Utilization Management Rounds

Ordering the wrong laboratory test is a significant source of diagnostic errors that harms patients (1). This problem is particularly common in the realm of genetic tests (2,3). One important intervention for improving genetic test ordering is to flag these tests and provide active utilization management with a laboratory genetic counselor.

We are laboratory genetic counselors who actively manage genetic test requests from care providers throughout our health system. We are frequently asked how providers respond to our recommendations for order modifications. It may come as a surprise, but the general response from our providers is positive. It may be the counselor in us, but we have found that being gentle, collaborative, prepared, and persistent is the approach that leads to a good outcome. In addition, we don’t view our conversations with physicians as an approval or granting of permission to test, but rather as a side-by-side collaboration in which we attempt to develop a shared vision with the ordering provider.

In a previous article in Clinical Laboratory News, we focused on the importance of preparing for the utilization management conversation with providers (4). We presented a case that illustrated how preparation can lead to a better test order. In this article we explain how to be realistic about what results can be achieved with difficult interactions. Our main message is that laboratories should set realistic goals for utilization management so that they can be successful and maintain a positive working relationship with providers.

It is critical that the laboratory not see utilization management as a competition between the utilization management team and the ordering provider, in which the winner is the one who prevails in getting what they want. Of course it feels good when the best test is ordered for a patient. But you don't need to win every case. Your goal with each interaction should be to understand the details of the case and then educate the provider about the best testing options for that particular patient. The provider can then make an informed decision she feels is best for that patient’s care. Although the provider may not choose to modify the order after the first conversation, even though it would be best to modify it, the interaction will often influence her decision-making the next time she orders a test.

Sometimes it might take two or three rounds of the same conversation—delivered in a professional, friendly, collaborative manner—to get through to the provider. In the following example, the utilization management consultant suggests sequential, or tiered, genetic testing rather than concurrent testing for three genes. How the consultant handles the doctor’s response illustrates the difference between being realistic and unrealistic with a challenging provider.

Case Study
A call with unrealistic goals

Utilization Management Consultant: "Hello Dr. TiredandOverworked, I am calling about patient, Mary DifficultCase, medical record number 111222. I noticed that she had a blood draw today for three genetic tests. I am calling to discuss whether we might perform these tests in a tiered manner. I can assist you with coordinating sequential testing if you wish."

Doctor: "No, I'd like to have all three tests performed at the same time, thanks."

Consultant: "You would not need to have another sample collected. The lab can use the sample we have received for sequential testing of all three genes. We will manage it."

Doctor: "Thanks, but I told the family to expect all of the results within three weeks. I would have to call them if the testing will take longer."

Consultant: "Yes, I understand. You could call the family and point out that if the first gene tested confirms a diagnosis, they will still have their answer within three weeks. It would just take longer if the other two tests are needed."

Doctor: "True, but I can’t predict how likely it is that the first test will provide a diagnosis. This family seemed anxious for test results."

Consultant: "So you do not wish to tier testing because it may take longer to obtain results? If it would be helpful, I could find out if the tests could be performed with a faster turnaround time. We might be able to complete all three genes sequentially within six weeks instead of nine weeks."

Doctor: "I am in a busy clinic. I do NOT want to change this order. You are annoying me. Goodbye."

Consultant: "I find you annoying as well, and I don’t think you are optimizing this testing."

Here is a gentler, more realistic approach to the same situation.

Consultant: "Hello Dr. TiredandOverworked, I am calling about patient, Mary DifficultCase, medical record number 111222. I noticed that she had a blood draw today for three genetic tests. I am calling to discuss whether we might perform these tests in a tiered manner. I can assist you with coordinating sequential testing with this collected sample if you wish."

Doctor: "No, I'd like to have all of the tests performed at the same time, thanks."

Consultant: "I am available to discuss detection rate, turnaround time, and cost for each of the three tests if that would help with your decision to do concurrent or tiered testing."

Doctor: "Thanks, but I told the family to expect all of the results within three weeks. I will have to call them if the testing will take longer."

Consultant: "I understand. If you have any questions that I might answer about tiered testing options for future patients, I am glad to be of assistance. My name is Super Lab Genetic Counselor and I can be reached at…"

Doctor: "OK. Thank you. I will consider this the next time I order testing, before I quote a turnaround time to the family!"

Consultant: "Very good. Thank you. I look forward to speaking with you again in the future and I am always happy to help you with these orders."

Summary

In this case study, the doctor was not putting the patient at risk with the test order. However, he was setting up the patient to have more testing and to face more expense than was warranted. The second, realistic approach to the call sets up the consultant to have a good relationship with the provider. Furthermore, the consultant has increased the chance for success the next time a similar issue arises by strategically and concisely layering into the conversation three main elements to consider when weighing tiered testing options: detection rate, turnaround time, and cost. It is our experience that we are usually successful the second time around.

REFERENCES

1. Epner P, Astion M. Focusing on test ordering practices to cut diagnostic errors. Clinical Laboratory News 2012;38(7):17–8. Available at: http://www.myadlm.org/publications/cln/2012/July/pages/ReducingDiagnosticErrors.aspx


2. Dickerson JA, Cole B, Conta JH, et al. Improving the value of costly genetic reference laboratory testing with active utilization management. Arch Path Lab Med 2014;138:110–3.


3. Miller C. Making sense of genetic tests. Clinical Laboratory News 2012;38(1):15. Available at: http://www.myadlm.org/publications/cln/2012/January/Pages/PSFGeneticTests.aspx


4. Sternen DL, Conta J. Guiding providers to improve their test orders: Tips and tricks for improving utilization of genetic tests. Clinical Laboratory News 2013;39(10):18. Available at: http://www.myadlm.org/publications/cln/2013/october/pages/PSF-Improving-Test-Orders.aspx