Providers are moving toward paying for value with two key approaches: encouraging simple high-value methods like a follow-up phone call with patients, and discouraging low-value, pricey services like unnecessary testing.
Both have their challenges, but the latter has been a particularly hard nut to crack. It's not for lack of trying.
One leading effort is at the University of Michigan's Center for Value-Based Insurance Design, created in 2005 to explore ways to lower financial barriers to high-value clinical services. The initial goal was to align patients’ out-of-pocket costs with the value of services. Now they're taking on the second part of the equation.
“We have more than enough money in the system. We can use more on good stuff and less on bad stuff,” Dr. A. Mark Fendrick, professor and director of the center, told Heathcare Dive.
For more than a decade, a number of initiatives have attempted to drive down use of low-value services. Providers know such tests and procedures can cost billions, harm patients, cause high out-of-pocket costs and lead to lost productivity and patient frustration.
But it’s also difficult to get clinicians to stop ordering tests and procedures when it’s been ingrained in them. That’s particularly true when few programs have shown consistent and verifiable progress, and patients face frustrating choices they often aren't equipped to make.
Low-value care and patients
When payers and employers look to cut costs, it’s often on the backs of consumers, or by influencing where they get care.
Anthem recently required members to get CT scans and MRIs in outpatient facilities rather than hospitals unless it’s an emergency. The payer also stopped paying for emergency department visits it deems unnecessary in hopes of getting members to visit less costly retail clinics and urgent care centers.
Putting more financial burden on patients is another strategy. A key tenet of high-deductible health plans is giving patients “more skin in the game.” The theory is that putting more service costs on the individual will make the patient choose care wisely. Members are often interested in HDHPs because they have lower premiums than other plans.
But patients are largely confused by their choices. Patient education programs, which were seen as a key plank to these consumer-driven plans, have not increased patient literacy overall. Plus, patients often have a difficult time even finding the cost and quality data they need to make informed decisions. So, in fact, HDHPs have moved more costs onto patients without actually helping them become better healthcare consumers.
Fendrick is no fan of such efforts and said the focus should be on changing habits through incentivizing cost and quality by increasing high-value care and limiting low-value care within the healthcare system.
“I don’t like this idea of asking my patients to shop around for their colonoscopy,” Fendrick said.
Recent evidence supports his view.
The American Journal of Managed Care found that HDHPs lower overall outpatient spending, but don't reducing low-value healthcare spending. Researchers found “no significant reductions” in annual spending on 26 low-value services they studied.
There was a small reduction in low-value spending on imaging, but not in overall imaging spending and no significant reductions in low-value laboratory spending. The study suggested that HDHPs “may represent too blunt an instrument to specifically curtail low-value healthcare spending.” Instead, the study said V-BID could be “a more nuanced mechanism … to spur value-based behavior.”
What is considered low value?
Fendrick formed the Task Force on Low-Value Care, a group that includes purchasers, patient advocates and employer groups, to find ways to reduce the billions being spent annually on healthcare services with no clinical benefit.
The task force analyzed a list of 400 potentially low-value procedures and tests. They looked at potential for harm, cost and prevalence, including the ability for purchasers to help reduce delivery of those services. The group narrowed the focus to a digestible list of five low-value healthcare services that have “broad scientific consensus advising against their use.”
- Diagnostic testing and imaging for low-risk patients before low-risk surgery
- Vitamin D screening
- Prostate-specific antigen screening in men 75 and older
- Imaging for acute low-back pain for the first six weeks after onset, unless there are clinical warning signs
- Use of more expensive branded drugs when there are generics available with identical active ingredients.
The task force estimates the five services total more than $25 billion in avoidable annual expenditures. For example, the group estimated that up to 90% of vitamin D tests are “clinically useless” and don’t “guide clinical care.” Though the task force said only patients with specific higher-risk clinical conditions need a vitamin D test, physicians nationally requested 6.3 million such tests in 2014 that were not clinically indicated. These tests cost more than $800 million.
One task force member, Beth Bortz, president and CEO of the Virginia Center for Health Innovation, estimated that Virginia spent more than $247 million on diagnostic testing and imaging for low-risk patients before low-risk surgery in 2015 alone.
She called reducing the five services “just the tip of the spear.”
In one effort to combat unneeded tests and procedures, AcademyHealth partnered with the ABIM Foundation on a project that seeks to improve clinician/patient conversations. Launched in 2012, the goal of Choosing Wisely is to reduce low-value care without revamping payment models or benefit design.
Results have been less than stellar.
A recent report published in Health Affairs found the program hasn't made changes in physician or patient behavior toward low-value care. Fendrick said one reason Choosing Wisely hasn't been as successful as hoped is that there is “no teeth in it.” He said incentives are a critical piece of changing provider behaviors.
The report suggested possible ways to reduce low-value services, including “multifaceted interventions that reinforce guidelines through personalized education, follow-up and feedback, as well as aligned financial incentives.”
The industry is learning that education on one single, narrow intervention isn't enough, Dr. Lisa Simpson, president and CEO of AcademyHealth, told Healthcare Dive.
Simpson said communication between clinicians and patients is key when making healthcare decisions, but what also matters is how healthcare is organized, delivered and financed. She said the healthcare system needs to support and reward conversations between clinicians and patients about low-value care.
“We can’t keep beating up on clinicians and systems to do more to get to high-value care; we have to help them stop doing what is low value," she said. "Understanding when a service is low value to which patient is the work of research and identifying interventions that work to eliminate low-value care is also the work of research. We have our work cut out for us."
Limited research on reducing low-value care
How reducing low-value care improves quality and lowers costs isn't a widely studied topic yet.
Henry Ford Medical Group in Michigan is making an effort with Choosing Wisely alerts on quality, safety and resources. The medical group focused on reducing unneeded antibiotic prescriptions, diagnostic testing for low back pain and vitamin D screenings.
Dr. Bruce Muma, medical director for Henry Ford Medical Group Population Health and chief medical officer for the Henry Ford Physician Network, said the medical group can track when the system triggers an alert and how those alerts influence quality, safety and cost savings.
Henry Ford found positives:
- Antibiotic use for bronchitis dropped from 77% in 2014 to 25% in 2017.
- Inappropriate vitamin D testing fell from 31% in 2014 to 2% in 2017.
- Orders for red blood cell counts when hemoglobin count was greater than seven decreased from 61% in 2014 to 42% in 2017.
Meanwhile, payers are also looking for ways to reduce low-value care and promote high-quality care. Blue Cross Blue Shield of Massachusetts launched the Alternative Quality Contract (AQC) in 2008. The pioneering payment model combines risk-sharing with pay-for-performance incentives. The contract also allows providers to assess their performance compared to peers for frequently used services. A 2014 study in the New England Journal of Medicine found AQC improved the quality of patient care and lowered costs over four years.
Though not specifically connected to cutting low-value care, the federal government is also interested in the greater use of V-BID. The Department of Defense is piloting a V-BID program next year and the Center for Medicare and Medicaid Innovation is testing V-BID in Medicare Advantage in multiple states. The model allows MA plans to offer “supplemental benefits or reduced cost-sharing” to enrollees with specified chronic conditions. The program focuses on services with the highest clinical value. The program is testing whether this can improve health outcomes and lower expenditures.
Barriers to reducing low-value care
A major hurdle is the lack of financial incentives for doctors to reduce low-value care. Malpractice is often on their minds, pushing them to overdo it on tests. Also, patients can be demanding.
Simpson said the perceived patient demand could be more about physician perceptions concerning patient questions rather than patients actually demanding services. That’s why it’s important for clinicians to have conversations with patients about the trade-offs in making informed choices.
Simpson added that payment incentives are a key to removing barriers. “If a system is financially rewarded for providing low-value services as part of a volume-based payment system, it is going to be very hard to make any progress. That is why we need to keep pushing on innovative payment models and good research to evaluate these to understand which types of payment systems work for which settings and services,” she said.