Will COVID-19 Wring Low-Value Healthcare out of the System?

When the COVID-19 pandemic spread to the U.S. last spring and the country went into lockdown, the utilization of healthcare services came to a screeching stop. Many experts are concerned that this “hiatus” will lead to greater illness — and healthcare costs — this year because care, especially for chronic conditions, was deferred or canceled.

Another unintended consequence of COVID-19’s hitting the pause button may be the elimination or attenuation of “low value” care: the wasteful tests, prescriptions and procedures that result in little, if any, improvement in outcomes. By some estimates between about $75 billion and
$100 billion is spent on low-value care and overtreatment each year, a relatively small fraction of the $3.6 trillion in annual healthcare spreading but, nevertheless, a great deal of money. Some experts see the pandemic and the resumption of healthcare as a rare opportunity to reset U.S. healthcare without so much low-value care.

Low-value care takes many forms. Walt Ellenberger, a senior director of healthcare business development and innovation at SAP, a software company, lists a few classic examples: overprescribing brand-name drugs when generics are available, prescribing antibiotics for viral infections and moving too quickly to surgical procedures for conditions such as back pain that can be managed with medications or physical therapy. The Choosing Wisely campaign launched by Consumer Reports and the ABIM Foundation in 2012 is aimed at rooting out low-value care. The publication and the foundation have worked with the specialty societies to develop lists of tests and procedures for physicians and patients.

Low-value care has ripple effects beyond the direct cost of care that doesn’t improve health. Low-value services may have harmful adverse effects. And they can trigger a cascade of follow-up tests or services that can lead to anxiety; the risk of still more adverse effects; and, of course, more higher healthcare costs.

Some experts see low-value care commanding resources that might otherwise go to more healthful interventions. “This unnecessary spending crowds out resources available to pay for high-value care or other important priorities outside of healthcare, such as education and transportation,” says Corinna Sorenson, Ph.D., M.H.S.A., M.P.H., an assistant professor of population health sciences at Duke University School of Medicine in Durham, North Carolina.

Says Ellenberger: “Many clinicians are already overburdened. Removing unnecessary testing and procedures frees them up for work they really need to do. It also frees up resources in the laboratory and diagnostic departments, which helps move patients through the health system more efficiently.”

Patient demand is one of the causes of low-value care. People are swayed by advertisements or believe that a low-value intervention is effective — the antibiotic prescription for a viral upper respiratory infection, for example. But, as Ellenberger notes, unnecessary services can backfire, lowering patient satisfaction and eroding trust in providers. “That can manifest itself in distrust in a specific provider or distrust in the entire healthcare system,” he says. “Either way, it can lead to poor outcomes and higher costs later.”

Physicians and other providers order low-value tests, treatments or procedures for a wide variety of reasons, says Sorenson, ranging from the inertia around established clinical practices and workflows to the volume incentives inherent in fee-for-service payment to fear of malpractice.

Avoiding reintroduction

When the pandemic first hit in March/April 2020, many hospitals and other providers pivoted to tests and procedures that were needed most and postponed elective procedures (although how “elective” they really are is open to debate). Furthermore, many people avoided going to the hospital or doctor for nonemergency health issues because they didn’t think it was worth the risk of infection. “Although this likely prevented them from receiving tests and scans they didn’t need, on the flip side, many people likely suffered because they didn’t get necessary care,” says Vikas Saini, M.D., president of Lown Institute, a healthcare think tank in Brookline, Massachusetts, that focuses on low-value care.

Sorenson says that some people may never seek out low-value care that was postponed. She also notes that the pandemic may shift perspectives on what care is truly necessary and whether there are better ways of delivering care that lowers costs and improves, or at least maintains, health outcomes. That said, Sorenson says the industry is at high risk of reverting back to “business as usual” given the pervasiveness of low-value care in American healthcare, partly because many providers are under financial strain.

But there’s an opposing point of view that disruption wrought by the pandemic is likely to mean less low-value care. David Nickelson, Psy.D., J.D., vice president of client growth-healthcare for Nerdery, a digital business consulting firm, believes healthcare won’t return to the way it was before COVID-19. “There has been an immense growth for digital health services as well as an emphasis on using data to improve the patient experience that will reduce the use of low-value services,” he says. “Many more people are now willing to receive services via telehealth or virtual care platforms, which can free up healthcare providers to focus on more pressing challenges or critical patients.”

This more optimistic take on the pandemic is that it has served as a kind of seminar of teachable moments about low-value care and a host of other festering issues. “It exposed the vulnerabilities of a healthcare system designed to be reactive in treating patients,” Ellenberger says. “A fragmented industry used to working independently had to collaborate with other stakeholders to effectively combat a common enemy in order to survive.”

Sorenson says the pandemic exposed long-standing flaws in the healthcare system, such as its fragmentation, inefficiencies and glaring disparities, as well as how susceptible these flaws leave the system and economy to crisis. But she also sees some positive developments: The pandemic has showcased that, with sufficient will and collective action, the healthcare system can make innovative payment and care delivery changes swiftly as long as there are sufficient will and collective action. Sorenson points to telehealth and coverage for its use: “Coupled together, there seems to be a growing awareness that we don’t want and can’t afford to return to our pre-pandemic health system.”

Sorenson says that the pandemic has created a natural experiment to better understand the short- and long-term impacts of eliminating low-value care on health outcomes, quality of care and costs. Rather than just springing back thoughtlessly to prior practices, she says steps should be taken to sideline low-value care. “If a service is truly low-value care (and its absence will have) minimal or no negative effects on health or quality of care ... steps should be taken to ensure it’s not reintroduced into the system or, at minimum, its use should be reduced,” she says.

In a commentary piece published in NEJM Catalyst Innovations in Care Delivery in August, Sorenson and three of her colleagues at the Duke-Margolis Center for Health Policy suggest the development of “do not restart” lists to educate providers and patients about low-value care services that should not be reinstated. Other possibilities include low-value services and reminders in electronic health records and clinical decision support tools that steer providers away from ordering or using low-value care services. Low-value care can also be discouraged by upping patient cost sharing while decreasing cost sharing for high-value care, notes Sorenson.

‘Televalue’ arrives

One of the truisms of the COVID-19 pandemic is that it accelerated the shift from in-person care to digital platforms. That switch, many believe, can help rid the system of some low-value care. “Relying on data-driven systems that transfer information more quickly to healthcare professionals and prioritizing patients’ needs will improve the overall quality of care in the healthcare system and reduce unnecessary or low-value services,” Nickelson says.

Nathan Ray, director of healthcare and life sciences at West Monroe, a management and technology consulting firm headquartered in Chicago, says that COVID-19 highlighted the possibility for sustained virtual care. “It has allowed for the reduction of volume, meaning not less interaction but, rather, more timely interaction with physicians,” he says. “Consequently, more patients can get the drug or therapy they need faster than booking multiple in-person appointments.”

Farzad Mostashari, M.D., Sc.M., is co-founder and CEO of Aledade, a company that operates accountable care organizations with and for primary care practices. He says that the value-based care that his company implements is built “to support virtual care tools in a responsible, high-value way.”

The pandemic, in Saini’s view, may also speed the move away from fee- for-service to value-based payment: “I foresee a greater openness and interest in capitated payment models in which providers are paid a flat fee per patient per month.”

Sorenson says that the COVID-19 pandemic has shown that value-based care and reducing low-value may go hand in hand. “Providers practicing within these models have been more successful in responding to the pandemic and weathering the ongoing economic uncertainties as a result of more predictable financial structures and associated investments in infrastructure, staff, programs and data systems to improve population health and care delivery,” she says. “These same capabilities are needed to reduce low-value care in the long term.”

Karen Appold is a medical writer in the Lehigh Valley region of Pennsylvania.