Could the price transparency impact have been undermined by an EHR feature that allows orders for daily tests to automatically repeat?


April 21—New research raised doubts about whether laboratory orders by hospital-based physicians would be affected by price information.

A one-year randomized clinical trial at three hospitals examined the effect of allowing physicians to see Medicare allowable fees displayed within an electronic health record (EHR) for some laboratory tests given to 98,000 patients with an average age of 55. The study found little effect on clinician ordering behavior.

“The number of tests ordered varied by hospital sites, but trends were similar between the intervention and control groups,” wrote the authors of the study in JAMA Internal Medicine.

The findings could be significant given that hospital finance leaders have been on the lookout for ways in which physicians can help control costs. Laboratory testing has been a target of such efforts because an estimated 30 percent of tests may be wasteful, according to one study. Related research recently found that higher physician spending was not associated with better outcomes for hospitalized patients.

The importance of the issue for hospitals also was highlighted in findings from a January executive survey by the American College of Healthcare Executives. Among the top issues confronting hospitals, 57 percent of surveyed executives named their biggest challenge as engaging physicians in reducing clinically unnecessary tests and procedures.

In addition to finding no significant changes in overall test-ordering behavior, the study authors found no noteworthy difference in the change to associated fees. Specifically, the mean associated fees per patient day in the control group decreased from $27.77 in the year before the study to $27.59 during the study period. Meanwhile the mean associated fees among the intervention group increased from $37.84 to $38.85.

Why Ineffective?

Among the reasons that the price transparency data had little effect, the authors theorized, was that the data was always displayed regardless of the appropriateness of the test.

“Future efforts may consider more selective targeting of price transparency,” they wrote.

In addition, 91 percent of resident physicians reported that unnecessary laboratory testing stemmed from their habit of placing onetime orders for repeated daily laboratory tests when patients were first admitted.

“The test may become more unnecessary later into the hospitalization, but if repeating orders were entered at the time of hospital admission, the clinician would not need to place another order for them and thus would not be presented with price transparency information when it would be most salient,” the authors wrote.

The study’s findings ran contrary to some previous research, including a 2013 study also in JAMA Internal Medicine that found presenting fee data to providers at the time of order entry somewhat decreased test ordering.

“Adoption of this intervention may reduce the number of inappropriately ordered diagnostic tests,” wrote researchers with Johns Hopkins Medical School.

Similarly, a systematic review of 17 published articles on provider price transparency for imaging and lab testing in 1982-2013 found that in “the majority of studies, charge information changed ordering and prescribing behavior.”

But it is far from unanimous that price transparency changes clinician behavior. A 2013 study in the Journal of the American College of Radiology found that giving providers price transparency did not in itself significantly influence inpatient imaging utilization.

A Deeper Look

The latest study found a small but significant difference in tests ordered for patients in intensive care units. And the authors theorized that a critical difference occurred in that setting.

“Because health care decisions are changing more rapidly in this setting, clinicians may be less likely to rely on repeating orders and therefore may have been exposed to the intervention more often,” the authors wrote, referring to the provision of Medicare cost data.

They suggested that future examinations of price transparency pair the financial data with EHR changes that disallow onetime orders of repeated laboratory testing over an extended duration.

Although the new study found a small but significant decrease in ordering for the most expensive tests, the researchers also found a small but significant increase for the least expensive tests. They believed the increase stemmed from physicians’ realization that they had previously overestimated the cost of cheaper tests.

In the future, lab test transparency initiatives probably should just focus on the costlier testing, the authors wrote.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, April 21, 2017