Physicians have an obligation to eliminate waste

Physicians and the public are urging doctors to bring cost into consideration at the bedside when ordering laboratory tests and imaging studies.  Although diagnostic testing represents an important component of the rising cost of medical care, asking what a test costs is the wrong question.

Cost-saving shouldn’t begin at the bedside, it should begin by training the next generation of doctors to think in terms of value; not bang-for-buck or potential yield of a study per dollar spent, but rather the clinical value. One right question, which academic attending physicians have asked trainees for decades is: “how will this test change your management?”  Every test ordered should include a pre-test assessment of the patient’s prior probability of disease (in terms of objective epidemiology and subjective features of the presentation) and the test’s intrinsic performance characteristics.  Some tests are “better” than others for ruling-in a given diagnosis, others for ruling-out.  Evidence-based diagnostic testing strategies provide valuable clinical data at a cost that patients and payers are willing to accept because the results of appropriate testing have an impact on outcomes that are important to patients.

We object to the discussion of the “cost of a test” being posed to healthcare providers in isolation.  Healthcare expenses have skyrocketed so far out of the everyday price range.  We cannot conceive of what a trillion dollars is (our healthcare expenditure), because it’s just too big a number.  Emphasizing a US dollar value is coercive, because we interpret the value as we would an expense out of our own pocket.  Indeed, one recent trial showed that a weekly flyer announcing “cost” to residents was sufficient to reduce daily lab utilization.  This is akin to reducing laboratory tests by sticking residents in the arm with a needle every time they ordered a blood test on a patient.

Furthermore, it is reductionist to assign a price tag to a routine lab test.  Are we referring to the cost to an individual patient (which would be variable based on their insurance—if they have insurance), the cost to the hospital laboratory, or the amount billed to a third party payer by CPT code?  In order to truly understand the expense of a lab test, we would need to account for the cost of the million dollar automated analyzer in the medical laboratory, the service contract with the manufacturer of this machine, the cost of reagents, and the salary of the technologist who operates it.  These are all bills that the hospital pays in order to allow us to provide patient care, a laundry list that comprises the “cost of doing business” like the hospital’s air conditioning, supply of 4×4 inch gauze pads, or the actual laundry.

As physicians our obligation to eliminate waste includes not just minimizing out-of-pocket expenses for our patients, but also stewarding responsible use of hospital or system-wide resources. Perceived cost should not deter the appropriateness of  “morning labs” any more than the cost of a blood pressure cuff should be taken into account when obtaining the 6 am vital signs.

However, a patient who has had stable bloodwork and has already clinically recovered from her pneumonia certainly does not need her blood drawn on the day of discharge. She doesn’t need it because it is a needle in her arm, it is a waste of the phlebotomist’s time, and it is a waste of the lab’s time to run it.  Sound, patient-oriented clinical judgments save money too.

Benjamin T. Galen is an internal medicine physician, and Christopher T. Erb is a pulmonary and critical care physician.

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