Low-value ser­vices re­main com­mon de­spite cam­paigns to dis­cour­age them

Modern Healthcare - - News - By Alex Kacik and Maria Castel­lucci

Mayo Clinic has adapted its elec­tronic health record to flag repet­i­tive lab­o­ra­tory tests. The not-for-profit health sys­tem looks to lower costs and im­prove care while safety and qual­ity ex­perts hope that other providers will take note and be more mind­ful of per­form­ing un­nec­es­sary pro­ce­dures.

The clinic’s EHR ag­gre­gates how of­ten cer­tain tests are or­dered along with cost data and guid­ance on how to re­duce re­dun­dancy, among other met­rics. It has been an im­por­tant tool as hos­pi­tals and health sys­tems look to get more bang for their buck, said Dr. Cur­tis Han­son, chief med­i­cal of­fi­cer at Mayo Med­i­cal Lab­o­ra­to­ries.

“Ex­cess lab tests are a prob­lem ev­ery­where . . . across the coun­try—it’s a com­mon re­cur­ring theme,” he said.

In­deed, ap­prox­i­mately $200 bil­lion is spent ev­ery year on health­care ser­vices in the U.S. that pro­vide lit­tle value to pa­tients. A Health Af­fairs study last week re­vealed that even a na­tional cam­paign to curb waste­ful ser­vices has failed.

The Choos­ing Wisely cam­paign was launched five years ago by the ABIM Foun­da­tion and Con­sumer Re­ports. Nearly 80 med­i­cal so­ci­eties have par­tic­i­pated by con­tribut­ing more than 500 rec­om­men­da­tions. But the in­vest­ment has yielded few div­i­dends.

“What we’ve learned is that it’s just re­ally hard to change prac­tice,” said Dr. Eve Kerr, one of the study’s au­thors and a pro­fes­sor of in­ter­nal medicine at the Uni­ver­sity of Michi­gan. Physi­cians worry about a mal­prac­tice suit should a hid­den ill­ness arise. Other physi­cians are swayed by pa­tient re­quests. “Cul­ture is one of the hard­est things to change, and it takes the long­est,” Kerr said.

One in­cen­tive, how­ever, is to try to ad­here to new pay­ment mod­els that re­ward lower costs and im­proved care.

Providers like Mayo are scru­ti­niz­ing many ser­vices, such as their lab test­ing pat­terns, to iden­tify vari­a­tion in treat­ment and out­comes. In a fee-for-ser­vice world, providers are paid for each or­der, leav­ing lit­tle in­cen­tive to re­duce the num­ber of tests, Han­son said.

Although lab spend­ing of­ten makes up only a frac­tion of hos­pi­tal bud­gets, it made sense for Mayo to re­think its strat­egy be­cause re­search shows that tests in­flu­ence most med­i­cal de­ci­sions. In­ap­pro­pri­ate tests can steer treat­ment in the wrong di­rec­tion.

Re­duc­ing the fre­quency of tests can im­prove pa­tient sat­is­fac­tion and keep their out-of-pocket costs down with­out harm­ing pa­tient out­comes, ac­cord­ing to a re­cent study pub­lished in JAMA.

Ph­le­botomies in par­tic­u­lar are of­ten overused in hos­pi­tals, re­searchers said. The more times blood is drawn, pa­tients be­come more sus­cep­ti­ble to ane­mia, which can lead to blood trans­fu­sions, longer hos­pi­tal stays, higher charges and even death. On av­er­age, providers could save up to $700,000 a year if they re­duce rou­tine blood­work, data show.

Be­cause ev­ery penny is start­ing to count both for providers and pa­tients, there has been an in­crease in ef­forts like Mayo’s and Choos­ing Wisely.

San­ford Health re­cently formed a work­ing group of clin­i­cians and in­for­ma­tion tech­nol­ogy ex­perts who meet ev­ery two weeks to go over data that de­ter­mines which tests have lim­ited clin­i­cal value.

Data show the Sioux Falls, S.D.based sys­tem overused the car­diac biomarker tro­ponin to treat my­ocar­dial in­farc­tion. Physi­cians were also us­ing out­dated medicine as treat­ment, said Dr. Jody Thomp­son, med­i­cal di­rec­tor of the lab­o­ra­tory at San­ford Med­i­cal Cen­ter Broad­way in Fargo, N.D.

While physi­cians may ini­tially re­sist change, it’s hard to re­fute qual­ity data, she said.

But re­duc­ing un­nec­es­sary lab test­ing is of­ten low on the totem pole, sec­ondary to is­sues such as sat­is­fy­ing qual­ity met­rics un­der the Merit-based In­cen­tive Pay­ment Sys­tem, Mayo’s Han­son said, adding that med­i­cal stu­dents re­ceive lit­tle train­ing on ap­pro­pri­ate uti­liza­tion of lab tests.

Lack of knowl­edge and train­ing was also a prob­lem with ad­her­ing to Choos­ing Wisely.

Kerr hopes to see med­i­cal so­ci­eties en­gage clin­i­cians and pa­tients in help­ing craft rec­om­men­da­tions. The Uni­ver­sity of Chicago is tak­ing a proac­tive ap­proach to ed­u­cate med­i­cal stu­dents on re­duc­ing waste­ful ser­vices, said Dr. Vi­neet Arora, a hos­pi­tal­ist and di­rec­tor of the GME Clin­i­cal Learn­ing En­vi­ron­ment In­no­va­tion at the uni­ver­sity.

“That is the wave of the fu­ture, but it does take time,” Arora said.

On av­er­age, providers could each save up to $700,000 a year if they re­duce rou­tine blood­work, data show.

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