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The Blue Cross crackdown on lab utilization.

The Blue Cross crackdown on lab utilization

The Blue Cross and Blue Shield Association has devised a controversial way to control test ordering: no reimbursement for a number of common diagnostic procedures if they do not address specific symptoms or patients at risk for certain diseases.

In cooperation with the American College of Physicians, the association developed guidelines on when to use the tests and when not to. These guidelines were unveiled in April. Now Blue Cross/Blue Shield will spend a year explaining them to physicians. Then, it appears, individual plans will begin to withhold payment for "inappropriate' tests.

The College of American Pathologists said the new approach may jeopardize quality medical care for millions of Americans. In the long run, "it will not be cost-effective and not in the best interests of the patient,' CAP president-elect William B. Zeiler, M.D., said.

Many common laboratory tests that now detect unsuspected diseases will not be performed under the Blues' guidelines, a CAP statement warned. "Physicians will be forced to choose between quality comprehensive laboratory medicine for their patients and the Blue Cross/Blue Shield alternative --medical decisions based on economics.'

In addition to 13 kinds of laboratory tests (see Figure I), the guidelines cover chest x-rays and electrocardiograms. Blue Cross/Blue Shield expects the plan to reduce national spending on tests by $6 billion a year. It estimates that $27 billion a year is currently spent on lab tests, $2 billion on chest x-rays, and $1 billion on ECGs.

Jared N. Schwartz, M.D., Ph.D., director of pathology and laboratory medicine at Presbyterian Hospital, Charlotte, N.C., commented on admission testing. "We're not trying to promote widespread screenings,' he said: "But for many patients the admission to the hospital is the first time in 15 to 20 years that they've seen a doctor. There are many examples in a lot of doctors' experience where some unknown problem, like anemia, was picked up as a result of a test done before a patient had hospital surgery.'

Dr. Schwartz is chairman of the CAP's program evaluation committee and a member of the microbiology resource committee. The latter was one of several CAP panels that reviewed and commented on the Blue Cross/Blue Shield guidelines when they were still proposals.

Press reports have stated that the guidelines are supported by such organizations as the American Society of Anesthesiologists, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Thoracic Society, and the American College of Radiology. Dr. Schwartz pointed out, however, that a Blue Cross/Blue Shield press release mentions these groups in connection with guidelines for chest x-rays, not those for laboratory testing.

And the American College of Obstetricians and Gynecologists had problems with guidelines covering such laboratory tests as routine urinalysis and urine cultures, Dr. Schwartz noted.

The guidelines do not just cover testing in hospitals but also apply to testing in physicians' offices. "Once the medical community realizes the implications of these guidelines, if indeed they are associated with reimbursement, there will be an uproar,' Dr. Schwartz said.

Finally, Blue Cross/Blue Shield spokesmen suggest the guidelines will provide physicians with standards they can follow to minimize their malpractice risk. It's quite possible, however, that malpractice suits will arise to challenge this push toward minimal testing.

Photo: Figure I The targeted lab tests
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Title Annotation:no reimbursement for certain routine tests
Author:Fitzgibbon, Robert J.
Publication:Medical Laboratory Observer
Article Type:editorial
Date:May 1, 1987
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