I attended the Southwest LHIN Primary Care Congress today, during which Dr. Jeff Turnbull of Health Quality Ontario gave a great talk that touched on the need to curb utilization wherever appropriate. Certainly reducing unnecessary diagnostic tests and therapeutics is a passion of mine, as I wrote about in a previous blog post, Resolve to be a rationally prescribing and rationally ordering physician.
Of course this is not an easy topic to address. One physician’s unnecessary test is another physician’s appropriate test. Guidelines do give us some insight into relative right and wrong, but the freedom of physician judgement is still considered relatively paramount by many. The idea of financial punitive measures for “inappropriate” testing would be met by many physicians with fierce opposition. My hope is that through education, and not legislation, that we can optimize evidence-based ordering of tests.
Physicians know that a big chunk of utilization is driven by patients who are increasingly demanding tests that may not be indicated. Many of us spend multiple visits each day explaining to patients why Test A is not indicated, and it would be naïve to think that some physicians are not giving into these demands out of sheer fatigue. So part of the solution will have to be patient education in addition to physician education.
Idea #1: The provincial government mandates that any approved laboratory or diagnostic radiology site include an itemized/total cost amount for a particular set of tests on the bottom of any report that is sent back to a physician.
Rationale: We need to be honest that most physicians have no idea what the tests they order cost the system. Giving cost feedback after the fact may influence any unnecessary ordering next time around. Education is never a bad thing, especially when we know that the physician has a 100% chance of seeing that dollar figure.
Idea #2: A website set up where Canadian physicians would choose from a drop down menu: their province, lab or radiology, and the tests intended to be ordered. Using fee codes from the province, the website would calculate the projected total amount of the testing.
Rationale: This could be used in the office to illustrate to patients the cost of any testing they are demanding. Physicians would need to be careful not to give the impression that the test is being refused because of cost, but primarily because of lack of utility. The cost must be framed as simply an additional reason not to order the test. Physicians could also use the website independently to explore the costs of tests for interest’s sake.
Other ideas that would be harder to implement:
– Change the lab requisitions to be completely blank. If you want to order a test, you have to go through all of the trouble to actually write it out. This would be met with resistance by physicians who would argue that it would take more of their time. In reality, the unnecessary tests cost far more than a few extra seconds of thought. If there are a block of tests you order for a certain condition, you can write them out for reference somewhere convenient, but the requisition must be free-form. Removing the TSH and B12 from the Ontario requisition was difficult enough, so this idea may stagnate.
– Provincial governments to create a secure database where patients could access a list of all medical costs incurred on their Health Card over the past year. The arguments against this idea are many: cost of maintaining the system, privacy, whether high-utilization patients should feel stigmatized by the overall cost, the fact this is unlikely to change patient behaviour (when they want a test, they want it now, they don’t care what their cost was over the past year.) I could live without this database, but it’s something to consider.
I hope that a combination of provincial governments, the CMA, provincial associations, and the Choosing Wisely campaign see some potential value in the first two ideas, as even in the absence of empiric data, I think the potential for savings is self-evident.