How labs are taming test utilization

The incentives to do utilization management are, if anything, even stronger with send-out tests, Dr. Astion says. “Even though we pass the charge through to patients and mark it up, we often do not get back what we’ve had to pay. For example, I have to pay one diagnostics company $2,000 on average and I might recover $1,300, because they might have a patent and my insurance company won’t pay that. In the case of Children’s, half of our patients are on Medicaid, so I’m going to get somewhere between zero and $50. So we just don’t recover our costs.”

Seattle Children’s focuses on the more expensive send-out tests, which tend to be rare tests. “And because they’re rare, physicians make more mistakes with them because they’re not ordering them every day. In addition, they are less likely to be retrieved; they take a long time to come back so you forget about them in your list of things you think the patient has.”

Preventing repetition of genetic tests is another productive measure, Dr. Astion says. Even if a genetic test was done seven years ago, it usually shouldn’t be repeated, because the result won’t change. But it’s difficult for most doctors to look back that far in a detailed medical record. Now, “we’re taking a deeper dive in the EMR,” he says. “It takes time but it’s worth it. On average, we save $437 per requisition under utilization management. Even though you’re canceling 11 percent and modifying 14 percent, the one you cancel might be a $3,000 test, so that pays for the 75 percent that go through.”

Clinicians need to understand that the laboratory has gotten a pass from insurance companies because it’s not as big a driver of health care costs, Dr. Astion believes. “But once you have a $1,000 test, lab tests become expensive items, like radiology scans which have been under utilization review a long time. Insurance companies start to take notice and so does the hospital. And that’s what is happening and the reason why people are talking about lab utilization.”

The Seattle Children’s Hospital program has been rolled out nationally and picked up as a toolkit by other children’s hospitals, under the name “Pediatric Laboratory Utilization Guidance Service,” Dr. Astion says, noting that more information can be found at www.schplugs.org. “It’s basically to help children’s hospitals or the pediatric component of any health system order tests better on kids.”

Focused attention to utilization will be a key component of the $5 million that the clinical laboratory at Intermountain Healthcare intends to save over the next five years, as part of an ambitious cost-cutting effort across the health system, says Stephen Mikkelsen, MS, MT(ASCP), laboratory services operations director of the Salt Lake City health system. But Intermountain is not opting for red flags or straight-up ordering curbs. Rather, Mikkelsen describes a low-key, persuasion-based model for getting physicians to see the merits of managing utilization.

Mikkelsen works with every clinical program at Intermountain to scrutinize test use, and he finds plenty of room for improvement. The current recommendations for prenatal testing of the American College of Obstetricians and Gynecologists, for example, “are quite a lot more limited than what doctors are ordering,”

Mikkelsen says. “We looked across the system and the ordering patterns were all over the map, so I met with the clinical program director and asked why.”

“We’re starting to have more and more conversations with doctors about their panels, versus just being this place in the basement that sends back results.”

The laboratory is not a gatekeeper, Mikkelsen stresses. “There’s no way the laboratory can tell doctors what they may or may not order. If you just come up and say, ‘This is what ACOG recommends,’ that doesn’t work. But what we can do, with evidence-based medicine, is have them look at the tests ordered and see how they have affected their patients’ outcomes post-delivery. You share it. You say, ‘This is what we’re seeing, here’s what your colleagues are doing.’ If you can show the tests were ordered but had no effect on outcomes, you can help doctors draw the conclusions you want with just the data.”

The laboratory achieved even wider impact by meeting with the cardiology department about the older, nonspecific cardiac markers. “You can pull patient charts for the last several years and review the data and see the old markers aren’t clinically relevant,” he says, adding that the cardiology department has agreed to no longer order CK-MB and CK. Mikkelsen estimates the system will save $1.2 million this year by eliminating just those two tests. Using similar retrospective peer reviews, providing surgeons with comparative data showing how much blood they were ordering versus their colleagues’ orders, last year Intermountain saved $460,000 in blood products.

Intermountain has already made a name for itself in cost-effectiveness, with its quality improvement program cited in the Institute of Medicine’s 2012 report “Best Care at Lower Cost,” Mikkelsen says, and Brent James, MD, executive director of Intermountain’s Institute for Health Care Delivery Research, has helped hospitals nationwide shift their focus to outcomes. “He has a course that people attend from all over the country, to learn how to look at their existing processes and how to improve them using evidence-based medicine.”

The laboratory, Mikkelsen believes, can bring a fresh set of eyes to test ordering and help clinicians make a course correction. Sometimes a few simple questions are enough for the laboratory to have a dramatic impact. After a patient walked into Mikkelsen’s corporate office with a concern about how to pay for the 92 tests her doctor had ordered for her, Mikkelsen asked her permission to get the doctor on the phone. He found out the physician wasn’t sure what he was looking for and ordered some of everything to see if a result would be abnormal.

“So we walked through what he was trying to rule in and rule out, and we got the test order down to just a few tests.” The next day the doctor called back. “He said, ‘That was a really valuable conversation to have. There are a lot of these tests and I’m not sure what we should be ordering. It never dawned on me that we could call you or somebody in the lab and have this conversation.’”

For its first test of whether prospective actions to intervene at the time of ordering could reduce overuse of tests, the Veterans Affairs Connecticut Healthcare System decided to focus on the 18,000 to 20,000 tests a year it sends out to reference laboratories, says Christopher A. Tormey, MD, assistant professor of laboratory medicine, Yale University School of Medicine, the major academic affiliate of VA Connecticut.

The VA took a two-tiered approach to send-outs: prospective auditing and a prospective laboratory formulary. “In the last two or three years, we’ve been experimenting with taking two or three tests out of the test menu, and working with our specialized clinicians in oncology and other services to drill down and make sure there’s a second set of eyes looking at the test request before it goes out the door,” Dr. Tormey says.

For some tests, the VA pathology and laboratory medicine service obtained administrative approval for test cancellation, typically based on evidence that test results would have no impact on patients. The most common policy-based cancellation was methylmalonic acid, used to evaluate patients with questionable vitamin B12 deficiency, but only useful for “gray area” cases, not for most patients.

Other tests were placed on the formulary and made orderable only by a special process. For example, “Our No. 1 test that we were sending out was vitamin D screening, and we were getting clinicians who were unsure which test to order and were ordering both options on the test menu: vit D 1,25 OH in addition to vit D 25 OH. So we essentially made vit D 1,25 OH a test that can be ordered only in consultation with laboratory medicine or endocrinology, and that saved a lot of unnecessary testing.” Send-outs of vit D 1,25 OH have dropped to fewer than 20 per year, with no complaints from primary care physicians, Dr. Tormey notes.

An algorithm-driven review helped stem another high-volume send-out: hereditary hemochromatosis genetic testing, generally a $209 test. “Many clinicians will test for mutations in HFE in a ‘knee jerk’ fashion,” Dr. Tormey says, “often based on slightly abnormal iron studies, increased hemoglobin/hematocrit, or even mildly abnormal liver enzyme tests.” The laboratory used a literature review to develop an algorithm (see page 80) to first test for transferrin saturation, to see whether the patient meets criteria for having an iron overload. “That was another place where we were able to streamline this broad-based testing that gets done for patients with questionable or unknown diagnoses.”

Clinician response has been positive, Dr. Tormey says. “We might call and say we were reading the note and didn’t quite understand why they were ordering test X. And nine-tenths of the time we end up getting a very reasonable person on the phone saying, ‘I didn’t realize this test was ordered,’ or ‘We have more information and totally agree the test is no longer necessary.’ It’s a minority of the time where somebody is upset or flatly refuses to cancel the test or consider an alternative.”

The overall cost savings of the prospective audits and formulary programs have been impressive. The system saved an estimated $90,000 to $100,000 per year from reviews and algorithms. That does not include the savings from tests the formularies prevented, and from prevention of “chart viruses” secondary to inappropriate tests (where bad data or a mistaken diagnosis attaches to a patient’s EMR), which are more difficult to estimate.

VA Connecticut plans to expand its test utilization controls on three fronts: reducing duplicate orders for send-out and in-house testing, expanding algorithmic approaches to lower-volume but higher-cost tests, and expanding the lab subspecialty formulary model for other high-priced tests. “One of the beauties of the VA system from a test utilization standpoint is that we have had an outstanding electronic medical record in place since the mid 1990s and it puts a great deal of patient data at our fingertips,” Dr. Tormey says.

“If we can figure out that a genetic test was done on a patient eight or nine years ago, then we can cancel an order of that same test. Right now, our system is not going to tell an ordering provider that such a test has already been done unless they specifically query for the lab result, so we would like to develop a clinician feedback system to notify them, first that a test has been done, and second, ask whether they want to do it again.”

The benefits would extend not only to molecular tests but also to tests like CBCs, Dr. Tormey says. “How many CBCs are really necessary over the course of one admission? On a single patient-by-patient basis it probably doesn’t make a big difference, but if you can cut your overall CBCs by a third by knocking out unnecessary duplicate testing, there can be a real cost savings.”

Laboratories that want to expand their test utilization controls don’t need the resources of the VA, however. Reference labs such as ARUP in Utah as well as the Mayo Clinic have developed algorithms that are open to the general public and are ready-made starter solutions for laboratories needing to manage test use. “A middle-sized nonacademic hospital could very easily start with these algorithms on the ARUP or Mayo Web sites, and slowly but surely start to target some of these tests,” Dr. Tormey says.

Control of costs is only one of the payoffs, he says. “The benefit of utilization review is getting better results for patients by preventing send-outs that are probably not necessary and, in some cases, provide information harmful to patient care because of bad data. It’s great that we’re able to control costs or reduce phlebotomies and lower the bottom line of our send-outs. But ultimately, preventing unnecessary or incorrectly ordered tests that can lead to problematic treatments for patients is the most important aspect.” The monetary benefits are certainly important, he says. “But they’re of secondary importance to improving clinical care for our patients.”

Anne Paxton is a writer in Seattle.