Michael Astion, MD, PhD, division chief, Laboratory Medicine
Imagine getting a $2,000 bill for a laboratory test, and then finding out the test wasn’t necessary and didn’t help doctors treat your child. Two years ago, Seattle Children’s saw more and more families getting stuck in this difficult position. So administrators asked Dr. Michael Astion and colleagues to identify when certain tests are unnecessary, and to help doctors pursue more affordable testing strategies. Now his team is spearheading an innovative project that could save families, hospitals and insurance companies millions of dollars a year.
“A lot of doctors have a 'more testing is better' mentality,” says Astion, division chief of Laboratory Medicine and a principal investigator in Seattle Children’s Research Institute’s Center for Child Health, Behavior and Development. “We need to pay closer attention to whether a test represents a good value for patients and families.”
Bonnie Cole, MD, Pathology
Right now, Astion’s team – which includes Drs. Bonnie Cole, Jane Dickerson, Stephanie Wallace and Rhona Jack, as well as a genetic counselor, Jessie Conta – is focused on maximizing the value of genetic tests. These can pinpoint the mutations behind a patient’s condition, and they’re becoming far more common as researchers identify more disease-causing mutations. They’re also expensive, costing anywhere from several hundred to several thousand dollars, and insurance often doesn’t cover them.
“A lot of these tests are ordered by pediatricians who are not medical geneticists and they don’t know how expensive they are, and might not be up to date on which test is going to give them the best information,” Astion says.
Jane Dickerson, PhD, co-director, Chemistry; associate director, Reference Lab Services
For example, a doctor might know that one of seven mutations could cause a patient’s condition, and then simultaneously order tests for all of them. They might not know that two mutations cause 85% of cases and that it’s wiser to test for those first. That’s when Astion’s team steps in.
They’ve developed a process for reviewing every request for a genetic test that costs more than $1,000. Collaborating with Jessie Conta, a genetics counselor, and Dr. Stephanie Wallace, a medical geneticist, as well as other pediatricians in the Division of Medical Genetics and the Division of Neurology, the team investigates whether the test could give useful information about the patient’s condition. About 70% of the time, they find that the doctor ordered the right test. The rest of the time, the team sees a way to reduce the testing’s cost or avoid it altogether. Then they walk the doctor through what they found.
“A lot of times we recommend that doctors follow a stepwise approach, testing for the most likely mutation first and then gradually working their way through the rarer mutations,” Cole says.
It’s up to the doctor to decide whether to change or cancel or test.
“If a doctor still wants a test, we still do it,” Astion says. “Usually, they’re surprised to hear that insurance won’t cover it and are happy to take a more cost-effective path.”
This approach has saved roughly $120,000 in testing fees in less than a year. That translates into around $470 in savings for every test request the team reviewed. And that’s just the tip of the iceberg. The team is broadening its focus beyond genetic testing and identifying other tests that are overused or mistakenly ordered. Along the way, they’re developing standardized policies and procedures that hospitals nationwide can follow.
“We’re going to be able to go to other hospitals and pinpoint the cost savings they’ll get if they implement what we’re doing here,” Dickerson says. “Hopefully they’ll see that it’s a lot more affordable to start a program like ours than to bear the costs of unnecessary tests.”