The use of physician profiling and prior approval (gatekeeping) in utilization management in the clinical laboratory

Abstract

Physician profiling is a technique that can be used to identify variations in practice among physicians. These data have been employed to control costs, improve quality, and assess compliance with practice guidelines. Physician profiling is frequently criticized for producing unreliable or misleading data that fails to reflect the realities of actual clinical practice. In principle, profiling physicians for laboratory test utilization should be straightforward as testing data can be readily quantified and linked directly to clinical encounters. However, the reality is more complicated as the profiles must take into account the individual specialty (or subspecialty) of the physicians, differences in case load and patient acuity. In this chapter we present our experience with physician profiling in our laboratory utilization management program. The case examples were chosen to illustrate how physician profiling can be used to assess and control laboratory test utilization. Another approach to reduce overutilization is the implementation of prior approval requirements (a.k.a. gate-keeping) before requests for targeted tests will be accepted. Traditionally prior approval was used by third party payers to restrict access to high cost procedures (such as radiology scans) and pharmaceuticals. The recent introduction of high cost molecular and genetic tests has prompted many payers to initiate prior approval mechanisms into clinical laboratory testing. As well, hospital laboratories employ gate-keeping strategies to control the utilization of expensive tests including genetics using laboratory directors to screen and approve test requests. In the second part of this chapter we will describe our experience with gate-keeping strategies and review the relevant literature on prior approval requirements to control laboratory utilization.