The Challenge of Addressing Low-Value Care Once It's Identified

Identifying low-value care can save a state hundreds of millions of dollars in just 1 year, found Beth Bortz, president and CEO of the Virginia Center for Health Innovation (VCHI). She and her fellow panelists, Lauren Vela, MBA, senior director of the Pacific Business Group on Health, and Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, discussed low-value care, unnecessary services, and what can be done to address overuse in healthcare during a panel at the University of Michigan Center for Value-Based Insurance Design’s (V-BID) annual V-BID Summit on March 14.

VCHI was trying to let CMS know that it could lower the cost of care and in the course of trying to understand how much low-value care was happening in Virginia and what could be done about it, VCHI came across ABIM Foundation’s Choosing Wisely initiative.

“We very much wanted our physician community in Virginia to be on board, and we thought the best place to start was with services that the physicians, themselves, identified and said, ‘These are tests and procedures that we routinely do that we know to be unnecessary and potentially harmful,’” Bortz explained. “So that was a great starting point for us.”

The point is not to look at simply if a test or procedure is done in a vacuum, because what could be a low-value service for many might be a high-value service for someone else, depending on what other factors and risks are taken into consideration.

Wolfson added that the Choosing Wisely campaign defines overuse as when the risks outweigh the benefits with the support of evidence. The campaign doesn’t even define low-value care, he explained. The campaign is clinically nuanced.

“It’s not an absolute,” he said. “There are times when the red flags would necessitate a test that is generally recommended not to be used.”

Clinical evidence is an important part of this process. With so many things that need to be paid for in healthcare, Vela said it would be a sham to pay for something that clinical evidence says does not need to be done. She said that identifying and addressing low-value care “looms as a very large opportunity.” The challenge is translating a conversation around low-value care into something that is action-oriented for employers.

The fact that the Choosing Wisely campaign and the actions of VCHI were never supposed to just be to reduce costs is also an important message to get out. Wolfson explained that the purpose of Choosing Wisely was to enhance safety, quality, and affordability—some of the recommendations actually increase costs. He provided the example of tube feeding versus manual feeding in nursing homes. While tube feeding is less costly, it kills people over time; but manually feeding a patient costs more money, so it was less popular.

“We wanted to take a baby step,” Wolfson said. “And a baby step was just looking at low-hanging fruit. Cost effectiveness is a more difficult, nuanced thing to be able to look at. We wanted to be able to get people in the game first and then think about cost effectiveness.”

In Virginia, Bortz’s organization looked at 42 measures out of approximately 500 and the claims data on 5 million Virginians and found that more than $700 million a year was spent on unnecessary care, as defined by the Choosing Wisely program and those services that received a D grade from the United States Preventive Services Task Force.

VCHI took this report out into the field to show to employers and providers. Bortz made the mistake of leading with the top 5 services by cost and “got schooled pretty quickly.” Physicians didn’t want to hear the word “waste” in these discussions and they wanted to see a low-value index, which should what services are they doing wrong all the time. Employers didn’t want their employees to feel like “this was all about a money grab.” They wanted to see the top 5 list by harm.

From the employer perspective, Vela explained that there may be need to take actions once these services are identified. Employers need to know how to measure the low-value care being provided in their population, or they won’t know if the endeavor is worthwhile to undertake. But ultimately, employers and health plans have to encourage physicians to stop ordering the services and tests that are identified as low value.

“What can the employer do to impact, at the end of the day, so the physicians have the information, the authority, and the incentive to do the right thing?” Vela asked.

The panel also discussed the top 5 low-value care services identified by the Task Force on Low-Value Care:

• Avoid unneeded diagnostic testing and imaging for low-risk patients before low-risk surgery
• Avoid vitamin D screening tests
• Avoid prostate-specific antigen screening in men 75 and older
• Avoid imaging for acute low-back pain for the first 6 weeks after onset, unless clinical warning signs (“red flags”) are present
• Avoid use of more expensive branded drugs when generics with identical active ingredients are available

Employers seem to believe that as the industry moves toward alternative payment models, some of these top 5 services will be taken care of.

“At the end of the day, it’s really, really tough to stop physicians from doing all these things…but, at the end of the day, if we have accountable providers who understand their accountability and can measure their accountability, then, in fact, this would be the great stuff for them to get rid of,” Vela said. “It’s the low-value care they want to get rid of.”

Bortz had been part of the task force that came up with the top 5, and since Virginia had so much data and access to an All-Payer Claims Database, the state’s data was used as a reference point to help provide a sense of scale. When choosing the 5, the task force knew it didn’t want to pick something right out of the gate that would prove controversial and possibly turn some people off the idea immediately. However, they wanted to ensure they picked at least 1 or 2 that were meaningful and could have a financial impact.

ABIM Foundation had created its own “dirty dozen” list that included 3 of the top 5 from the task force. Wolfson views these lists as a signal to the community that employers and purchasers are thinking about the issue and “are not going to tolerate low-value care.”

“We have well-intentioned people doing things routinely because that’s how it’s been done,” Wolfson said. “You’ve got to get their attention.”

However, since the Choosing Wisely campaign took off in 2012, there has been only some movement in the use of identified unnecessary tests and procedures. Wolfson explains that nothing happens without and intervention, and even then it takes time.

“We talked about underuse for 30 years,” he said, and admitted that he was part of that conversation. Shifting in the other direction to prevent overuse will take time, he said. “I’m very humbled about what it’s going to take to stop people from doing things they’ve been doing for a long period of time.”