Pathologists at Pinnacle of Move to Curb Unnecessary Testing

Pam Harrison

October 31, 2014

TAMPA, Florida — An estimated 20% to 30% of laboratory tests performed in the United States are inappropriate, warned speakers presenting here at the American Society for Clinical Pathology (ASCP) 2014.

"The fee-for-service environment has encouraged a volume-driven approach to healthcare," said Stephen Kroft, MD, from the Medical College of Wisconsin in Milwaukee, who is outgoing president of the ASCP. "The more you do, the more you get paid, without really needing to focus on whether you're seeing value for those healthcare dollars," he told Medscape Medical News. This isn't happening just to pathologists, of course, he added.

In fact, as several presenters pointed out, the United States spends far more than any other developed nation on healthcare without achieving proportionately better outcomes. "Many of the laboratory tests done in this country are unnecessary, meaning the testing doesn't add any value to patient care," Dr Kroft said. "We just don't need to be doing as much testing as we do."

The approach is typically driven by physician request — "the doctor wants it, the doctor gets it," he explained.

The speakers here agreed that this model of healthcare financing is unsustainable.

Today, accountable care and other organizations are insisting that physicians take a more holistic approach to patient care, where the team is paid for the quality of outcomes they achieve, including keeping patients out of the hospital.

"This means we can no longer sit back and say, 'the physician ordered it, so we're going to do it'," Dr Kroft pointed out.

There is now a strong movement for pathologists and laboratorians to play more of a stewardship role by governing the use of laboratory testing and helping physicians get the answers they really need.

Dr Kroft reported that he recently established a laboratory utilization committee at his institution.

Lab Guiding Test Orders

This committee is charged with establishing best practices and reducing inappropriate laboratory testing. Now, when a physician orders a particular test and the system sees that it might not be the right one, it'll send that physician a pop-up message saying: "Are you sure you actually want this test?"

The laboratory will be there to help physicians, Dr Kroft explained.

"We are the experts on performance characteristics, the clinical indications, the utility of these tests. We need to say, 'No, the test you want to answer your question is such and such.' Instead of ordering a 'shot-gun' menu, there might be algorithms or cascades to guide physician ordering. It's a bit of a different paradigm," he explained.

Other ways to curtail unnecessary testing is to create laboratory formularies analogous to formularies in a pharmacy. Tests without evidence to support their clinical utility will not be on these formularies.

"The idea is for us to engage fully with our clinical colleagues, to make sure they are ordering the right test at the right time for the right patient, and to help them interpret the test when we get the results back," Dr Kroft said.

Pathologists and laboratorians are going to have to learn to sing their own praises. "I consider pathology and laboratorians to be indispensable now," said Alfred Campbell, MD, from the Carolinas Pathology Group in Spartanburg, North Carolina, who was also speaking at the meeting.

The idea is for us to engage fully with our clinical colleagues, to make sure they are ordering the right test at the right time for the right patient.

"We have a habit of hiding in our offices and in our labs. In the past, that was alright. In the future, that's not going to be alright. We are going to need to be more vocal about who we are and what we do," Dr Campbell told Medscape Medical News.

Pathologists and laboratory medicine specialists already submit to quality reviews every year, do interim inspections on their own, and undergo inspection by an accredited agency on a regular basis. "So we've been ahead of everyone in terms of quality," he said.

Proving value to other members of the healthcare team and to third-party payers might take time and a new mindset, but it is eminently possible, said Michael Talbert, MD, from the University of Oklahoma Health Sciences Center in Oklahoma City.

He explained that the laboratory at the children's hospital affiliated with his center deployed a new test about a year ago. It was projected that the hospital would save 81 days of inpatient care by facilitating more rapid diagnosis and discharge of children who did not need to be hospitalized for a problem they did not have.

"This provided incredible value to our community," Dr Talbert reported. "We now have the ability to care for more children who are very sick in a hospital that is almost always full."

Dr Kroft and Dr Campbell didn't soft-pedal the challenges facing the specialty.

Third-party payers all want more quality for less money, and there isn't much the specialty can do about the bundling of payments to hospitals — "bundling is payer's speak for less money," Dr Campbell quipped. In addition, new diagnostic codes that document in great detail the reason a test was ordered will require significantly more time and training of lab personnel.

Then there is the encroachment of technology companies developing products that conduct lab tests with a single drop of blood. And organizations like the Centers for Medicare & Medicaid Services are refusing to pay for more than one unit of service, no matter how many biopsies come in from a single patient.

There are also significant decreases in reimbursement for different stains on the same specimen, the threat of lower payment rates based on median prices reported by labs for each test, and decreased payments for all Medicare patients.

"I have no doubt that pathologists are going to make less money than they do now. The healthcare pie is shrinking and we are all going to be fighting for a piece of it," Dr Kroft said.

But he and Dr Campbell said that with every challenge, there is an opportunity — an opportunity to grow professionally, to affect the top and bottom line of an organization, to create efficiencies, and to better deliver patient care.

"What has happened to labs in this country is that we have become 'black boxes' — manufacturers of widgets — and the more widgets we can push through the assembly line, the better off we are. But I didn't go to medical school to make widgets. We are going to be incentivized to do what we've been trained to do, to do the stuff we went into this business for, and to take care of patients. I see this as an enormous opportunity, and I think it's going to be an exciting time," Dr Kroft said.

Dr Kroft, Dr Talbert, and Dr Campbell have disclosed no relevant financial relationships.

American Society for Clinical Pathology (ASCP) 2014. Presented October 9, 2014.


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