Digging Deep (Into Your Own Pockets) to Root Out Low-Value Care

I’ve been to Oregon, and it’s beautiful. But I had no idea the state had a real problem with low-value care. I’m glad I didn’t get sick when I visited lest the hospitals and doctors there subject me to a lot of unnecessary tests and procedures.

That dodged-a-bullet thought came to mind as I read a new report on the prevalence of low-value care in Oregon and recommendations on how to reduce it. If you follow my posts, columns and podcasts, you know I have a real thing about low-value care. It’s medical care that offers little or no clinical benefits to patients and that can actually hurt if not kill you. I really don’t like it, and neither should you.

Neither should Oregonians. The new report, Better Health for Oregonian: Opportunities to Reduce Low-Value Care, said 40 percent of nearly 10 million medical services received by state residents from 2016 through 2018 were low-value and cost more than $529 million to provide over that three-year period.

The Oregon Health Leadership Council and the Oregon Health Authority retained the Washington Health Alliance to produce the 50-page report, which you download here. The report is based on the WHA’s analysis of the OHA’s All Payer All Claims Database, which includes claims from commercial insurers, Medicare and Medicaid.

The WHA defined a medical service as low-value if it was wasteful (service was very likely unnecessary and should not have occurred) or likely wasteful (appropriateness of the service should be questioned).

The WHA separated the nearly four million medical services that fit its definition into types of services with prevention screenings being the most overused low-value service. In ranked order, here’s how the services fell by category: 

1. Prevention screening (35.5 percent)
2. Common treatments (31.8 percent)
3. Preoperative evaluation (16.3 percent)
4. Diagnostic testing (12.2 percent)
5. Disease approach (4.1 percent)

The top five low-value services, in ranked order, were:

1. Prescribing opioids for lower back pain
2. Ordering preoperative lab tests for low-risk surgery patients
3. Conducting annual cardiac screenings for low-risk patients
4. Prescribing antibiotics for urinary tract infections and ear aches
5. Ordering PSA tests to screen male patients for prostate cancer regardless of age

If you follow this stuff, the ranked order of the service categories and specific services was interesting but not necessarily surprising. What was interesting and surprisingly was how the low-value services broke down by payer.  

If you looked at the percentage of low-value claims by payer, commercial health plan ranked first: 

1. Commercial (49 percent of claims were for low-value services)
2. Medicaid (45 percent of claims were for low-value services)
3. Medicare (31 percent of claims were for low-value services)

But, if you looked at the rate of low-value claims, the ranked order was essentially reversed:

1. Medicare (595.5 low-value services for every 1,000 patients)
2. Commercial (355.1 low-value services for every 1,000 patients)
3. Medicaid (272.7 low-value services for every 1,000 Medicaid patients)

What makes those two findings interesting and surprising is I don’t know what to make of them.  The most overused low-value service for patients with commercial health insurance was an annual cardiac screening. The most overused low-value service for both Medicare and Medicaid patients was opioids for lower-back pain. You could blame fee-for-service medicine yet many preventive services are free under most private and public health insurance plans. 

Maybe what the report is trying to say is that the roots of low-value care go a lot deeper than we think. That means the solutions are much more nuanced and varied than we think. We think that if we publish a list of low-value services that they’ll magically just go away similar to what President Trump said about the coronavirus. That clearly was and is not true.

“The issues are complex, there are many voices at the table, and systematic change will take time and sustained leadership,” the OHLC and OHA said politely in the report.

So what does the report recommend we do? Here are a few distilled and less polite action items from the report:

• Hospitals, medical practices and health plans can use the data in the report to dig deeper into their own numbers
• Hospitals, medical practices and health plans can use their own numbers to identify utilization patterns of individual practitioners
• Hospitals, medical practices and health plans can target offending practitioners with custom interventions to change their utilization patterns
• Hospitals, medical practices and health plans can use financial incentives to penalize or reward individual practitioners based on their use of low-value medical services
• Health plans specifically can use the data in the report to adjust benefit designs and utilization management protocols to discourage the use of low-value medical services

In short, the time for lists is over. The time to use money to reduce low-value care is here. Healthcare is a business just like any other business and, as a business, it responds to financial incentives. Why it took so long to figure that out, I’m not sure.   

To learn more about this topic, please read “Now Is the Time to Nip Low-Value Care in the Bud” or listen to the June 26 episode of 4sight Friday Roundup, our weekly podcast series.

Thanks for reading.

Stay home, stay safe, stay alive.