Improving the value of costly genetic reference laboratory testing with active utilization management.

Area of Science:

• Medical Diagnostics
• Genetics
• Healthcare Management

Background:

• Send-out tests, particularly genetic tests, pose risks due to complexity, including delays, errors, and financial liability.
• Managing these external tests is crucial for patient safety and healthcare efficiency.
• Misunderstanding and overuse of expensive genetic send-out tests are significant concerns.

Purpose of the Study:

• To develop and implement an active utilization management program for genetic send-out tests.
• The program aimed to mitigate patient risks associated with send-out testing.
• To enhance the overall value and appropriateness of genetic send-out tests.

Main Methods:

• A utilization management program was designed and implemented in a pediatric tertiary care center.
• A rotating team of consultants and a genetic counselor reviewed send-out test requests.
• Defined criteria were used to identify and manage high-risk genetic send-out tests.

Main Results:

• Over an 8-month period, 251 cases were reviewed.
• Nearly 25% of genetic test requests were modified, primarily reduced.
• Significant cost savings were achieved, reducing the overall send-out bill by 2% and 19% of managed test requests.

Conclusions:

• Active utilization management strategies can be effectively implemented for expensive send-out tests.
• Minimal technical resources are required to establish such programs.
• The implemented strategy improved the value of genetic testing for patients and reduced costs.