Utilization Management in Next Era of Healthcare Nudging Doctors Toward Evidence-Based Laboratory Testing

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In a recent article, Don Berwick describes three eras of healthcare: The first era, which began in antiquity and lasted until about 1970, was the professional era. In this era, physicians made all the decisions and were accountable only to themselves.

The second is the top-down management era, beginning alongside the emergence of modern health insurance and continuing through the present day. This era is epitomized by micromanagement of physicians by health insurers, regulators, and hospital administrators. It is also a corporate era in which healthcare administrators have multiplied and individually profited.

The third, hoped-for era, will be the era of clinical teamwork. This era, assuming that it actually comes to pass, will restore the centrality of the doctor-patient relationship. However, rather than reverting to the unmanaged professional era, the third era will provide clinically thoughtful managerial structures that support physicians in delivering efficient, evidence-based care. Physicians will need measurement and accountability to be sure, but without the bureaucratic micromanagement that currently clutters electronic medical records and eats up such a huge portion of a clinician’s day.

So what does this have to do with laboratory testing? Lots. We know that enormous variation and waste accompany the laboratory test orders that enter our laboratories. As doctors run frantically inside the clinical hamster wheels created by corporate bean counters, they have very little time to ponder the most efficient algorithms for placing laboratory results. They need help.

They need easy access to testing guidance, nudges toward evidence-based testing, and professional feedback when they deviate from recommended patterns. But these tools need to be provided in a professional, collegial fashion, overseen by trusted medical peers. Medicine is nothing if not complex. Patients’ disease presentations vary enormously, as do patient preferences.

 

Doctors need the flexibility to deviate from generally recommended practices, provided that they’re doing so in smart ways and for the right reasons. Local physician leaders have the professional background, proximity, and personal relationships to navigate such issues properly. Third-party payers, regulatory bodies, and non-clinically-trained administrators do not.

In recent years, certain commercial laboratories have developed partnerships with health insurers in an effort to micromanage physicians’ laboratory ordering practices. These top-down approaches burden doctors by forcing them to order through new IT systems and placing clinically arbitrary, patient-agnostic rules on which tests can and can’t be ordered.

At ARUP, we believe strongly in test utilization management. There is enormous quality to be gained and money to be saved by steering physicians toward more efficient, clinically appropriate testing. But we also believe that the right way to govern utilization is through local clinical leadership, not distant insurance companies.

We work with our clients to help them establish utilization management committees, detect and measure potentially inappropriate test ordering, and provide comprehensive online educational materials on best practices in laboratory testing.

Physicians’ clinical work can and should be managed, but it needs to be managed in ways that preserve and reinforce the centrality of the physician-patient relationship. And it needs to be managed in ways that take advantage of physicians’ expertise. Because in the end, the important thing is delivering value to the patient; not just delivering short-term profits to commercial laboratories and insurance companies.

By Brian Jackson, MD, MS, Vice President and Chief Medical Informatics Officer, ARUP