The use of ordering protocols and other maneuvers: the Canadian experience

Canada's socialized, single-provider, fee-for-service environment has provided an opportunity for widespread implementation and evaluation of a number of utilization control measures. Enforced consolidation of services certainly eliminates redundancy but the implementation cost and disruption of such a measure is high. Whether noncompetition will eventually eliminate any cost savings achieved is difficult to predict. Risk sharing in which ordering doctors and laboratories are paid from the same source of funds and both groups stand financially responsible for excess utilization seems to be an effective approach. From a fiscal standpoint it is, but such measures can create ill will. Establishing utilization caps has an absolute fiscal effect but, unless very carefully designed and monitored, may create more problems than they solve. Utilization control can be achieved using a minimal list requisition form. Form control is also essential to ensure the success of protocol and CPG implementation. The development of protocols and CPGs has proved to be very effective in reducing laboratory testing while also standardizing aspects of medical practice. Such guidelines work well when (1) dealing with testing areas of high volume (or high cost); and (2) amenable to simple rules on which there generally can be agreement. A collaborative implementation environment is necessary. After about 15 such protocols, however, it becomes increasingly difficult to define new areas to target. Physician chart audits are a useful adjunct to help deal with problem areas and to keep all physicians highly aware of good ordering practices. Utilization problems have not been solved in the Canadian system. Certain ventures, however, have proved to have a positive effect. It is likely that when electronic knowledge support tools become a standard feature of medical practice the protocol-CPG approach will be maximized.