Progressing From Identifying and Measuring to Reducing Low-Value Care Services

Low-value care that offers no benefit to patients, or can actually cause more harm than good, is costly to patients and the healthcare system. While low-value services are being identified and measured, it has been more difficult to reduce the use of low-value care.

During a webinar hosted by the University of Michigan’s Center for Value-Based Insurance Design (VBID) and VBID Health, A. Mark Fendrick, MD, director of the V-BID Center and co-editor-in-chief of The American Journal of Managed Care^®, explained that reducing the use of low-value care creates more headroom in the health system to improve care and spend money elsewhere.

Fendrick noted that he likes to speak about headroom because even though physicians are not in healthcare to save money, they do want to have the opportunity to improve the healthcare of the populations they serve.

“I did not go to medical school to learn how to save people money,” Fendrick said. “There is more than enough money in the US healthcare system—we just spend it in the wrong places.”

In general, he said, Americans do not care about healthcare costs overall—they care about what healthcare costs them. If healthcare costs are thought of as an iceberg, patients only pay the tip of the iceberg that is above the waterline. That small portion seems like a lot to them, personally, but what other payers cover is the larger portion below the waterline.

“Americans tend to care only about the tip of the iceberg,” Fendrick explained. The goal is to shrink the portion patients cover and get to a situation where patients pay very little for high-value care.

First, that means identifying low-value services. VBID Health’s Task Force on Low-Value Care identified the top 5 most commonly overused services that shoud be reduced:

1. Diagnostic testing and imaging prior to low-risk surgery
2. Vitamin d screening
3. PSA screening in men 70+
4. Imaging in first 6 weeks of acute low back pain
5. Branded drugs when identical generics are available

However, while there has been great progress with measuring low-value care, the hard part is reducing the use of low-value care, Fendrick said.

At this point, it remains unclear which levers will be most effective, if implemented, at reducing low-value care, because few of them have been implemented and studied, but Fendrick has his suspicions based on what he has seen as a provider.

“Most utilization of low-value care is provider- or supply-side drive,” he said, which means levers on that side, such as payment rates, payment models, and clinical decision support will likely be more impactful than levers on the payer side, such as network design or prior authorization.

Beth Bortz, president and chief executive officer of the Virginia Center for Health Innovation (VCHI), highlighted a real-world example of making progress on reducing the use of low-value services. Her organization set up a series of conversations in Virginia to build consensus with various stakeholders that they wanted to tackle low-value services.

VCHI was able to leverage the state’s all-payer claims database to find that 39% of members had been exposed to at least 1 low-value service in 2017. The database even allowed VCHI to see regional differences and that more members in Northern Virginia (43%) were exposed to low-value services compared with Central Virginia (37%).

Using that data, VCHI decided to look at the top 5 measures by cost and found that the service that had the largest portion of low-value dollars was the same one at the top of VBID Health’s list: don’t obtain baseline laboratory studies in patients without significant systemic disease undergoing low-risk surgery.

However, while VCHI looked at the top 5 measures by cost, that wasn’t necessarily how all stakeholders wanted to identify and discuss low-value services. Not everyone wants to tackle the top 5 by cost, Bortz explained. Physicians were more curious to see which tests and procedures they were performing inappropriately most of the time. For instance, an electrocardiogram may be costly, but it was being used appropriately most of the time. In contrast, vitamin D screening is cheap, but it probably doesn’t need to be done.

While physicians were interested in services being used inappropriately most of the time, employers wanted to focus on tests that caused the most harm if they were unnecessary.

“It’s really important that you think about the audience you’re talking to,” Bortz said. She added, “If you’re speaking particularly to physicians, you don’t want to talk about waste.”

When physicians hear the word “waste,” she said, they get unhappy because the think the suggestion is that they are doing something wasteful. However, they are receptive to the idea of addressing low-value care. In contrast, employers have the opposite mindset. When they hear the word waste, they get excited about sitting down and figuring out how to deal with waste in the system, Bortz said.

As part of reducing use of these low-value services, VCHI is launching pilot projects with interested partners, such as federally qualified health centers, Medicaid and the state employee health plan, a health system collaborative, and an employer task force.