations clear to providers at the time of order.
A testing formulary, in the simplest definition, is a list of tests available for a ðphysician to order. Formularies are often implemented in an effort to control inappropriate ordering of expensive, esoteric lab tests. With a formulary in place, the laboratory, in association with the test utilization committee, can eliminate obsolete tests (e.g., bleeding times), set frequency recommendations on certain tests (such as genetic tests that should be ordered only once per patient), and/or implement ordering tiers in which certain tests require pathologist or medical director approval.
If good medical practice is the focus, then efforts to monitor and perfect test utilization will have longevity and will be successful in our changing healthcare environment. The overriding goal in regards to clinical testing is to do the right test on the right patient at the right time and do it accurately while being cognizant of costs and resources. In today’s healthcare environment, this concept not only speaks to the importance of having a well-thought-out test utilization process, but is a laboratory’s formula for being a partner in a value-based or outcome-based ACO-type reimbursement environment.4
Kim Futrell is products marketing manager, Orchard Software Corporation.
1. Commins J. Residents save $2M by eliminating needless lab tests. HealthLeaders Media. Oct. 2013. Accessed at: www.healthleadersmedia.com/page-1/HEP-297529/Residents-Save-2M-By-Eliminating-Needless-Lab-Tests
2. Jones K. Three in 10 laboratory blood tests unnecessary. General Health News. Nov. 2013. Accessed at: www.medindia.net/news/three-in-10-laboratory-blood-tests-unnecessary-127916-1.htm.
3. Brimhall B, MD, PhD, and Johnson C. Executive War College. Leveraging Information in New Ways to Benefit Healthcare in a Non-Fee-for-Service Environment. April 2014.
4. Hanson CA, MD. Laboratory Test Utilization Strategies. Mayo Clinic Mayo Medical Laboratories. Accessed at: www.mayomedicallaboratories.com/articles/hot-topic/2013/01-01-test-utilization-strategies-pt-1/index.html.