At the 2015 American Association of Clinical Chemistry Annual Meeting, Dr. Jonathan Hoyne, moderated the session and co-presented, “Laboratory Test Utilization: Leading the Charge Towards Lab Stewardship.” Two additional speakers joined him: Robert Benirschke, of Peoria Tazewell Pathology Group, and Kevin Foley, of Kaiser Permanente.
The three presenters covered the what, why, and how of test utilization, providing a deep background on the subject and tangible direction on how to tackle utilization within health care organizations of all sizes.
“Everyone knows that health care spending is out of control, especially when compared to the rest of the world,” says Dr. Hoyne. “That is bad enough, but it has been getting worse. Our rate of increase over the last several years has been increasing single digits each year. As it all complies, it equals a looming healthcare crisis.”
To articulate the various factors, Dr. Hoyne detailed some key statistics. The clinical laboratory and its activities contribute to:
- 4% of total health care spending
- ~10% of total spending for private insurers
- 25% of high-intensity encounters
- 60% of medical decisions
Additionally, the laboratory costs are increasing by 15-25 percent annually, primarily driven by molecular assays and one third of laboratory orders are considered wasteful. Finally, testing approaches vary widely within the industry.
“There are huge differences between how institutions, systems, regions, and countries deal more with history and facility-specific practices than medicine,” says Dr. Hoyne. “Honestly, it has more to do with how we have always done it than clinical outcomes.”
There are two primary forms of utilization issues, under utilization and over utilization, each with unique drivers.
- Underutilization is primarily driven by not applying practice guidelines, not properly leveraging screening tests, and a lack of focus on preventative medicine.
- Overutilization is primarily driven by standing orders, care sets, no communication between a patient’s multiple physicians, and taking a shotgun approach to testing.
Dr. Hoyne finished his presentation by outlining many of the root causes of test utilization issues in health care. These root causes were:
- Health care architecture: Increased utilization and fee-for-service payment models
- Industry: Launching of emerging tests prior to evidence base being established
- Government: Increased regulations and insurance coverage
- Epidemiology: Increased screening, chronic diseases rising, and aging population
- Patient: More informed, Google, and patient equate satisfaction and utilization
- Bundled tests
- Laboratory: Bundled tests, confusing nomenclature (vitamin d and genetic testing), rapidly growing test menus, increased complexity, and skyrocketing costs
- Physicians: Increased specialization, unaware of costs, defensive when presented with feedback, desire to be thorough, convenience of shotgun approach, and inexperienced, young physicians
- Information technology: The default answer to system changes is usually no and the proliferation of bundling of tests and utilization of computerized physician order entry
The ultimate challenge, according to Dr. Hoyne, is for clinical laboratories to perform appropriate test requests while simultaneously minimizing the risk of financial losses to the institutions they serve. But, laboratories need dedicated resources to tackle utilization.
“One of the most striking issues is a lack of resources to take on overutilization,” says Dr. Hoyne. “Even though the literature shows it is very effective, very few laboratories are investing in this area and dedicating the right resources to get the job done. This needs to be a priority for laboratories, especially as we move to value-based medicine.”