Blue Cross to Seek Cutback in Lab Tests

In an unprecedented move to eliminate “unnecessary” medical lab tests, the national Blue Cross and Blue Shield Assn. today announced guidelines to discourage physicians from indiscriminately ordering routine blood tests, chest X-rays and electrocardiograms.

The guidelines are expected to affect the care of the estimated 75 million Americans insured by Blue Cross or Blue Shield and also could influence the reimbursement policies of other private insurers as well as Medicare and state Medicaid programs.

Payment of Claims

The recommendations are not likely to be enforced on individual payment of claims for Blue Cross or Blue Shield subscribers, according to Dr. Ralph Schaffarzick, medical director of Blue Shield of California and a drafter of the guidelines. Instead, insurers can use the guidelines to identify health care providers who do not follow the recommendations.

“If physicians, groups of physicians or hospitals are found to be routinely using tests inappropriately, we will discuss this with them and try to modify their patterns of practice,” he said in a telephone interview from San Francisco. “But it would be pragmatically impossible to apply the guidelines through the routine payment process (for individual claims).”

The 79 state and regional Blue Cross and Blue Shield organizations must decide on an individual basis whether to adopt the guidelines, and they are expected to do so. Blue Shield of California is to discuss them at a meeting in Los Angeles on May 27, Schaffarzick said.

The recommendations were developed in conjunction with the American College of Physicians, which represents most internists, and are to be presented today at the group’s annual meeting in New Orleans. They are based on a series of articles on diagnostic testing by academic experts commissioned by the Chicago-based Blue Cross-Blue Shield and published in the college’s Annals of Internal Medicine.

The nation is “spending $6 billion to $18 billion a year on procedures which do not aid in the diagnosis or treatment of illness,” said Bernard R. Tresnowski, the association’s president.

Instead, tests should be used selectively, for example by limiting presurgical chest X-rays to patients with known or suspected chest disease, according to guidelines.

But even before today’s official announcement of the guidelines, the College of American Pathologists had issued a statement criticizing them, saying such rules would jeopardize “quality medical care.”

The guidelines “are simply too restrictive and not workable,” said Dr. Jared Schwartz of Presbyterian Hospital in Charlotte, N.C., a spokesman for the organization whose 10,000-member physicians run medical testing laboratories.

AMA Caution

The American Medical Assn. reserved specific comment, but its chairman cautioned that overemphasis on “cost-effective” medicine might harm patients.

“The identification of a serious problem may be improbable, but if it happens to one patient, the probability is 100%,” said AMA Chairman Alan R. Nelson, a Salt Lake City internist, in a telephone interview. “The American public wants that protection.”

The Blue Cross-Blue Shield guidelines cover the 15 most common categories of medical tests for screening, diagnosing and monitoring patients. These lab procedures account for much of the $30 billion spent in the United States each year for medical testing. Between 20% and 60% of these tests are estimated to be unnecessary, according to David Tennenbaum, an association official.

The most widely used tests are blood counts, which are used to detect anemia, tumors and infections, and biochemical profiles, which simultaneously determine cholesterol, blood sugar, kidney function and up to 10 to 20 additional chemical measurements. Other common tests include cultures of the blood or urine to diagnose infections, tests for syphilis and measurements of blood clotting.

In recent decades, with increased emphasis on the use of lab tests to diagnose illnesses, many patients and physicians have come to equate good medical care with extensive testing, regardless of whether the patient is likely to have the condition a test is designed to detect. Such test-ordering is most commonly done when patients undergo complete physicals or enter the hospital.

Malpractice Suits

Some doctors also order extensive tests to protect themselves against possible malpractice lawsuits for failure to diagnose an unsuspected malady.

Thus, while most hospitals have eliminated as wasteful “routine standing orders” for laboratory and X-ray procedures on newly admitted patients, many physicians have simply ordered the same test themselves.

But in recent years, a growing number of academic specialists has urged their colleagues to spend more time examining and talking to their patients and to limit their test-ordering. Other physicians, however, maintain that limitations on test-ordering could interfere with good medical care.

As an example, Schwartz of the College of American Pathologists said the guidelines might end reimbursement to pathologists for microscopic examination of some surgical specimens, such as the placenta delivered during a Caesarean section. Such an examination can provide important information about the mother’s health, he said.

“A Caesarean section is not a routine procedure,” Schwartz said. “Microscopic examination of the placenta may be important in determining the reason a Caesarean section was required.”