By Ed Dolan

U.S. health care reformers face a daunting task. Our country spends more on healthcare than any of its wealthy peers but lags in terms of health outcomes. Just why do we spend so much and get so little for it?

Not because Americans visit the doctor more or spend more days in the hospital. In both categories, according to a report from the Commonwealth Fund, the U.S. ranks below the OECD median. Instead, the excess spending

is likely driven by greater utilization of medical technology and higher prices, rather than use of routine services, such as more frequent visits to physicians and hospitals.

A new study from Kaiser Health News provides a thought-provoking case study that focuses on the high cost of urine drug testing (UDT). Doctors who prescribe opioids for pain management order UDTs monitor compliance with recommended treatments and check for illegal substances that might interfere with health. Up to a point, such tests improve outcomes, but evidently, some practitioners go far beyond that in pursuit of revenue. According to the study, some practitioners receive more than 80 percent of their income not from treatment, but from testing.

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

What is more, as the report explains, attempts at cost control have sometimes had perverse results:

Tests to detect drugs in urine can be basic and cheap. Doctors have long used testing cups with strips that change color when drugs are present. The cups cost less than $10 each, and a strip can detect 10 types of drugs or more at once and display the results in minutes. After noticing that some labs were levying huge charges for these simple urine screens, the Centers for Medicare & Medicaid Services moved in April 2010 to limit these billings. To circumvent the new rules, some doctors scrapped cup testing in favor of specialized — and much costlier — tests performed on machines they installed in their facilities. These machines had one major advantage over the cups: Each test for each drug could be billed individually under Medicare rules. “It was almost a license to steal. You had such a lucrative possibility, it was very tempting to sell as many [tests] as you can,” said Charles Root, a longtime lab industry consultant whose company, CodeMap, has tracked the rise of testing labs in doctors’ offices.

The Kaiser report focuses on the cost of excess testing to Medicare, which by 2014 reached $8.5 billion per year, more than the entire budget of the Environmental Protection Agency. But private insurers, too, are struggling to cope with the same problem. In a separate discussion, Dr. Anthony Guarino, a clinician and expert witness in pain management cases, offers some common-sense guidelines for distinguishing excess from medically necessary testing. In his view,

Excessive and unnecessary UDTs cost patients, insurance companies and the government hundreds of millions of dollars per year. There are no guidelines from any medical society that justifies this form of testing. When testing occurs repeatedly for a question that has already been asked and answered (i.e. Is the patient reliable and forthcoming), this testing is unnecessary and not medically justified.

The case of overuse of UDT illustrates one of the most formidable barriers facing would-be healthcare reformers: Every dollar of excess healthcare spending is a dollar of revenue for some healthcare provider—a revenue stream that the providers will fight doggedly to protect.