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Escalating Health Care Cost due to Unnecessary Diagnostic Testing MUHAMMAD AZAM ISHAQUE CHAUDHARY*, AND ASIM NISAR**
RECEIVED ON 12.05.2016 ACCEPTED ON 16.08.2016
ABSTRACT
Focusing on health care systems can improve health outcomes now and in the future. Growing economies
have serious concerns on the rising cost of health, whereas, in under developed countries like Pakistan,
it is not emphasized yet at all. The research is conducted to improve a unique aspect of health care
systems to provide effective, patient-centred, high-standard health care while maintaining the cost
effectiveness. Research is being qualified in two paradigms qualitative and quantitative. In qualitative
research, expert’s interviews have been taken to get the basic knowledge of radiology based testing and
their prerequisites, in quantitative research ordered are being analysed to check the frequency and if
they are unnecessary or qualified medical necessity guidelines as established in qualitative method.
Analysis was made on the basis of the trinity relationship of diagnosis, symptoms and respected order to
determine the necessity of the order to get its impact on cost of the overall health of those patients and
point out more than 50% unnecessary orders are being performed in two government hospitals. The
situation is alarming and policy makers should focus on unnecessary ordering to avoid out of pocket
expenses and improve quality of care. The research helps in successful application of health care system
modifications and policies pertaining to one aspect of health systems, i.e. cost-effectiveness of health
care.
Key Words: Cost-Effective, Health System, Radiology Orders.
* Department of Engineering Management, Center for Advanced Studies in Engineering, Islamabad. * * Asian Institute of Technology, Thailand.
Mehran University Research Journal of Engineering & Technology, Volume 36, No. 3, July, 2017 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 5 6 9
1. INTRODUCTION
what resources are required. Health systems and health
systems research leads to the creation of scaffold that
must satisfy the demands and needs of its constantly
dynamic building blocks. Health care is a management,
treatment and prevention of disease or illness; it also
refers to the physical well being through health service
providers and hospitals. How are you? It is that simple
question which is being asked by every two humans
when they meet. This simply relates the concern of one
to another about knowing his/her current physical,
H uman minds have a limited ability to grasp
and process multiple pieces of information
simultaneously, but they desire to produce
more to reap more benefits. A high level of productivity
requires dropping the quantity/extent of information to
be analyzed every time to only the most necessary and
vital data. Developing a regular routine work in advance
leads to the creation of frameworks, and sticking to it
consistently wipes away the difficulty of thinking about
what needs to be done, its sequence, and when and
Mehran University Research Journal of Engineering & Technology, Volume 36, No. 3, July, 2017 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 5 7 0
Escalating Health Care Cost due to Unnecessary Diagnostic Testing
mental, financial and social status. We are concerned
here about the physical and mental health of human
beings that is one of the top concerns of humanity.
Nowadays quality of care has become too expensive
[1]. Not everyone can easily afford it. Health care
expenditures are growing around the world in an alarming
rate. The United States spends 17% of their GDP (Gross
Domestic Product). They are forecasted to reach 20.3%
of their GDP which equals to $4.4 Trillion dollars [2].
OECD (Organization for Economic Cooperation and
Development) countries average spending more than
7% of their GDP [3]. Such an alarming rise creates many
risks for the sustainability of the future of health of the
world. Now the question is where the health care cost
goes? There are various ways to see health expenditures,
although it is clear that cost may be increasing due to
increasing cost of drugs and medicine, increasing rate
of emergency to inpatient ratio, and excessive laboratory
testing’s [4]. Due to technological advancement doctors
start relying on technology to diagnose problem and
that increases the cost. Our focus is to highlight
expensive laboratory testing in Pakistan and see if these
are being ordered right with proper diagnosis along with
chief complaint or if it is just a wastage of money and
resources. Such research has never been conducted in
Pakistan before that may help policymakers to establish
certain policies pertaining to health systems to improve
overall health of individuals along with decreased cost
of care.
2. LITERATURE REVIEW
Pakistan is currently 6th most populous country with a
population of more than 191 million people and an annual
growth rate of 4% per annum. No satisfactory attention was
given till the 1970’s. Afterthat a 5 year plan was introduced
to take care of infrastructural growth, but it was still limited
to the government employees and the total spending was
only 1% of the GDP. The rest was an out of pocket expense
[5]. According to WHO (World Health Organization), they
defined Health as a state of absence of any disease and a
complete wellbeing “physically and mentally” [6]. Health
system is defined in several ways. “WHO’s defines “Health
Systems” as “All activities with the primary objective to
promote reinstate or maintain health”. All such activities are
usually grouped into six classes that include service delivery
as well as, the health workforce, including health information
system related Medical products, vaccines and technologies,
health system financing and governance with right kind of
leadership [7]. The another way of defining Health systems
is based on the actors contributing to the system. Van
Atteveld et. al. [8] reviewed 144 studies on health care and
global health research. They concluded that most of the
studies lacked analytical models mostly descriptive,
economic approach dominated, and there were no
comparison among different systems.
Alliance for health policy and system research studied and
listed 41 health system frameworks developed till now [6]
few have been developed for better knowledge, comparisons
among different frameworks their performance [9].
Researchers believe that nowadays medicine has prompted
communication among each other and different nations
readily borrow ideas from another country’s experiences.
According to their own cultural setting they alter and modify
ideas. But due to procedural variations among them and
different structures of individual nations, developing an
appropriate analytic framework that is good for everyone is
yet to be done. There is no particular system or framework
that covers all aspects of healthcare. The background of
each healthcare system has its own dependence on several
actors and environment which fails to create a basis for all
[10]. Common health fund recently published a study by
comparing 18 different health systems around the world but
are still unable to provide any specific system that fits for all
[11]. In a recent comparison of health care systems around
the world, it was evident that caring needs are touching high
Escalating Health Care Cost due to Unnecessary Diagnostic Testing
Mehran University Research Journal of Engineering & Technology, Volume 36, No. 3, July, 2017 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 5 7 1
expectations and viz a viz cost containment is also required
including laboratory services for a sustainable growth in
health care services [12].
The question frequently raised in health policy debates is,
“Will health systems be financially sustainable in future?” It
is usually termed as the ability of the governments and others
to sufficiently finance health care in the face of growing cost
pressures, with the following three most commonly cited
challenges named as population ageing, innovation or new
technologies and quality of care which is consumer
expectations around the world. Although the idea of
‘financial sustainability’ comes into view to be vital to health
policy debates, but still it has not been part of most health
system objectives, including those of the WHO’s health
system performance framework” [6].
The problem of financial sustainability can be broadly
characterized in the following three ways which includes
increased health expenditure due to demand and supply of
health services, technological progress, demographic
changes and consumer expectations. Some believe limited
resources or an inability of government or unwillingness
to generate sufficient resources to meet its health system
obligations which might be due to financial crisis [13].
Substantial research has been done by different institutes
and researchers on why health care costs are raising across
the globe. The factors that get most attention are connected
with the increasing volume of services used. These include
the following parameters coupled with rising income and
expectations are technology advancement, population
ageing and changing utilization patterns. Although it
depends upon country as per their clinical setting,
operating methods, and specific case evaluated, studies
have evidently reported that up to 40% of lab testing can
be considered as wasteful [14-17].
It is evident from the analysis and projections that the
population ageing contributes comparatively less to rising
health care costs in comparison to technological
modernization (10% less of the growth in health care costs)
[18-20]. Health care expenditures are rising in at alarming
rate. Advancement in technology is one of the key factors in
raising heath care cost which is laboratory orders [21]. From
2005-2010 it is evident that laboratory testing cost increased
by 29% of the total health care cost in United States [22]. Fig.
1 shows Health expenditures as a share of GDP of OECD
countries.
FIG. 1. HEALTH EXPENDITURE AS A SHARE OF GDP OECD COUNTRIES 2015 [23]
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Escalating Health Care Cost due to Unnecessary Diagnostic Testing
Getting quality of care is the right of every human in this
world but nowadays cost of health care is becoming a raising
issue as quality of care is directly proportional to the cost of
health care. This relationship forced policy makers, and
researchers to devise a strategy of lowering the costs. Now
some suggest to see health care professionals other than
doctors, and put emphasis on telemedicine, and believe that
a cure is better than care [24].
Because of rising healthcare costs, USA took few steps to
control the rising cost of healthcare. Successful efforts were
made for the mandatory use of electronic health records,
along with introducing physicians quality reporting system,
and creating medical necessity policies as to check and
perform an analysis whether the service is planned to deliver
medically required/ necessary for the patient or it is not
required. Emanuel elaborates that simply by reducing
avoidable health complications, there could be more than
10% of saving per year [25].
3. RESEARCH GAP
Currently top spending nations are following utilization
pattern to regulate care needs and see whether the service is
required or not. This concluded to be creating local coverage
policies, but it happens when some specific area or people
start providing that kind of services. There is a requirement
to check and analyze the patterns on laboratory orders and
specifically high cost orders that are made to contain cost in
health care. This research specifically focuses on Pakistan
to check if unnecessary tests have been ordered as compare
to the rest of the world and devise a strategy to stop
unnecessary testing and create check and balance to reduce
wastage of money and resources.
4. RESEARCH METHODOLOGY AND DATA ANALYSIS
Research is being qualified in two paradigms qualitative and
quantitative. In qualitative research, expert’s interviews have
been taken to get the basic knowledge of radiology based
testing and their prerequisites. Question were being asked
with respect to the specialty and create a basic understanding
of why imaging orders have been placed and study all those
procedures in which medical decision making are involved.
Research methodology of the paper is be described as
shown in Fig. 2.
FIG. 2. RESEARCH METHODOLOGY FLOW DIAGRAM
Escalating Health Care Cost due to Unnecessary Diagnostic Testing
Mehran University Research Journal of Engineering & Technology, Volume 36, No. 3, July, 2017 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 5 7 3
We initiated the research with a simple question that whether
in Pakistan the radiology orderings are based on medical
necessity or not? In order to get the answer of the question
the research methodology selected was qualitative and
quantitative. The qualitative research was conducted
through interviewing physicians about the radiology
orderings and its basics that can be seen from Fig. 3. The
quantitative research helped us to compile relevant and
specific data and analyze it for findings that can be seen
from Fig. 4.
On the basis of qualitative research, quantitative research
was carried out in which retrospective data of radiology
investigation was collected for six months from two reputed
government hospitals of Islamabad and Rawalpindi.
Methodology used to understand and investigate the domain
and problem respectively is shown in Fig. 3.
Light blue ordering techniques were selected as primary
source of investigation because of the fact that these are
most ordered procedures are costly as well.
After qualitative research data collection was carried out to
investigate whether unnecessary tests was being ordered
or not. This methodology is described as shown in Fig. 4.
The underlined research methodology helped us to gather
data pertaining to the distinct radiology orders. Total number
of orders which had considerable information documented
were 2395.All the imaging studies were being ordered by
different physicians including x-ray, ultrasound, MRI
(Magnetic Resonance Imaging) and CT (Computed
Tomography) scan and other laboratory orders but only
MRI and CT scan were included in this study. These radiology
orders were charted on the basis of cost as these were the
FIG. 3. QUALITATIVE METHOD FLOW DIAGRAM
Mehran University Research Journal of Engineering & Technology, Volume 36, No. 3, July, 2017 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 5 7 4
Escalating Health Care Cost due to Unnecessary Diagnostic Testing
most expensive laboratory diagnostic orders. First total
number of MRI and CT scan were identified other than
emergency patients. Only inpatient and outpatient facility
were taken in this study. The reasons of prescribing MRI/
CT scan were identified. Analysis was made and following
were the results. Table 1 shows total MRI/ CT scan stats.
Data shows that CT scans were ordered more on female
whereas more MRI ordered on males. Total 166 MRI/CT
Scan orders were analyzed. These are all being ordered
in outpatient and inpatient facility. None of the order
were based on monitoring was analyzed. Then analysis
were made on the basis of symptomology in each gender
as shown in Table 2 to identify reason of unnecessary
orders.
Table 2 shows diagnosis/complaints on which various
orders have been made, but out of 166 orders data,
showed that 99 orders were placed due to user defined
complaints without prior physician’s clinical evaluation
to justify the test requirement and medical necessity.
Although very less document evident exists, at the
time of order reason were not clearly written or
identified. Rest 67 orders have rational of being
prescribed.
5. RESULTS
Most of conclusion/findings of the study showed normal
study which creates an alarming situation and proof the
concept of unnecessary orders have been performed in
Pakistan as well. As stated above, researchers believe
40% of laboratory testing is unnecessary but in case of
Pakistan data shows more than 50% of testing is
unnecessary. As shown in Fig. 5, data showed that out of
166 studies, 77 studies findings were normal and 17
findings were unknown because of some technical issue
or tests not performed well. According to experts these
77 studies which ere found normal can be further reduced
by careful clinical examination.
As shown in Fig. 6 maximum number of orders have
been made on user defined complaints. During interviews
most doctors said that when pateints vist them in service
doctor most of them answered as patient visit us in
severe painan order of MRI and or CT scan was most
commonly ordered.
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TABLE 1. MRI/CT SCAN ORDERED STUDIED
FIG. 4. QUANTITATIVE METHOD FLOW DIAGRAM
Escalating Health Care Cost due to Unnecessary Diagnostic Testing
Mehran University Research Journal of Engineering & Technology, Volume 36, No. 3, July, 2017 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 5 7 5
From Figs. 5-6 results shows that more than 50% of the
diagnostic orders made were unnecessary (combining the
normal findings and unknown findings together), this all
adds extra burden to financial cost. Country like Pakistan
if we analyze last seven years i.e. (since 2007-2008 Rs. 60
billion to 2013-2014 Rs. 102 billion) have been allocated
for the health sector, which is merely equal to 1% of their
GDP. Recently Government of Pakistan has also allocated
Rs. 2/- Billion under Prime Minister National Health
Program to become a welfare state without having any
policies in place and check and monitoring of quality of
care. By analyzing above findings there is a need of expert
system be designed to formulate policies to stop
unnecessary testing and save cost. Orders should be
prescribed as per medical necessity guidelines and if
proper documentation and history of the patient
formulates the basis of order then test should be
performed, otherwise it should be referred to the review
process. This way unnecessary radiation exposure can
be reduce and out of pocket expenses can also be
minimized.
6. RESEARCH LIMITATIONS
Medical necessity applies to all aspects of practicing
medicine but the scope of this research limits its boundaries
by focusing only on medical necessity of imaging orders.
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ssenizziD 2 1 3
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hsaR 1 1
htaerBfossentrohS 1 1
smelborPyranirU 2 2
tnialpmoCdenifeDresU 12 02 14
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TABLE 2. MRI/CT SCAN ORDER DIAGNOSIS DETAILS
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Escalating Health Care Cost due to Unnecessary Diagnostic Testing
FIG. 5. MRI/ CT SCAN RESULTS FINDINGS
FIG. 6. SYMPTOMOLOGY GRAPH W.R.T MRI AND CT SCAN ORDERS
7. CONCLUSIONS
The rapid growth in the medical sciences has kept things
difficult for the human beings to cope up with the changing
domain knowledge. From very basic of surgery to basic
body checkup, medical practices have taken a new turn.
The core reason is the ongoing research throughout the
world that is adding valuable information about human
body. With the changing medical practices, it is imperative
that the associated procedures must also evolve. There
are various phases of evolution that have taken place in
medical practices, however, the need of a standardized
medical practice has still remained a key challenge. In
earlier days, physicians generally relied on the physical
check up to determine the root cause of any disease.
With the advancement in technology and availability of
modern day equipment, the reliance has generally reduced
on physical checkups. Rather all the physicians generally
rely on medical tests for determining the root cause of a
disease. This research opens a new era of cost
containment in health care industry. Policy makers and
healthcare financial analysts will get benefited from it to
lower down the cost of providing care by developing
knowledge base decision support system. Health care
insurances will also get benefited from the research to
evaluate the healthcare claims. This is one of the biggest
reason that no insurances are covering health care
benefits as without check and balance, anyone can order
any kind of expensive or inexpensive testing without
documenting a proper diagnosis. More than 50% of orders
that have been made will be an eye opening situation for
the policy holders. Any test that have been ordered must
comply medical necessity guidelines, and be placed after
clinical examination which will reduce unnecessary
exposure to the radiations and healthcare cost. Experts
have the opinion that a clinical perspective of medical
necessity is very rare, it merely goes with the
organizational culture desire and most often influenced
by the physicians and lied in the health care compliance
context. It is very important here to understand that if a
service rendered to a patient that is not medically
demanded, it can save money if some framework or
policies have been implemented to monitor the care
delivery process. Cost effectiveness of the health care
system needs to be prioritized throughout the world,
especially in developing countries like Pakistan, where
more than 50% of people are below the poverty line.
Escalating Health Care Cost due to Unnecessary Diagnostic Testing
Mehran University Research Journal of Engineering & Technology, Volume 36, No. 3, July, 2017 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 5 7 7
Morbidity and mortality rate can be reduced by
emphasizing on treatment rather than unnecessary
investigation.
8. FUTURE RESEARCH
Future research can be carried out on unnecessary
prescription and other laboratory orders to improve health
care in Pakistan and decrease cost of care. Such research
analysis forms the basis for policy makers to design effective
policies for better health care.
ACKNOWLEDGEMENTS
Authors are highly thankful to Higher Education
Commission of Pakistan, for the provision of scholarship
for higher education and research. Authors are grateful
to anonymous reviewers, for reviewing the paper along
with editorial board and providing valuable feedback.
Authors also acknowledge the hospitals and doctors who
shared clinical data and played a key role to successfully
complete this research.
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