Study defines ‘low-value care,’ evaluates toll on healthcare industry

Low-cost, high-volume health services account for a high percentage of unnecessary health spending, according to a new study, published in Health Affairs.

A team led by UCLA researchers analyzed claims data on patients in Virginia that reflected nearly all public and private payment sources, including fee-for-service Medicare, Medicare Advantage, Medicaid, private insurance, as well as consumer out-of-pocket costs.

Forty four services that were designated as “low value” in specific clinical situations according to evidenced-based guidelines were analyzed. These services likely represent only a small proportion of “low-value care,” defined as having little or no health benefits in certain clinical situations.

The low-value services in certain situations included:

·      Lab tests for low-risk patients undergoing low-risk surgeries;

·      Stress cardiac or other cardiac imaging in low-risk patients without symptoms;

·      Routine head CT scans for simple dizziness; and

·      Imaging within the first six weeks of onset for low back pain without any other medical red flags present.  This is the most common presentation of back pain that typically resolves itself.

Researchers found that the 5.5 million people in the database received 5.4 million of the 44 services. Of that number, 1.7 million were low value, meaning that nearly one-third of the time they were medically unnecessary, and 3.4 million were high-value services that carried health benefits. Looking at the low-value services, they found that 1.6 million (93%) were very low cost and low cost ($538 or less per service), compared with 119,000 (7%) that were high and very high cost ($538 or more).

The cost for low- and very-low-cost, low-value services totaled $381 million, compared with $205 million for high- and very-high-cost, low-value services. This $586 million represented 2.1% of Virginia’s total $28 billion in healthcare costs for the year. Overall, about 20% of the 5.5 million people received at least one low-value service during the year analyzed.

The decision to employ Milliman’s MedInsight Waste Calculator to the data obtained through Virginia’s All Payer Claims Database was originally undertaken as part of Virginia’s State Innovation Model Design grant from the Centers for Medicare and Medicaid Innovation.

Bortz

“We had strong multistakeholder support in Virginia from our employer, health plan, health system, and clinician partners to see how we could tackle low-value healthcare in a data-driven way,” says Beth A. Bortz, president and CEO, Virginia Center for Health Innovation (VCHI).

One step further

VCHI wanted to take the thinking behind the ABIM Foundation’s Choosing Wisely initiative, that seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures, by tying its improvement plan to real Virginia data.

“In this way, we could actively measure our impact and identify future targets for improvement,” Bortz says. “Healthcare value can be improved in two ways-by reducing the number of low-value healthcare services or by increasing the number of high-value services. While both actions are worthy goals, efforts to reduce low-value healthcare are a more urgent priority, since the associated savings will be required to support the purchase of additional high-value services.” 

“The current economic incentives in healthcare typically reward the provision of more services, regardless of their value to the patient,” Bortz says. “The same service that can be lifesaving for one patient can be harmful and unnecessary for another. What is needed is clinical nuance to determine if we are providing the right service, at the right time, to the right patient.”

Next: Low-value services

Low-value services

Fendrick

“These commonly used, ‘little ticket’ low-value services, are not a significant contributor to clinician income,” says A. Mark Fendrick, MD, director of the University of Michigan Center for Value-Based Insurance Design. “Starting with the low-lying fruit is a way to begin a national movement to remove wasteful care with as little disruption as possible.”

Fendrick hopes that weeding out low-value care becomes a significant part of the move from volume to value. “Just as providers and plans have united around increasing high-value care, there should be similar alignment to discourage use of unnecessary services,” he says. “… The billions saved can provide payers resources to be devoted to high-value services that are currently underused.”

Rising healthcare expenditures are a significant concern for employers, with many believe they are not receiving exceptional value for their investment in terms of employee health and well-being, according to Bortz.

“Achieving higher value, with value defined as the health outcomes achieved per dollar spent, is a frequently lauded aim of health reform efforts at the state and national levels,” she says. “If value improves, patients, payers, providers, and suppliers can all benefit in terms of better health, while the economic sustainability of the healthcare system increases. Hence the considerable emphasis on moving the U.S. healthcare system from one that pays for the volume of services provided to one that pays for the value of care received.”

Defining “low value”

There are different reasons why a test or procedure might wind up in the top five low-value care services," says Bortz.

“It may be because the average proxy cost of the individual procedure is high,” she says. “It may be because the procedure is done unnecessarily a great deal.”

For example, in Virginia, population based screening for 25-OH-Vitamin D deficiency has a low-value index of 100%, because all vitamin D screenings performed in 2015 in Virginia were determined to be of low value.

“Therefore, this would be one service where we could really drive change if we work with providers to recognize the low value of ordering vitamin D screenings,” Bortz says.

Conversely, she says, it will be much harder to drive change in physicians ordering annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms, because 93.8% of the time clinicians are ordering EKGs for low-risk patients appropriately.

“For these reasons, we have decided not to use cost as the sole determinant in selecting which measures to tackle first,” she says. “We want to take into consideration the potential for harm from the procedure to the patient, as well as frequency with which clinicians are ordering the procedure correctly. We do not want to start our work trying to get clinicians to find needles in haystacks.”  

Many patients think that more is necessarily better when it comes to healthcare, according to Bortz.

“But when we talk about the provision of antibiotics, imaging with radiation, and invasive testing, this can be far from the truth,” she says. “Patients, clinicians, and purchasers all need to become more sophisticated in their service selection criteria. It is also important to recognize that we are also providing too little high-value care. Services such as immunizations and cancer screenings that go underutilized for certain patients are equally troubling. At VCHI, we are focused on improving the value of healthcare in Virginia, and this requires both reducing low-value care and increasing high-value care.”

The elimination of unnecessary care can create more “head room” for managed care plans to devote more resources to services we know that improve health, says Fendrick.