Utilization management of clinical laboratory testing is a big trend in laboratory medicine at the moment as innovative labs strive to add more value
DATELINE: DENVER, COLORADO—Interest in improving the utilization of clinical laboratory tests is at an all-time high among medical laboratories throughout the United States. Last week a national gathering of pathologists and laboratory professionals gathered in the Mile High City to share success stories and identify the best approaches to helping physicians better utilize lab tests.
This one-day conference on laboratory test utilization was organized by Mayo Medical Laboratories and the Mayo Clinic as part of its 27th Annual Conference on Laboratory Outreach. The keynote speaker was Michael G. Rock, MD, Chief Medical Officer at Mayo Clinic Hospitals/Mayo Foundation and an at-large member of the Board of Trustees of the American Hospital Association (AHA) and its Executive Committee.
Analysis of Key Trends in Healthcare
In recent years, Rock has been involved at the highest levels of healthcare strategy development, both at the Mayo Clinic and with several national hospital associations, including the American Hospital Association. He provided attendees at this conference with a razor-sharp analysis of key trends in healthcare. Rock then identified and explained the essential steps that innovative hospitals and health systems are taking to reshape their organization in order to provide the range of clinical services needed to support integrated healthcare and personalized medicine.
Rock started with a quick review of the major forces for change that are familiar to most regular readers of Dark Daily. In particular, he emphasized that the transition away from fee-for-service will be swift and in its place will be new payment models, such as bundled payment and capitation.
Ongoing Increase in the Number of ACOs and Medical Homes
He also noted that the rapid increase in the number of accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) provides powerful evidence that the integration of clinical care is well underway. In support of this fact, Rock stated that, at the end of 2013, there were 606 ACOs in operation and 5,739 medical home sites—with 27,820 clinicians—already providing services to patients.
Based on developments at the Mayo Clinic and analysis done by strategists within the American Hospital Association, Rock offered a list of specific responses that hospitals, health systems, and physicians are implementing in order to make the “volume to value” transition:
- Redesigning care to improve quality and reduce costs.
- Developing strategic partnerships through M&A, engagement with hospitals/providers, and offering community services.
- Engaging in new delivery models of care, including medical homes; hospital at home; bundled care; and ACOs.
- Experimenting with risk-based payment.
- Embracing transparency in quality and pricing.
- Redefining the “H” within their communities.
- Critically reassessing their business model(s).
Retailers Want to Expand into Healthcare
One of the interesting points made by Rock is that major retailers are entering the healthcare marketplace. His examples ranged included such retail giants as Walgreens (NASDAQ:WBA), CVS (NYSE:CVS), and Walmart (NYSE:WMT). With their consumer focus and easy access, these savvy retailers have the potential to attract significant market share away from those hospitals and health systems that don’t respond with their own improvements to patient care and the patient experience.
Having set the scene for the day’s focus on better utilization of clinical laboratory tests, the remainder of this workshop was devoted to presentations about the strategies, tactics, and lessons learned at several nationally-known medical laboratory organizations. Overall, the improvements that resulted from a range of utilization management efforts were impressive.
Projects to Improve Utilization of Clinical Laboratory Tests
In her presentation about utilization management efforts of her institution, Leslie J. Donato, PhD, Co-Director Cardiovascular Laboratory Medicine and Co-Director Hospital Clinical Laboratory and Point of Care at Mayo Clinic, described one project that was designed to reduce unnecessary repetitive lab test orders.
According to Donato, she and her team defined three categories of rules that can be used as part of a hospital’s decision support system. They are:
Never tests (hard stop)
• Do not contribute to decisions during inpatient stay
• Often expensive and/or send-out
• Examples: Thrombophilia w/u, genetic tests
Redundant normal values (often soft stop)
• Rule triggered by previous result and anticipated change
• Examples: iCAL, Mg, CBC with or without diff
Using Three Categories to Manage Clinical Pathology Laboratory Tests
Having defined the three categories, Donato continued by explaining how the utilization management team (UM) in her lab developed a game plan to better manage utilization of lab tests within each of these three categories:
Never tests, identified with these methods:
• Review top send-outs,
• Opinions/consensus of lab leadership, and,
• Opinions/consensus of medical staff leadership.
Frequency-limited tests, identified with these methods:
• Review literature and other institutions’ experience,
• Opinions/consensus of lab/medical leadership, and,
• Association for Clinical Biochemistry & Lab Medicine (UK) National Minimum Retesting Interval Project.
Redundant normal values, identified with these methods:
• Need data on ordering patterns and results, and,
• Hardest to do, often highest volume.
Projects to Reduce Unnecessary Daily Hospital Inpatient Lab Test Orders
Another example of effective utilization management was given by pathologist Jeffery P. Pearson, MD, who is the System Medical Director, Laboratories and Pathology at Bronson Methodist Hospital, in Kalamazoo, Michigan. To address the unnecessary testing that happens because physicians have the habit of ordering tests daily on hospital inpatients, Pearson and his team looked at daily test orders.
“As we involved physicians on this project, we asked two questions about daily test orders,” noted Pearson. “First, rather than basing a lab test order on in interval of time, isn’t it best that a lab test be ordered to answer a relevant clinical question?
“Second, since physicians treating patients in the MICU and PICU don’t seem to need daily labs, why is it that so many other medical specialties order daily lab tests on their patients during an inpatient stay?” asked Pearson. “During one 12-week period before we implemented changes, the number of lab tests performed due to daily orders was 14,126.
“The utilization management team implemented a simple rule,” he continued. “Daily lab orders were restricted to three occurrences. The only exception is PT/INR and aPTT.
Medical Lab Test Utilization Effort Triggered a 48% Decrease in Unnecessary Tests
“These changes were implemented earlier this summer, on July 1, 2015,” stated Pearson. “We tracked a decline in daily labs from 4,700 tests per month to 2,451 tests per month. That simple restriction produced a 48% decrease.”
At Children’s Hospital of Seattle, a team of lab professionals has addressed the financial and clinical issues that surfaced as physicians ordered increasing numbers of complex genetic and molecular tests. Their presentation was delivered by:
One major strategy by the lab was to hire genetic counselors to work within the lab and support physicians as they considered the need for a genetic test and which genetic test was likely to provide them with the best information to use in diagnosing and treating the patient. The team from Children’s Hospital of Seattle described how a collaboration with neurologists was established.
“Neurology represented a significant opportunity for the lab to contribute value,” declared Astion. “Genetic testing for neurologic condition—such as epilepsy, ataxia, and other neuromuscular disorders—often involves expensive and expansive genetic test panels.
Genetic Counselors in the Medical Laboratory Supported the Neurologists
“At the time we started this project, no genetic counselor was in the neurology clinic to help navigate selection and ordering of complex genetic testing,” he continued. “There was also no policy dealing with prior authorization for genetic tests.”
During her part of this presentation, Conta described the steps taken to improve utilization of genetic tests by the neurology department. She also provided some data about the outcomes from this improvement project.
“As our genetic counselors worked with the neurologists, most modifications to the original lab test order consisted of changing the order to a less expensive equivalent genetic test,” she stated. “Over time, the modifications increased as neurologists became familiar with the UM process and had greater rapport with the genetic counselors in the lab.
“The lab’s genetic counselors did help raise awareness of newer next-generation sequencing genetic testing panels and other test alternatives that would help neurologists improve diagnoses and better guide the selection of therapies for their patients,” added Conta. “The improvement in utilization of genetic tests was significant. As of February 2014, the average cost per genetic test order from neurology was $4,497. That fell to $2,977 by May 2015, a reduction of 34%.”
Saving Millions with Utilization Management at Cleveland Clinic
Rounding out this one-day conference on improving the utilization of lab testing was Gary W. Procop, MD, who is Medical Director, Enterprise Test Utilization at the Cleveland Clinic. His message emphasized the need to engage physicians in UM activities. “We’ve organized test utilization committees that are led by a physician and a laboratory professional,” described Procop.
“It is a multidiscipline committee with full transparency,” he continued. “One lesson we’ve learned is that it is essential to have the support and involvement of the information technology group. That’s because many strategies to improve utilization of laboratory tests involve Clinical Decision Support Tools (CDST) and Computerized Physician Order Entry (CPOE) to inform and engage the physician at the time that he or she is ready to enter a lab test order.
“Since we launched this UM program in 2011, our lab team can document $2.7 million in cost savings from improved utilization of lab tests,” added Procop. “The results of these utilization management projects are shared with physicians and administration. It helps to keep them engaged and supportive of our ongoing efforts to improve the utilization of clinical laboratory tests.”
Helping physicians better utilize clinical laboratory tests is becoming an essential service for any medical laboratory organization that wants to stay in the forefront of laboratory medicine. Effective utilization management programs are not complicated to create and administer. And, as demonstrated by the examples shared above, the payoffs can be substantial.
The best news of all is that there is plenty of low-hanging fruit to be harvested by laboratories that do an effective job of engaging physicians in a collaborative effort to improve the utilization of medical laboratory tests. As healthcare continues its transition to value-based and budgeted reimbursement, it will be timely for all labs to offer utilization management services in support of their client physicians.
Robert L. Michel
Editor, Dark Daily