Testing, Testing… $, $$, $$$

If doctors knew the exact price of expensive medical tests would they order fewer of them?

That’s exactly what Johns Hopkins researchers wanted to know.

The answer has just been published in the Journal of the American College of Radiology, and it’s a resounding: No!.  According to the investigators, revealing the costs of MRIs and other imaging tests up front had no impact on the number of tests doctors ordered for their hospitalized patients.

“Cost alone does not seem to be the determining factor in deciding to go ahead with an expensive radiographic test,” says the study’s senior author, Daniel J. Brotman, M.D., director of the hospitalist program at The Johns Hopkins Hospital. “There is definitely an over-ordering of tests in this country, and we can make better decisions about whether our patients truly need each test we order for them. But when it comes to big-ticket tests like MRI, it appears the doctors have already decided they need to know the information, regardless of the cost of the test.”

Some earlier studies have suggested that much of the expense of laboratory tests, medical imaging and prescription drugs is unknown or hidden from providers and patients at the time of ordering, leaving financial considerations largely out of the health care decision-making process and likely driving up costs. Other studies have shown that doctors ordered fewer laboratory tests in some cases when they were given the price up front.

But, imaging tests appear to be “a different animal.”

Although there are certain inherent disincentives, aside from cost, to ordering some major tests, such as the potential danger of radiation used, physicians also need to learn how to explain to patients why they may not need them.

For the six months of the study, Brotman and his colleagues identified the 10 imaging tests most frequently ordered for patients at The Johns Hopkins Hospital. Five of these were randomly assigned to the active cost display group and 5 to the control group. During a 6-month baseline period from November 10, 2008, to May 9, 2009, no costs were displayed. During a seasonally matched period from November 2009, to May  2010, costs were displayed only for tests in the active group. At the conclusion of the study, the radiology information system was queried to determine the number of orders executed for all tests during both periods.

And, when they compared the ordering rates to the rates from a six-month period a year earlier, when no costs were displayed at all, they found no significant difference in ordering patterns.

Is this a good or a bad thing?

Certainly there are many instances when expensive tests are justified. When a key diagnosis is needed there are limited options for comparison shopping.  For example, when a patient appears to have had a sub-acute stroke, an MRI is needed regardless of cost.

That is not to say there aren’t times when physicians need to look more closely at whether too many imaging tests are being ordered. Do ventilated intensive care unit patients really need a daily chest X-ray to look for potential lung problems?  Especially when there is good medical evidence that outcomes aren’t compromised if X-rays are ordered only when the patient’s condition appears to be worsening.

“For too long, there has not been enough attention paid to the bottom line in health care,” Brotman says. This isn’t about rationing care to hold down costs, he says, but about choosing tests a little more wisely.

Even though price transparency didn’t influence the way physicians ordered imaging tests in this study, financial considerations may play a role in other circumstances if tied to clinical evidence.

If you show a provider that he or she is ordering four times as many CT scans as a colleague whose patients have similar outcomes, it could change the decision-making calculus for the better.

“Cost transparency must be part of the solution to solving fiscal challenges in medicine,” Brotman says. “Providers have no idea how much they’re spending. Patients don’t know either. Having everyone understand more of the economics of health care is a great place to start cutting costs in medicine.”

Seems logical to us.