Studies Explore Prevalence of Low-Value Care in Safety Net and By Practice Ownership

A pair of studies published in JAMA Internal Medicine investigated the incidence of low-value care by practice ownership and location and in practices serving safety-net populations, highlighting important opportunities to reduce unnecessary spending.

One of the articles focused on whether safety-net patients, defined as Medicaid beneficiaries or the uninsured, are more or less likely to receive low-value care than patients covered by private insurance. Researchers used data from 2 multi-year national surveys to identify 193,062 eligible visits to a physician’s office from 2005 to 2013, and collected information on the patient’s insurance status at the time of the visit and the proportion of the practice’s patients who were uninsured or on Medicaid. Those with more than 25% of such patients were deemed safety-net practices, while those with 1% to 10% were used as a non-safety-net comparison group.

Using guidelines, the researchers compiled lists of 9 low-value services, including prescribing antibiotics for upper respiratory services or inappropriate imaging for low back pain, and 12 high-value services, such as tobacco cessation or appropriate medical treatment for depression. They then calculated 2 composite measures for each visit that represented the rate of low- or high-value care administered out of all opportunities for one of the criteria.

They found that the rates of low-value care did not significantly differ among the safety-net and privately insured patients. The privately insured patients were slightly more likely to receive high-value services than the Medicaid patients, but had slightly lower odds of receiving high-value care services compared with the uninsured patients. There were no differences in the rates of low-value or high-value services delivered by safety-net and non—safety-net physicians.

The researchers concluded that because the “overuse of low-value care is just as common among patients with Medicaid or without insurance as among privately insured patients,” state Medicaid programs and safety-net practices may benefit from efforts to reduce their rates of low-value care while improving the use of more high-value services.

These opportunities for improvement likely exist in other types of practices as well, according to the second study, which examined the provision of low-value care in hospital-based or community-based practices owned by hospitals or physicians. Through the use of national surveys, the authors compiled data on over 31,000 primary care visits for complaints like headache or back pain that commonly result in low-value treatments.

The researchers determined that patients visiting hospital-based practices were more likely to receive low-value imaging services and specialty referrals than those at community-based practices. Among the community-based locations, those owned by hospitals were more likely to refer patients to specialists than those owned by physicians. During visits to hospital-based practices, patients were more likely to receive low-value care if they had been seen by a clinician who was not their usual primary care provider.

“Ultimately, these results raise general concerns about the provision of low-value care at hospital-associated primary care practices,” the study authors wrote. “Because almost one-third of health spending is considered potentially wasteful, our findings have important implications for policy makers, healthcare practice leaders, and clinicians, who have an interest in providing the highest-quality care at the lowest per capita cost.”