不适当的实验室检测:通过对医疗保险和商业支付方报销情况进行长达一年的大规模研究,量化了重大浪费现象。

Dave Smart, Jeff Schreier, Ila R Singh
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引用次数: 0

摘要

背景实验室检测超出了管理健康所必需的范围,被认为是低价值的医疗服务,会给患者带来风险并浪费资源。在全国范围内衡量过量检测对于识别浪费和优化医疗资源分配以达到最大效果至关重要:测量医疗保险和许多美国商业支付机构的不适当实验室检测及其成本:对 2019 年理赔数据进行回顾性分析,测量了 6,400 万名医疗保险参保者和 1.68 亿名商业保险参保者进行 4 项常用实验室检测的频率。化验项目包括 25- 羟基维生素 D、前列腺特异性抗原、血脂组合和血红蛋白 A1c。临床指南、医学文献和付款人建议被用来确定适当的检测频率。过量检测的成本是根据 2019 年临床实验室收费表计算得出的。对 2022 年数据的针对性分析证实了 2019 年的趋势:对 10 亿份门诊检验报销记录中的 8,400 万项检验项目进行分析后发现,7% 至 51% 的检验项目超过了建议频率,其中不乏严重过度使用的项目:例如每周进行血红蛋白-A1c 或前列腺特异性抗原检验。保守估计,4 项超量检测的成本超过 3.5 亿美元:这项涉及 2.32 亿人的广泛研究发现,在接受检测的 6050 万人中,有 1440 万人(23.8%)接受了过度的实验室检测,而这些检测可能几乎没有益处,反而可能造成伤害。将研究结果推广到所有实验室检测表明,仅医疗保险一项在 2019 年就可能产生了 19.5 亿至 32.8 亿美元的直接超额支出,这还没有考虑到过度检测的隐性成本(如下游护理)。解决不必要的检测问题对于降低成本和将资源转用于为患者带来更多益处至关重要。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Inappropriate Laboratory Testing: Significant Waste Quantified by a Large-Scale Year-Long Study of Medicare and Commercial Payer Reimbursement.

Context.—: Laboratory testing, beyond what is essential for managing health, is considered low-value care, posing patient risks and wasting resources. Measuring excess testing on a national level is crucial to identify waste and optimize healthcare resource allocation for maximum impact.

Objective.—: To measure inappropriate laboratory testing and its cost across Medicare and many US commercial payers.

Design.—: A retrospective analysis on 2019 claims data measured the frequency of 4 commonly used laboratory tests among 64 million individuals with Medicare and 168 million with commercial insurance. Tests included 25-hydroxy vitamin D, prostate-specific antigen, lipid panel, and hemoglobin A1c. Clinical guidelines, medical literature, and payer recommendations were used to determine appropriate testing frequencies. Costs of excessive testing were calculated using the 2019 clinical lab fee schedule. A targeted analysis of 2022 data confirmed 2019 trends.

Results.—: Analysis of ∼84 million tests from ∼1 billion outpatient test claim records revealed that 7% to 51% of tests exceeded recommended frequencies, with some egregious overuse: for example hemoglobin-A1c or prostate-specific antigen every week. The conservative cost estimate for 4 excess tests surpassed $350 million.

Conclusions.—: This extensive study, involving 232 million people, found that 14.4 million of 60.5 million individuals (23.8%) tested had undergone excessive laboratory testing, with likely little benefit and possible harm. Extrapolating findings to all laboratory testing suggests that Medicare alone may have incurred direct excess expenses from $1.95 to $3.28 billion in 2019, without factoring the hidden costs of excessive testing (eg, downstream care). Addressing unnecessary testing is crucial to lowering costs and redirecting resources for greater patient benefit.

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