Tackling Low-Value Care Will Take a Group Effort
March 19, 2019
Paying for treatments that don’t offer real value for patients is a pervasive problem in the United States, with as much as $340 billion being spent on this low-value, or unnecessary care alone. Eliminating low-value care and its costs to our health care system has taken on even greater importance with health care spending reaching nearly 18% of GDP.
During a briefing with partners of the Going Below The Surface Forum, three leaders in the effort to reduce low-value care in the United States explained why this has been such a tough challenge to tackle.
Daniel Wolfson, Executive VP and COO, ABIM Foundation, heads Choosing Wisely, a national effort that helped to kick off the conversation about low-value care more than 7 years ago. Choosing Wisely works with organizations representing medical specialists, particularly those that develop clinical guidelines, as a way to better target low-value care yet ensure that quality, safety, and doing no harm are top of mind. To date, Choosing Wisely and its partner organizations have developed more than 550 recommendations, but it’s hard to change “how physicians have been wired,” said Wolfson.
Choosing Wisely has had success at the state level, where they have seen the most progress, Wolfson noted. A. Mark Fendrick, MD, Director, University of Michigan Center for Value-Based Insurance Design, concurred, pointing to work that he and colleagues had undertaken in Virginia. Their analysis of the Virginia All-Payer Claims Database revealed more than $586 million in unnecessary costs associated with 44 types of low-value care that included labs, medications, imaging exams, diagnostic procedures and other treatments. Fendrick is working with other states, including Washington State, to similarly identify wasteful services and reduce spending.
Some of the services identified as wasteful are based on Choosing Wisely’s recommendations, as well as on efforts led by the US Preventive Services Task Force (USPSTF), which examines preventive treatments based on data and clinical evidence. USPSTF rates preventive treatments from A to D, with D ratings reserved for treatments that are considered low-value or unnecessary and should not be utilized or reimbursed under Medicare. An important caveat, Fendrick said, is that many of the USPSTF recommendations are based on clinical nuance. That means for certain patients, tests or treatments are useful and/or beneficial to their care.
“I’m always asked what my three favorite high-value care and low-value care examples are,” said Fendrick. “For low value, they are colonoscopy, coronary stents and back surgery. For high value, they are colonoscopy, coronary stents and back surgery. Clinical nuance matters.”
Eve A. Kerr, MD, MPH, Director, Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, agreed. At her organization, she has been leading efforts to assess the opportunities to reduce low-value care, focusing on treatments or interventions that are “never do, never repeat, repeat infrequently, or rarely do.” She said the challenge is to target the root causes of low-value care, and to always evaluate whether those efforts are working or have unintended consequences. Encouraging collaboration among health care colleagues also is vital in these efforts, Kerr said.
The GBTS Forum intends to make an impact by helping to call further attention to low-value care and building on Wolfson, Fendrick and Kerr’s efforts. Forum members plan to examine concrete actions that the health care sector could take to reduce this type of wasteful spending. They recognize that it will take many organizations, working together, to make a real difference, but they are excited about taking these next steps.