Aug 29, 2018 | Laboratory Pathology
Just eleven common tests and procedures blamed for 93% of low-value services and 89% of wasted spending
Overuse of medical laboratory tests and diagnostic procedures has been a long-standing issue among pathologists and other healthcare providers. Now a Washington State healthcare watchdog organization has put a $282-million price tag on the cost of what it calls “wasteful” spending for “low-value” clinical laboratory tests and other procedures in a single year.
A study by the nonprofit Washington Health Alliance (WHA) examined insurance claims between July 2015 and June 2016 from 1.3 million patients who received one of 47 procedures or tests that had been previously labeled by the US Preventive Services Task Force and Choosing Wisely campaign as overused.
Many pathologists and clinical laboratory managers are familiar with the “Choosing Wisely” initiative. This is a collaboration involving most medical specialty associations. These associations are highlighting a list of medical lab tests and other diagnostic procedures that are ordered inappropriately and with greatest frequency. Thus, the WHA study—involving 1.3 million patients—provides more evidence and credibility in support of the “Choosing Wisely” campaign.
In its study, the WHA determined that, over this 12-month period:
- More than 45% of the healthcare services examined were determined to be of low value because they have been shown to provide little benefit in certain clinical scenarios;
- 622,341 (47.9%) patients underwent a low-value test or procedure they didn’t need;
- 36% of spending went to low-value services, resulting in an estimated $282 million in wasteful spending; and,
- Eleven common tests, procedures, and treatments—such as: preoperative tests, laboratory studies prior to surgery, and too frequent cancer screenings—account for 93% of low-value services and 89% of the estimated wasted spending.
The WHA found that problematic procedures and tests aren’t necessarily “big-ticket” services but collectively result in unnecessary costs.
“Many of the services are individually low cost, and, therefore, a doctor or patient may not consider it problematic,” Susie Dade, author of the WHA report and Deputy Director at the Washington Health Alliance, told The News Tribune.
“In the alliance’s analysis, we found that about 80% of the low-value services examined for this report are low cost (meaning less than about $500). However, we all pay the price with increased premiums and healthcare costs,” she noted. Precision medicine approaches to personalized healthcare reduces these costs and improves outcomes.
Opportunity for Education/Improvement
The report, “First, Do No Harm: Calculating Health Care Waste in Washington State,” used the new MedInsight Health Waste Calculator from actuarial consulting firm Milliman, to produce the analysis.
The report found the following 11 tests and procedures (listed in descending order based on volume) were the most overused low-value services:
- Too frequent cervical cancer screening in women;
- Preoperative baseline laboratory studies before low-risk surgery;
- Unnecessary imaging for eye disease;
- Annual EKGs or cardiac screening in low-risk, asymptomatic individuals;
- Prescribing antibiotics for acute upper respiratory and ear infections;
- PSA (prostate specific antigen) screening;
- Population-based screening for 25(OH)-D deficiency;
- Imaging for uncomplicated low back pain in the first six weeks;
- Preoperative EKG, chest x-ray, and pulmonary function testing prior to low-risk surgery;
- Cardiac stress testing; and,
- Imaging for uncomplicated headache.
Nancy Giunto (above left), Executive Director of the Washington Health Alliance, called her state’s results “stunning” and noted the WHA report provides “a clear opportunity to educate patients and engage healthcare stakeholders on areas of improvement.” Such an individualized approach to healthcare is at the heart of precision medicine. She’s shown above with previous WHA Executive Directors Mary McWilliams and Margaret Stanley. (Photo copyright: Washington Health Alliance.)
US Healthcare Culture Partly to Blame
“The list of 11 is a starting point for us,” Dade told Modern Healthcare. “I think they will become a rallying point for coming up with specific education and specific interventions.”
Dade suggests the healthcare culture in the US plays a role in the epidemic of unnecessary testing.
“In some cases patients ask for or agree to things because they don’t realize the potential for harm, be it physical, emotional, or financial, that can happen with unnecessary tests, procedures or medications,” Dade told The News Tribune. “In other cases, tests are ordered by providers, with little input or even awareness of the patient.
“In a ‘more is better’ culture in healthcare, there is a belief that it’s better to have additional tests because it’s better to be safe than sorry. However, this doesn’t account for the potential for different kinds of harm.”
- Gilbert Welch, MD, MPH, a professor at The Dartmouth Institute, told National Public Radio (NPR) part of the blame should be placed on a healthcare system that often incentivizes healthcare providers to do more than what is medically necessary.
“The medical system is still dominated by a payment system that pays providers for doing tests and procedures. Incentives matter. As long as people are paid more to do more they will tend to do too much,” Welch said.
Value-based Care the Solution to Overuse
The Washington Healthcare Alliance believes one key to eliminating overuse can be found in the transition from fee-for-service healthcare to value-based reimbursement models. The WHA report states: “We need to keep our collective ‘foot on the gas’ to transition from paying for volume to paying for value in healthcare.” In addition, the alliance suggests value-based provider contacts should include measures of overuse, and not just measures of access and underuse.
The report also suggests consumers take a more active role in their healthcare decision making by asking these five questions before having a medical test or procedure:
- Do I really need this test or procedure?
- What are the risks and side effects?
- Are there simpler, safer options?
- What happens if I don’t do anything?
- How much does it cost, and will my insurance pay for it?
Clinical laboratories and anatomic pathology groups can help put the brakes on unnecessary laboratory testing and procedures by guiding physicians toward evidence-based medical care and a renewed focus on “do no harm.”
“What we strive for is substantially reducing the risk of preventable harm,” the report states. “Reducing unnecessary overuse of healthcare services is one important way to do this. The result of the ‘more is always better’ culture present in today’s healthcare delivery seems to be ‘first, do something.’ It is time to get back to ‘first, do no harm.”
—Andrea Downing Peck
Related Information:
First, Do No Harm: Calculating Health Care Waste in Washington State
New Study Finds Hundreds of Thousands of Washington Patients Receive Unnecessary Tests, Procedures and Treatments
Washington Residents’ Tab for Unneeded Care in a Year: $280 million-plus
Unnecessary Medical Care: More Common than You Might Imagine
You’re Getting Nickel and Dimed for Low-Value Medical Tests in Washington, Report Says
Jul 20, 2012 | Coding, Billing, and Collections, Compliance, Legal, and Malpractice, Digital Pathology, Laboratory Hiring & Human Resources, Laboratory News, Laboratory Operations, Management & Operations, News From Dark Daily
New lab test market could open up if research findings lead Consumer Reports and nine medical specialty associates join forces to target the overuse of certain diagnostic procedures, including some medical laboratory tests
For years, pathologists and physicians have spoken out about the overuse of medical laboratory tests and other diagnostic procedures. Now an interesting alliance of a medical specialty association and Consumer Reports has come together with a highly-publicized plan designed to reduce unnecessary or inappropriate testing by encouraging physicians to more deeply involve patients in the process.
It is the American Board of Internal Medicine Foundation (ABIMF) that is working with Consumer Reports. Their common goal is to stanch the overuse of unnecessary healthcare tests and procedures that do not improve patient outcomes and do run up healthcare costs. Experts estimate the wasteful use of healthcare resources accounts for as much as 30% of current healthcare costs in the United States.
The program is called “Choosing Wisely” (CW). According to a story in Modern Healthcare (MH), “Choosing Wisely” is a campaign to get physicians and patients to discuss whether a particular test is likely to improve patient health or outcome.
Pictured above is the press conference conducted by the American Board of Internal Medicine Foundation (ABIMF) to announce the launch of the “Choosing Wisely” campaign. The goal of this campaign is to reduce overutilization or unnecessary ordering of diagnostic procedures. Each of nine medical specialty associations has put forth a list of specific diagnostic procedures that should be part of this campaign and a number of clinical laboratory tests are on these lists. (Photo copyright by American Society of Nephrology.)
Participating in this initiative are about 375,000 physicians in nine specialty societies. Each of these nine medical specialty groups has identified five diagnostic tests or procedures within their specialty area that warrant re-evaluation by physicians and patients as to whether they will provide useful information or lead to a positive outcome. Clinical laboratory managers and pathologists will be interested to learn that a number of these medical specialty associations have included clinical laboratory tests on their respective lists.
“What we’re asking for is for people to have a conversation,” stated Daniel B. Wolfson, M.H.S.A., ABIM Foundation Executive Vice President and Chief Operating Officer, in the MH story. “These are not rules; they are guidelines used to guide most—but not all—cases,” he explained.
Writing in a commentary in The Huffington Post (HP), Donald M. Berwick, M.D., Chief Executive Officer of the Institute for Healthcare Improvement and former Administrator of the U.S. Centers for Medicare & Medicaid Services, called the program a game-changer. The physician specialty societies support their claims of overuse with copious scientific citations, Berwick noted.
“These societies have shown tremendous leadership in starting a long overdue and important conversation between physicians and patients about what care is really needed,” said Christine K. Cassel, M.D., President and Chief Executive Officer of the ABMF. “Physicians, working together with patients, can help ensure the right care is delivered at the right time for the right patient.” She was quoted in a Choosing Wisely press release.
According to the release, Consumer Reports is working with American Association of Retired People (AARP) and other organizations representing the lay public to get the word out about the “Choosing Wisely” campaign.
Specialist Physicians Identify Some Medical Laboratory Tests for Review
Below are listed the recommendations made by the different medical specialty associations that identify a clinical laboratory test:
American Academy of Allergy, Asthma & Immunology
- Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
- Don’t routinely do diagnostic testing in patients with chronic urticaria.
- Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.
American Academy of Family Physicians
- Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease. read article.
American College of Physicians
- In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
American Society of Clinical Oncology
- Don’t perform surveillance testing (biomarkers) or imaging… for asymptomatic individuals who have been treated for breast cancer with curative intent.
- Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20% risk for this complication.
American Society of Nephrology
- Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.
- Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10g/dL without symptoms or anemia.
In its coverage of the “Choosing Wisely” initiative, Clinical Laboratory News, a publication of the American Association for Clinical Chemistry, (AACC) reported that the utilization changes CW seeks may sound like bad news for the lab,. But sometimes these types of program can end up promoting appropriate clinical laboratory testing over other options, the writer noted.
Medical laboratories should emphasize making sure the right clinical lab tests are used at the right time, suggested Stephen E. Kahn, Ph.D., Chair of AACC’s Evidence-Based Laboratory Medicine Committee.
The “Choosing Wisely” initiative, at a minimum, does provide another opportunity for pathologists and clinical laboratory managers to add value to physicians and their patients by helping clinicians have confidence they they are ordering the right test at the right time, supported by evidence-based medicine (EBM) guidelines.
—Pamela Scherer McLeod
Related Information:
U.S. Physician Groups Identify Commonly Used Tests or Procedures They Say Are Often Not Necessary
“Choosing Wisely”: Physicians Step to the Front in Health Care Reform
June 2012 Clinical Laboratory News: Screening Tests in the Age of Austerity