There is evidence that making clinicians aware of test costs reduces requesting, and this has been used as justification for including costs at the requesting stage as a means of reducing unnecessary testing. This would go into the typical arsenal of 'demand management'.
Clinicians are already under pressure to make complex management decisions that are in the best interest of the patient. How does adding more information into this equation at this stage help?
The way costs are interpreted will be dependent on how they are framed. So I could say that it costs £50 to manage a possible infection. Adding a CRP into the mix, at about £5, is relatively trivial. Or I could say that a CRP is about 50 times more expensive than a standard biochemical test, and that this is now a considerable burden on lab expenditure.
The clinician will either then choose to do the test (it's not that expensive, it doesn't really matter) or choose not to do the test (I need to do my bit to save the health economy money). There are at least two problems with this approach.
1. It leads the clinician away from their primary purpose, which is to optimise care for the patient in front of them. They cannot be expected to make an accurate economic assessment on the basis of one piece of information.
2. True costs of testing will be hidden. So there is less pressure to reduce high volume but low cost testing. This adds up, but an individual clinician working in isolation cannot be expected to understand or evaluate this.
There must be an optimum level of testing. What we need are ways to understand the utility of diagnostics across whole pathways. We need to understand how these tests benefit (or harm) patients. We need ways of assessing the true costs of tests to the health service, with transparency of how labs price their tests, and with inclusion of downstream costs. We then need to find ways to help clinicians order these tests accurately.
All this must include an assessment of cost effectiveness. But keep this out of the clinic and do it with proper informed debate.
I will add that this almost certainly needs new ways of working between labs and users, and needs approaches to contracting that break the insidious link between activity and income. But that's another blog.
