Test utilization: a united front against waste

Tier 1 tests are those that any generally primary care or community-based internists should have open access to order, while tier 2 tests are available only to specialists. For tier 2, many of which are genetic and tend to be more expensive, “We wanted to have the additional training and education of a subspecialist to drive those test orders, rather than just have the Wild West with an open menu.”

Most important is tier 3: tests that the expert panels did not see a need to offer to the patient population upon this review. “You need an exceptional case with an exceptional justification to obtain a level 3 test.”

“There are so many new tests coming on the market right now, some that haven’t necessarily been proven in the clinical arena to be medically useful. For example, if I came across a new blood marker for asthma or pulmonary fibrosis, and I wanted our institution to place it on the formulary, our expert subcommittees would actually review the data, much as a pharmacy and therapeutics committee would review a new drug for clinical benefit versus risks, and so on.”

“It isn’t that the tier 3 tests are excluded permanently from our formulary, but I’d describe it as putting them up higher on the shelf. You need to take more steps to have the test approved before we would draw a specimen.”

How controversial have the tier assignments been? “Nobody got a black eye over it,” Dr. Levy says. “But there were some heated discussions about test X or test Y.” For example, with inflammatory bowel profile, “there’s controversy about the utility of these tests in managing patients with abdominal pain or other GI symptoms. The committee thought the IBD panel should be tier 3, meaning it’s available but you’d really have to build a case to get approval for it.”

“I don’t think the company that performed these tests was happy with our approach. I was told they tried to lobby our GI physicians to ask us to reverse our decision. But we have proceeded.”

The institution chose not to go down the path of putting dollar signs for approximate prices in its electronic ordering system. “There has been discussion about that to help create an environment of cost consciousness among our providers, but we have not yet done it.”

But, Dr. Levy explains, “Our tiered formulary system was largely driven by the effort to marry the tests themselves, their utility in clinical patient management, and the ordering provider. It wasn’t a financial model where we drew a line saying any test over $1,000 is going to get different scrutiny. What we did is line up all the reference lab tests and say ‘Let’s get our specialists to think about these.’”

An added advantage of the formulary approach is that it can help protect an institution from becoming the go-to site for reference tests that other hospitals may wish to dodge because of the expense. “You may be caught in a position of processing blood and reporting results of patients with little or no contact with your health system, and that could potentially have a really negative effect on your bottom line.”

“With reference lab testing, the way the reimbursement models work, we become the payer of last resort,” Dr. Levy says. “I doubt that Rochester is the only place where this is happening. With a formulary of tests and criteria as to who can order them, you avoid the potential problem that could arise if you don’t have a laboratory test management system and a nearby health system does.”

With so much pressure on high value care, the formulary approach fits the value metric nicely, Dr. Levy believes. “We are trying to be absolutely certain we do not bend the quality curve. We are only trying to bend the cost curve.”

With or without the Affordable Care Act, says Kent Lewandrowski, MD, associate chief of pathology and director of laboratories and molecular medicine at Massachusetts General Hospital, insurers have been pushing for more risk sharing, and physicians are becoming financially accountable for the cost of care.

“Hospitals have long had a motivation to consider utilization management because of DRGs, but now clinicians are being incorporated into the loop of accountability where their potential income could be impacted. And they understand the problem much more quickly. The younger clinicians especially are really grabbing hold of utilization management, saying this is an area where they can make an impact beyond being a clinician.

“We used to take the approach of finding a target of opportunity, basically finding the clinicians and trying to take one foxhole at a time,” Dr. Lewandrowski says. Now, however, the laboratory is achieving a more pervasive impact by using informatics.

With the computerized physician order entry system and middleware designed by pathologist Anand Dighe, MD, PhD, director of the hospital’s core laboratory, “we not only have a better grasp of who is ordering what tests and why, but we also interact with the physician at the time of ordering the test.”

“Any doctor trying to order a 1,25 vitamin D on an inpatient, for example, encounters a pop-up message saying that’s not the preferred test to assess vitamin D status, while an attempt to order CK-MB is met with a pop-up saying CK-MB is no longer indicated; stick with troponin.”

“That’s basically wiped out CK-MB testing,” he says.

In addition, the utilization controls are more agile than they used to be. “We have a committee that decides which tests will be flagged. But now we work out many decisions by e-mail with the clinicians—for a cardiac issue we send an e-mail to a trusted cardiologist, for vitamin D we talk with an endocrinologist.”

That means speed, he says. “With e-mail, you can ask 15 specialists what they think of this idea, and get an answer from the vast majority, sometimes within minutes but certainly within a day or so.”

The occasional roadblock is posed by having to go to the IT department to make changes. “They’re very busy, they put things in order of priorities, and yours may not be very high. Even though you have clinical approval for something, it may take months to roll out. But Anand can go in and put a pop-up anywhere he wants in the system now within a five-minute period.” Dr. Lewandrowski estimates that the system has about three dozen pop-ups at any one time.

On the other hand, pop-ups have hazards. “We don’t want to flood physicians with them. Everyone hates pop-ups, so you have to use them judiciously and keep them focused. If they’re highly effective in educating physicians, you can then turn them off because the culture has made the change.”

A new and effective informatics tool is a search function with built-in decision support on the CPOE system, Dr. Lewandrowski says. These online laboratory handbooks provide not just a list of tests and specimen requirements, but also advice on what situations the test should be used for.

“Clinicians will always look for resources to solve their problems, and pathologists therefore have to make themselves a resource. Some clinical pathologists are known in their organizations as people who can be helpful, and others are invisible. The key is to be very much engaged with clinicians.”

Screening algorithms can also keep down the number of tests ordered. “I think there will always be a baseline of individual patient clinical pathology consultations of the type ‘I’ve got this patient with X, what should I do?’ OK, that’s one level. But that’s only about 10 percent, at most, of our utilization management activity. Clinical pathology functions more on a population level. For example, if you implement a celiac screening algorithm, you’re not just impacting one particular patient and physician; you’re impacting all of them.”

The cost savings of utilization controls can be straightforward in some cases. “If you eliminate expensive sendout tests, you know exactly what you’re saving. But it’s much more difficult in the area of automated chemistry and hematology, where you’re pulling tests out of a preexisting operation where the fixed costs are already covered.”

“Say you eliminate albumin from a comprehensive metabolic panel. In that case, all you really save are reagent costs. But you need to have a sense of that, because your hospital administrators will always ask how much did you save. And sometimes it’s not that much and other times it’s hundreds of thousands of dollars.”

Dr. Lewandrowski is also hoping to design a system at Massachusetts General to improve access to expert information about molecular diagnostics. “The vast majority of pathologists are not specialized in genetics, so with genetic disorders probably the best route is to have a geneticist able to provide that advice. And in some cases we could be saving thousands per test.”

Molecular microbiology poses special problems, he adds. “These tests are cropping up like dandelions all over the place. Clinicians might ask, ‘Why don’t we do PCR for Lyme disease?’ That sounds like it must be the ultimate test. But it turns out that although it has some very limited applications, it’s not the optimal test and is frequently misleading.” Keeping tabs on such tests is a continuing challenge, he says.

From the patient’s perspective the clinical laboratory is disconnected from payment concerns—unlike pharmacy. “When we go to the doctor, we’ll get whacked with a nasty copay if we don’t accept a generic drug. But whether the doctor orders 50 tests or no tests, it doesn’t impact us in any way.” He can’t say whether there will ever be a copay for the lab. “But I think probably with genetic tests in the future, it will be worthwhile to have a higher-level approval process.”

For a large laboratory, getting an IT specialist on staff should be a priority, in Dr. Lewandrowski’s view. “You have to start by building an informatics infrastructure to support your utilization management; otherwise you’re going to be looking at raw data coming out of your system that gives very little insight into where a problem occurs.”

In many organizations, the capabilities of informatics have matured, he notes. “And that’s really key to an ongoing successful utilization management program.”

Anne Paxton is a writer in Seattle.