Test menus and profiles: signs of change under DRGs.
A survey of MLO's Professional Advisory Panel discloses that cost pressures are encouraging a growing nubmer of laboratories to restructure their offerings, sometimes in a last-ditch effort to control costly overordering. At this point, the changes are not widespread. the makeup of test menus and profiles remains largely unchanged at most of the clinicla laboratories surveyed.
The great majority of the 222 participating panelists, laboratorians at the supervisory level or higher, work in hospitals. While all of the institutions represented in the survey were subject to prospective payment, almost 70 per cent came under the system only last year.
Nonetheless, a significant minority already report indications of a subtle shift in delivery of services. In the future, it seems, one priority will be paramount: to obtain the most diagnostic information from the least possible amount of testing.
Predictions vary widely on how fixed per-case payments will influence patterns of laboratory testing. Some experts look for hospital laboratories to dwindle into Stat facilities and blood banks, farming out the bulk of their workload to high-volume free-standing labs. Others recommend squeezing the most out of high fixed operating costs by bringing more types of testing in-house, preferably from the outpatient market.
The majority of panelists' laboratories are still in the wait-and-see phase, as Figure I shows. Test menus have remained unchanged at 67 per cent of the hospital laboratories, grown larger at 20 per cent, and become smaller at 13 per cent. Laboratories in small hospitals (under 200 beds) led the way in expansion of menus. Twenty-six per cent of them reported more tests available, compared with about 15 per cent of the labs in mid-size (200-399 beds) and large hospitals (400 or more beds).
One small hospital with a bigger menu is 44-bed S.E. Lackey Memorial Hospital in Forest, Miss. After acquiring a new random-access chemistry analyzer with therapeutic drug monitoring capabilities, the laboratory introduced organ-specific profiles, including renal, lipid, and thyroid panels, and began performing digoxin, theophylline, and other drug assays. "Our patient load has stayed fairly stable," laboratory supervisor David Denham said, "and we're starting to pick up some outpatient work from the community. The more you batch on this analyzer, the more cost-effective it becomes."
In a related finding, 62 per cent of the surveyed laboratories are sending the same volume of testing to reference labs now as they did before DRGs. Nearly a quarter have cut send-outs, while 14 per cent have increased them. Smaller hospitals, which led the way in test menu expansion, are also the most active in trimming send-outs; 33 per cent of them have cut reference lab volume, compared with 24 per cent of the mid-size institutions and only 13 per cent of the large ones.
Some small institutions, though, have increased send-outs to reduce labor costs. One is 22-bed Rinehart Memorial Hospital in Wheeler, Ore., whose laboratory has weathered a 25 per cent staff cut. "It gets down to nickels and dimes," chief technologist Gene Werst said. "Since 60 per cent of the hospital's expenditures are on salaries, there are really only two choices. Cut staff or increase automation--if the lab can afford it."
Under DRGs, prompt diagnosis and treatment are major goals of case management, and preadmission testing can be an important strategy in shortening length of stay. Eighty-nine per cent of the panelists' labs perform preadmission testing--92 per cent of those in small and medium hospitals and 83 per cent in large hospitals (Figure II).
For the most part, this phenomenon predates DRGs. Only 1 0 per cent of the institutions offering preadmission testing began it since prospective payment came into effect. Many panelists report that their hospitals saw the handwriting on the wall several years ago and began serious efforts to trim the average patient stay.
In the quest for economy, preadmission and admission test batteries are sometimes trimmed. Admission testing requirements have changed at 22 per cent of the labs since the initiationof DRGs. Some hospitals have eliminated mandatory admission tests altogether; others have streamlined preoperative screening panels, leaving more to the physician's discretion. Several panelists report that the traditional 24- or 48-hour time limit for preadmission testing has been stretched up to seven days.
At 170-bed Somerset (Pa.) Community Hospital, a quick admission profile is part of a recent drive to encourage ambulatory surgery, according to chief technologist James Plock. "We're now doing just the upper part of a CBC and an abbreviated uringalysis using the Chemstrip 9, which provides everything except the microscopic examination," Plock said. "Radiology is in on it too. They've revamped the criteria for admission x-rays." Patients arrive at the lab as early as 6:15 a.m. on the day of surgery or on the previous day if possible. Plock reported that the hospital's surgical short-stay program now accounts for more than half of all surgery performed there.
We asked survey participants whether routine ordering had been either limited or eliminated for three very common test procedures: differentials, microscopic urine examinations, and cross-matches. With remarkable consistency, nearly a quarter of all hospital respondents said yes in each case (Figure III).
Routine ordering was cut for all three tests at a 250-bed Midwest hospital, the laboratory's administrative director reported. "We've probably eliminated about three quarters of the diffs as a result. We offered physicians a choice: a complete blood count, or a hematology profile minus the diff. Our pathologists discussed the options with the medical staff. Now, most order he CBC initially and use the profile for follow-up."
Instead of routinely performing microscopic urinalyses, the laboratory now uses a dipstick first and then goes on to the microscopic exam for certain values. (Physicians can still order microscopics separately, of course.) As for crossmatches, the laboratory conducted a study to find out which patients received them and whether the blood was actually used. On the average, the lab has eliminated setting up about 20 units a day.
We asked what kinds of test profiles were offered, without defining their parameters. As Figure IV shows, cardiac profiles were offered most widely, by 85 per cent of the hospital labs. Next came liver prolfiles, offered by 76 per cent; thyroid, 69 per cent; lipid, 67 per cent; and renal, 33 per cent. More
than a third offered other types of panels or profiles as well.
Fifty-six per cent of hospital laboratories supply clinicians with interpretive comments on the results of test profiles. The range is from 52 per cent at small hospitals to 61 per cent at large hospitals. Only 5 per cent of all labs report that profile interpretations were introduced since prospective payment began.
The new Medicare cost controls do appear to be spurring some evolution in the actual makeup of panel test groups, as Figure V shows. Again, the majority of respondents report no change. But 17 per cent have altered test profiles since going onto the DRG system. In personal interviews, a number of other panelists said such changes are already in the planning stge, often in tandem with acquisition of new instruments.
DRGs have helped shape the inpatient test menus at 305-bed Palomar Memorial Hospital in Escondido, Calif. At the same time, they have sharpened the hospital's interest in the outpatient market, where test changes of a different nature have resulted.
Lawrence R. Macklin, assistant administrative director of the Palomar Memorial laboratory, said: "Our DRG implementation committee, which includes laboratory representatives along with clinicians from various specialties, recommended replacing our 18-test chemistry panel with organspecific mini-panels for inpatients.
"But in the outpatient market, the demand is completely different. We have found that price sensitivity is much greater and that internists and family practitioners prefer larger panels at deep discounts."
The hospital, which recently hired a marketing director, went head to head with independent laboratories in offering "customized" outpatient panels at discount rates. "Private labs are telling their physician accounts, 'Hey, you're each a little different; tell us what you want on the panel,'" Macklin said.
His laboratory responded by developing general health screens with add-on options, such as Rh testing for ob/gyns. So far, the strategy is working, and outpatient volume is rising. "With this system," Macklin aded, "you have to learn the rules of the game and play them the best you can."
Some laboratories have discontinued panel testing altogether to encourage leaner, more thoughtful clinician orders. "We still offer the same tests--just not on a panel like we used to," said Erin K. Johnson, laboratory supervisor at 30-bed Merrill Pioneer Hospital in Rock Rapids, Iowa. As a result, johnson believes needless test ordering has dropped significantly. Because of volume declines, such chemistry tests as calcium, albumin, and phosphorus are now sent to a reference laboratory.
Other institutions have taken less drastic action. A small minority have begun efforts to sharpen the diagnostic focus of panel testing by, for example, cutting the number of tests within a certain panel. As Figure V also shows, 13 per cent of the surveyed labs have developed new test profiles specifically to improve cost-effectiveness, while only 5 per cent have devised test groups to identify particular disease states or DRGs.
At 124-bed Doctor's Hospital in Hollywood, Fla., organ-specific profiles are being developed to replace a larger, more generaling chemistry panel. "We will have profiles for liver, anemia, and coagulation; an admitting profile; and a four-test panel of glucose, BUN, sodium, and potassium," administrative laboratory director Patricia Weitzner reported. The lab will institute a policy of requiring pathologist approval for profiles that depart from the lab's approved ordering sequence.
The laboratory at 204-bed Good Samaritan Hostpial in Pottsville, Pa., is devising liver, lipid, and other organ-specific profiles to supplement a broad chemistry screening profile, according to Patricia Baldwin, former chief technologist and now the hospital's director of quality assessment. "The old panel is still available, but iths not being ordered nearly as frequently. By eliminating many extraneous tests, we're ultimately saving the patient money." Clinicians now use the larger panel mainly for wide-ranging investigation of vague, nonspecific symptoms.
Overall, panelists reported an encouraging medical staff reaction to more cost-effective panel testing. Clinician response was rated generally positive i n 48 per cent of the hospital labs, mixed in 47 per cent, and largely negative in only 5 per cent.
At Good Samaritan Hospital, the new panels were developed by consensus among the pathologist, lab manager, chief technologist, and the medical staff. As a result, Baldwin said, clinicians have accepted the changes willingly. At other hospitals, laboratorians expressed frustration that physicians are clinging to old ordering habits despite the availability of more efficient options.
Many DRG experts recommend laboratory participation in hospital utilization committees, and almost 60 per cent of the surveyed labs are heeding that advice. These committees, however, have take little direct action to control or influence test ordering, laboratorians report. Only 21 per cent of the utilization groups have set up test ordering guidelines.
In addition, it seems that few physicians face any limits on test profile ordering (Figure VI). Only 7 per cent of the panel report that profile orders require prior approval by the medical department or other justification.
A similarly low percentage reported that their laboratories had developed protocols for automatic follow-up testing, also known as progressive, sequential, or reflexive testing. This extension of the laboratory's discretionary role has been heralded as one possible route to speedier diagnoses, but only 10 per cent of Hospital-based panelists and 20 per cent of those in independent labs report that they have explored it. Most algorithms in current use are simple test sequences based on commonly encountered abnormal results. One hospital lab's protocol for reflexive cardiac profile testing is shown in Figure VII.
Often, developments in test menus and profiles are closely linked to the acquisition of more advanced instruments. We asked the panel what new technologies their laboratories had acquired, or planned to acquire, for more economical testing. Interestingly, 41 per cent replied "none." In interviews, some of these respondents explained that their labs had already become highly automated in anticipated of greater productivity demands.
Among those who mentioned a specific new technology, chemistry instrumentation, computers, automated hematology instruments, and therapeutic drug monitoring analyzers ranked highest. Many of the 15 per cent who cited new chemistry analyzers are investing in the more selective random-access analyzers, rather than continuous flow instruments that perform every test on every specimen.
Finally, we asked panelists what major changes in test menus and profiles they expected in 1985 as a result of prospective payment (Figure VIII). Forty per cent foresaw no changes at all. A cut in overall testing and the elimination of some profiles and panels was predicted by 16 per cent, and 11 per cent expected the development of more organ-specific profiling. Only 5 per cent predicted an increase in protocols for progressive testing.
The ripples of change, then, are just beginning to influence test menus. Reality will take a while to catch up with or belie some of the health care experts' more futuristic predictions--for instance, that the laboratory will virtually disappear from the hospital setting, or conversely, that it will assume sweeping new powers in the diagnostic process.
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|Author:||Becker, Brenda L.|
|Publication:||Medical Laboratory Observer|
|Date:||Apr 1, 1985|
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