Escalating Health Care Cost due to Unnecessary Diagnostic Testing

Focusing on health care systems can improve health outcomes now and in the future. Growing economies have serious concerns on the rising cost of health, whereas, in under developed countries like Pakistan, it is not emphasized yet at all. The research is conducted to improve a unique aspect of health care systems to provide effective, patient-centred, high-standard health care while maintaining the cost effectiveness. Research is being qualified in two paradigms qualitative and quantitative. In qualitative research, expert’s interviews have been taken to get the basic knowledge of radiology based testing and their prerequisites, in quantitative research ordered are being analysed to check the frequency and if they are unnecessary or qualified medical necessity guidelines as established in qualitative method. Analysis was made on the basis of the trinity relationship of diagnosis, symptoms and respected order to determine the necessity of the order to get its impact on cost of the overall health of those patients and point out more than 50% unnecessary orders are being performed in two government hospitals. The situation is alarming and policy makers should focus on unnecessary ordering to avoid out of pocket expenses and improve quality of care. The research helps in successful application of health care system modifications and policies pertaining to one aspect of health systems, i.e. cost-effectiveness of health care.


INTRODUCTION
what resources are required. Health systems and health systems research leads to the creation of scaffold that must satisfy the demands and needs of its constantly dynamic building blocks. Health care is a management, treatment and prevention of disease or illness; it also refers to the physical well being through health service providers and hospitals. How are you? It is that simple question which is being asked by every two humans when they meet. This simply relates the concern of one to another about knowing his/her current physical, H uman minds have a limited ability to grasp and process multiple pieces of information simultaneously, but they desire to produce more to reap more benefits. A high level of productivity requires dropping the quantity/extent of information to be analyzed every time to only the most necessary and vital data. Developing a regular routine work in advance leads to the creation of frameworks, and sticking to it consistently wipes away the difficulty of thinking about what needs to be done, its sequence, and when and mental, financial and social status. We are concerned here about the physical and mental health of human beings that is one of the top concerns of humanity.
Nowadays quality of care has become too expensive [1]. Not everyone can easily afford it. Health care expenditures are growing around the world in an alarming rate. The United States spends 17% of their GDP (Gross Domestic Product). They are forecasted to reach 20.3% of their GDP which equals to $4.4 Trillion dollars [2].

OECD (Organization for Economic Cooperation and
Development) countries average spending more than 7% of their GDP [3]. Such an alarming rise creates many risks for the sustainability of the future of health of the

LITERATURE REVIEW
Pakistan is currently 6th most populous country with a population of more than 191 million people and an annual growth rate of 4% per annum. No satisfactory attention was given till the 1970's. Afterthat a 5 year plan was introduced to take care of infrastructural growth, but it was still limited to the government employees and the total spending was only 1% of the GDP. The rest was an out of pocket expense [5]. According to WHO (World Health Organization), they defined Health as a state of absence of any disease and a complete wellbeing "physically and mentally" [6]. Health system is defined in several ways. "WHO's defines "Health Systems" as "All activities with the primary objective to promote reinstate or maintain health". All such activities are usually grouped into six classes that include service delivery as well as, the health workforce, including health information system related Medical products, vaccines and technologies, health system financing and governance with right kind of leadership [7]. The another way of defining Health systems is based on the actors contributing to the system. Van Atteveld et. al. [8] reviewed 144 studies on health care and global health research. They concluded that most of the studies lacked analytical models mostly descriptive, economic approach dominated, and there were no comparison among different systems.
Alliance for health policy and system research studied and listed 41 health system frameworks developed till now [6] few have been developed for better knowledge, comparisons among different frameworks their performance [9].
Researchers believe that nowadays medicine has prompted communication among each other and different nations readily borrow ideas from another country's experiences.
According to their own cultural setting they alter and modify ideas. But due to procedural variations among them and different structures of individual nations, developing an appropriate analytic framework that is good for everyone is yet to be done. There is no particular system or framework that covers all aspects of healthcare. The background of each healthcare system has its own dependence on several actors and environment which fails to create a basis for all [10]. Common health fund recently published a study by comparing 18 different health systems around the world but are still unable to provide any specific system that fits for all [11]. In a recent comparison of health care systems around the world, it was evident that caring needs are touching high expectations and viz a viz cost containment is also required including laboratory services for a sustainable growth in health care services [12].
The question frequently raised in health policy debates is, "Will health systems be financially sustainable in future?" It is usually termed as the ability of the governments and others to sufficiently finance health care in the face of growing cost pressures, with the following three most commonly cited challenges named as population ageing, innovation or new technologies and quality of care which is consumer expectations around the world. Although the idea of 'financial sustainability' comes into view to be vital to health policy debates, but still it has not been part of most health system objectives, including those of the WHO's health system performance framework" [6].
The problem of financial sustainability can be broadly characterized in the following three ways which includes increased health expenditure due to demand and supply of health services, technological progress, demographic changes and consumer expectations. Some believe limited resources or an inability of government or unwillingness to generate sufficient resources to meet its health system obligations which might be due to financial crisis [13]. be considered as wasteful [14][15][16][17].
It is evident from the analysis and projections that the population ageing contributes comparatively less to rising health care costs in comparison to technological modernization (10% less of the growth in health care costs) [18][19][20]. Health care expenditures are rising in at alarming rate. Advancement in technology is one of the key factors in raising heath care cost which is laboratory orders [21]. From 2005-2010 it is evident that laboratory testing cost increased by 29% of the total health care cost in United States [22]. Fig.   1 shows Health expenditures as a share of GDP of OECD countries.

FIG. 1. HEALTH EXPENDITURE AS A SHARE OF GDP OECD COUNTRIES 2015 [23]
Getting quality of care is the right of every human in this world but nowadays cost of health care is becoming a raising issue as quality of care is directly proportional to the cost of health care. This relationship forced policy makers, and researchers to devise a strategy of lowering the costs. Now some suggest to see health care professionals other than doctors, and put emphasis on telemedicine, and believe that a cure is better than care [24].

RESEARCH METHODOLOGY AND DATA ANALYSIS
Research is being qualified in two paradigms qualitative and quantitative. In qualitative research, expert's interviews have been taken to get the basic knowledge of radiology based testing and their prerequisites. Question were being asked with respect to the specialty and create a basic understanding of why imaging orders have been placed and study all those procedures in which medical decision making are involved.
Research methodology of the paper is be described as shown in Fig. 2. We initiated the research with a simple question that whether in Pakistan the radiology orderings are based on medical necessity or not? In order to get the answer of the question the research methodology selected was qualitative and quantitative. The qualitative research was conducted through interviewing physicians about the radiology orderings and its basics that can be seen from Fig. 3. The quantitative research helped us to compile relevant and specific data and analyze it for findings that can be seen from Fig. 4.

FIG. 2. RESEARCH METHODOLOGY FLOW DIAGRAM
On the basis of qualitative research, quantitative research was carried out in which retrospective data of radiology investigation was collected for six months from two reputed government hospitals of Islamabad and Rawalpindi.

Methodology used to understand and investigate the domain
and problem respectively is shown in Fig. 3.
Light blue ordering techniques were selected as primary source of investigation because of the fact that these are most ordered procedures are costly as well.
After qualitative research data collection was carried out to investigate whether unnecessary tests was being ordered or not. This methodology is described as shown in Fig. 4 Table 2 to identify reason of unnecessary orders.

RESULTS
Most of conclusion/findings of the study showed normal study which creates an alarming situation and proof the concept of unnecessary orders have been performed in Pakistan as well. As stated above, researchers believe 40% of laboratory testing is unnecessary but in case of Pakistan data shows more than 50% of testing is unnecessary. As shown in Fig. 5, data showed that out of

RESEARCH LIMITATIONS
Medical necessity applies to all aspects of practicing medicine but the scope of this research limits its boundaries by focusing only on medical necessity of imaging orders.