Improving the Value of Care: Reducing the use of Low-Value Services

By Howard Beckman, MD, FACP, FAACH, FNAP. Chief Medical Officer, EagleDream Health

In the March 7, 2017 issue of the Milbank Quarterly1, Schlesinger and Grob reported on a study to quantify the populations’ commitment to reducing low value care. Regretfully, even though estimates are that 30% of care delivered is unnecessary, they found that overall one-third of Americans currently cannot envision benefits from avoiding low-value care. Worse, the percent rose in poorer and minority communities. They also found that while “many Americans would avoid common forms of low-value care like unnecessary antibiotics or excess imaging for lower back pain, few favor clinicians who avoid these practices”. Finally, they conclude that “avoiding low-value care is enhanced, blaming providers is reduced, and disparities are further diminished if messages put more emphasis on the health risks of these tests and treatments”. They concluded that, “in the short run, [discouraging low value care] would be enhanced by fine-tuning how low-value care is characterized. In the longer run, building robust public support for reducing low-value care may require refocusing attention away from specific tests and treatments and toward the relational benefits for patients if clinicians spent less time on testing and more time on personalized care”.

While the approach suggested by Schlesinger and Grob has merits, there are other approaches that can and should be taken; especially by practitioner organizations involved in risk contracting.

At EagleDream Health, we encourage the identification of low value services and measure the practitioner variation in provision of those services. That difference in utilization can serve as a focal point for determining the specific indications for a service by a medical group, health system or ACO. Based on that data, discussions among specialists can focus on the populations for which benefit has been shown, where indication creep has occurred, and encourage reflection on the risk/benefit ratio if, in fact, there is limited or no benefit to a service. As I have facilitated many such discussions, I can attest to the fact that practitioners appreciate the opportunity to compare their approaches to those of trusted colleagues when accurate timely accurate data is available.

In addition, as we begin to look at the comparative costs of episodes of care, we can begin to see what services are associated with lower episode costs and what services increase the cost of an episode without improving, or even decreasing value. For example, an orthopedist may experience higher episode costs for spinal stenosis because of his/her performing more spinal fusions but 3, 6, and 12 month self-reported outcomes may be no better than those who perform less complicated surgeries, or recommend physical therapy. In addition to state of the art population risk adjustment, exploring what adds and does not add value for specific diagnostic groups is critical to the success of ACO contracting.

What else can be done to encourage reduction in low value care, while at the same time increasing the use of high value care? Possibilities include defining a clear set of high and low value services and creating a value score for practitioners that provides comparison data to encourage increasing value. Similar to prompts to order a high value test or service, one could tie providing ACP/AAFP/AAP/USPHSTF guideline recommendations as prompts when low value series are ordered by EMR.  Recent recommendations have been made regarding a number of potential procedures2-4.

Employee or federal benefit design could increase co-pays for low value services (spinal fusion) while lowering co-pays for high value services (medication co-pays for antihypertensive medications). The result can be constructed to be cost neutral with reduction in low value services paying for the increase in high value services. The result, lower overall costs with improved outcomes.

In addition, similar to the marketing campaign to stop smoking, public health groups could develop campaigns to reduce potentially harmful, low value services. Explaining the harms of low value care with specific stories could make the point to disparate groups quite clearly.

Finally, probably nothing is more valuable than a trusted continuity practitioner reviewing the positives and negatives of a possible course of action. When done correctly, this shared decision making, with the practitioner being the expert in the benefits and risks of varied medical paths and the patient being the expert on their goals for care and weighting those risks and benefits is a powerful tool to do what is right for each specific patient. This personalized care is at the heart of the medical home/neighborhood model and with value driven payment reform, becomes a cost effective way to weigh evaluation and treatment choices.

EagleDream Health is interested in helping make actionable, accurate, reliable data available to you and your practitioners. We look forward to talking with you about both structure and function. For more information, contact Michael Howard, SVP of Marketing at Michael.Howard@eagldreamhealth.com.

Bibliography
  1. Schlesinger M, Grob R. Treating, Fast and Slow: Americans’ understanding of and response to low value care. Milbank Quarterly. 2017;95:70-116.
  2. Handlesman DJ. Testosterone and male aging: Faltering hope for rejuvenation. JAMA. 2017;317:699-701.
  3. Qaseem A, Wilt TJ, et al. Non-invasive treatments for acute, subacute and chronic low back pain: A clinical practice guideline form the American College of Physicians. Ann Intern Med. 2017;166:514-530.
  4. Delitto a, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: A randomized trial. Ann Intern Med. 2015:465-473.

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