Low-value services remain common despite campaigns to discourage them
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.