Should we be Stewards of the Healthcare Dollar?

Recently I have been questioning the return on investment of laboratory testing and who’s paying attention to the cost. Just because we can order a test, should we? Without clinical context, what laboratory tests really make sense? How many of us know the true cost of the labs we order?

I recently had the opportunity to look at multiple practices’ lab ordering patterns. The disparity among pediatricians who are all practicing great medicine was striking to me. One large practice had ordered hundreds of chlamydia screens on teens with not one single positive in a three month period. Another group ordered CBC, TFTs and Lipid Panels on all adolescents girls prior to their records being transferred to an adult provider. Some practices were ordering Flu A/Flu B on a large number of patients with cough/fever in May and June. Another appeared to order a large number of Vitamin D levels on patients of all ages. Is any of this bad medicine? No. Is it the most cost effective care? Probably not.

I am inclined to think that much of this lab ordering is driven by three issues:

  • Conscientious doctors trying to follow published guidelines from the AAP or the US Preventive Task Force
  • Caring doctors who want to reassure a parent or avoid a missed diagnosis
  • Most providers don’t even consider the costs of the tests we order

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Many practices are incorporating the chlamydia screening guidelines to fulfill the HEDIS measure. Yet we know that there are wide inaccuracies in how sexually active patients are defined based on claims and pharmacy data. A quick survey of the cost of urine screens for chlamydia varied from $48 to over $150, and sometimes those costs become the patient responsibility.

On June 30th, the AAP published updated guidelines for screening adolescents and young adults for STIs. The changes have moved beyond chlamydia screening to include additional testing and follow-up. The question becomes, should every practice follow the guidelines explicitly or in some cases are we over-testing?

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A survey of lab costs puts Lyme ELISA at anywhere from $225-385. For those patients with vague symptoms that we KNOW don’t have lyme, is it really worth that amount of money to reassure a parent? This is especially concerning when we know how inaccurate results can be in the context of low clinical suspicion. Measuring Vitamin D levels can cost between $50 to $250.

Should we order tests on every patient with fatigue, or advise them to get at least 8 hours of sleep and take make sure they get adequate nutrition including Vitamin D before we order the test?

As science moves towards more available testing, and insurance companies are cost-shifting, creating higher out of pocket expenses for patients, who is better positioned to be stewards of the healthcare dollar than those of us ordering the tests? The next time you decide to incorporate new guidelines or order labs because a parent asks you, think about the value of knowing the result. Will it change your care for the patient? If it was your money, would it alter which boxes you check?


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