Test Utilization: Payment Policies More Effective than Practice Recommendations in Curbing Orders of Low-Value Tests

When it comes to getting physicians not to order low-value laboratory tests, money talks. At least, that is the punchline of a new study finding that changes in payment policies are more effective than clinical practice recommendations in curbing utilization of low-value tests.

The Diagnostic Challenge

Overtreatment or low-value care accounts for roughly $75.7 billion to $101.2 billion worth of waste in the US. And those estimates are probably well below actual costs to the extent that “tests beget tests” and lead to unnecessary medical procedures. But while overutilization of low-value tests has been well documented, the question of how and why these patterns continue and how they can be changed has received far less attention.

Of course, there have been initiatives to reduce such overutilization, particularly via programs to educate physicians about the problem and recommend best practice guidelines discouraging them from ordering low-value tests. One notable example is “Choosing Wisely,” a set of recommendations from the American Board of Internal Medicine.

The JAMA Study

Published online on Feb. 10 in JAMA Internal Medicine, the study is based on cross-sectional analysis of claims data to compare the effects of the Choosing Wisely recommendations versus payment policies for two laboratory tests that have long been associated with overutilization and low value: screening for vitamin D and thyroid hormone triiodothyronine (T3) levels. The researchers looked at records from three different health systems covering roughly 54 million people:

• The US Veterans Health Administration (VHA);
• The US employer-sponsored insurance market; and
• Ontario, Canada (one of the places where the Choosing Wisely recommendations have been adopted).

Vitamin D and T3 are both on the list of low-value tests that Choosing Wisely recommends physicians not use for broad, population-based screening. And Canada is one of the more than 20 countries that have adapted the Choosing Wisely recommendations. But Ontario differs from the other two systems in one regard: In 2010, it instituted a payment policy to eliminate coverage for broad vitamin D testing.

The Findings

The researchers found that vitamin D testing in Ontario declined 92.7%(!) after the new payment policy took effect. By contrast, the declines in testing after publication of the Choosing Wisely recommendations against broad vitamin D screening were far more modest, including:

• 4.5% in Ontario;
• 13.8% for the VHA; and
• 14% for US employer-sponsored insurance.

But that was not all. The study also found that low-value T3 testing actually increased—albeit only by small levels—after the release of the Choosing Wisely recommendations, including:

• 0.3% in Ontario (where the 2010 payment policy affected only vitamin D and not T3 screening);
• 0.7% for the VHA; and
• 3% for US employer-sponsored insurance.

Takeaway: The Need for a Diverse, Balanced Approach

The findings suggest that recommendations alone may be insufficient to significantly reduce utilization of low-value services and that pairing recommendations with policy changes may be more effective, concluded the study authors led by James Henderson, PhD, from Consulting for Statistics, Computing & Analytics Research (CSCAR) at the University of Michigan. At the same time, the authors acknowledged that payment policy changes may go too far and may need to be accompanied in additional interventions, including payment incentives, to avoid the potential for underutilization of needed services.