Is this test really necessary?

Is this test really necessary?

I am sure most of us at one time or another have wondered if a test we were asked to perform was necessary. Seeing the same patient name and identical test values day after day, we find it hard to believe someone is actually looking at all of the data. Many of us have a nagging feeling that a lot of tests are for naught.

I recall a colleague's story of a snowy day when his laboratory was short-staffed. In order to use the limited staff most efficiently, management decided the lab would not perform differentials on any CBCs in which the white cell count was within normal range. Technologist were instructed to review slides only if a physician called to ask about differential results. Several hundred CBCs were performed that day, but not one physician called.

Until fairly recently, laboratories were used primarily to answer preliminary questions about patients. Physicians frequently ordered betteries of tests to assist them in a rapid diagnosis--and to cover any potential liability. Pathologists, many with salaries tied to gross laboratory revenue, were anxious to see volume increase.

The shrinking health care dollar has changed all of that, and use of lab services is being scrutinized more than ever. Most labs were just adjusting to DRGs when the latest blow arrived--the Blue Cross/Blue Shield guidelines for test ordering.

Developed in conjunction with the American College of Physicians, the guidelines address utilization of high-volume and usually highly profitable lab tests. Blue Cross/Blue Shield estimates that annual national expenditures on lab tests total $27 billion and that 20 to 60 per cent of the tests are unnecessary. If the superfluous tests are cut along with unnecessary chest X-rays and electrocardiograms, estimated savings can amount to $6-8 billion per year.

Clearly the guidelines, which other carriers may adopt eventually, will have a strong impact on lab operations and staffing. Administrators will see the cost of performing tests rise significantly as many of our most profitable tests decrease in volume. In addition, there will be a reluctance to introduce new procedures unless it is certain that carriers will pay for them. Internal monitoring of test utilization will intensify, but hospital labs affiliated with teaching institutions will have serious problems trying to curtail the ordering patterns of overanxious medical students and residents.

While endorsed by many medical organizations, the guidelines are firmly opposed by the College of American Pathologists, which feels they are too restrictive and may result in missed diagnoses for many asymptomatic patients.

A major question is, "Will the guidelines really be effective in changing physicians' test ordering habits?' I am sure that a sizable number of physicians, lacking a vested interest in reducing costs, will continue to overuse lab services. This will lead to difficulties for labs, which will have to police test ordering habits. Patients may have to foot the bill for some or all charges rejected by insurers.

The effectiveness of any laboratory utilization program depends on the active support of all involved, including the ordering physician and the lab director or pathologist. I hope these parties can join with insurers to find a mutually acceptable way to eliminate unnecessary testing. Pathologists must take a more active role in hospital utilization committees so they can influence medical staff decisions on what constitutes appropriate testing in particular circumstances. Insurers should give pathologists some latitude in deciding the proper ordering pattern for a particular illness.

There are other ways to improve ordering. For example, medical schools must do a better job of educating students about how best to order for a specific illness. While we're at it, let's also try to curb excess in Stat and off-hour testing.

Many of us in the laboratory have mixed emotions about testing guidelines. As health care providers, we are justifiably concerned about the effect such programs will have on our livelihood. On the other hand, the health care consumer in us recognizes the need to be reasonable when it comes to spending on tests. I hope the two sides can coexist.