Opioid prescriptions are among the three services that make up two-thirds of low-value care

Low-value care spending drops marginally, despite best efforts

February 26, 2021
by John R. Fischer, Senior Reporter
Despite efforts to educate clinicians and increase payment revisions, little has changed in the amount spent on low-value healthcare for traditional fee-for-service Medicare patients.

That’s according to a new RAND Corporation study, which recorded only a marginal drop between 2014 and 2018. “Because the majority of American medicine operates using a fee-for-service payment model, there is little incentive for physicians and hospitals to deliver less low-value care. Second, there are cultural and patient expectations that more care is often better care that influences physician decision-making, and in a rushed visit it takes less time to order the low-value test than to counsel the patient on why it may not be necessary. Third, there is also an asymmetry of risk/reward,” lead author John Mafi, an adjunct physician policy researcher at RAND and an assistant professor of medicine at the David Geffen School of Medicine at UCLA, told HCB News.

Low-value care is defined as patient services that offer no net clinical benefit in specific scenarios. Despite this, an estimated 10% to 20% of healthcare spending funds it. This issue has led to efforts aimed at reducing such care, including the the 2012 launch of Choosing Wisely, an initiative designed to encourage physicians and patients to hold more discussions about evidence-based medical practice and the issue of low-value care.

When assessing the proportion of 21 million Medicare participants over 65 receiving any of 32 low-value services, Mafi and his colleagues found the number only decreased from 36.3% in 2014 to 33.6% in 2018. They also calculated annual spending with claims-based low-value care measures from the Milliman MedInsight Health Waste Calculator, a software program that indicates care deemed wasteful by the Choosing Wisely campaign and other professional physician society guidelines. Spending per 1,000 individuals receiving low-value care went down from $52,766 to $46,922 during the same time span.

Two-thirds of the problem, they say, lies with opioid prescriptions for acute back pain, preoperative laboratory testing, and antibiotic prescriptions for upper respiratory infections. Opioids are especially concerning, due to growing awareness of their harm and the nationwide opioid crisis. Its use for back pain, along with antibiotic prescriptions for upper respiratory infections, rose during the study period, while preoperative laboratory testing fell.

What concerns the authors is that low-value care not only increases costs for patients and healthcare payers, it also is linked to harmful outcomes. For instance, about one in every 1,000 antibiotic prescriptions is associated with serious complications that lead a patient to be admitted to a hospital emergency department.

The findings, according to Mafi, highlight worrisome trends and underscore an urgent need to improve the quality and safety of care delivered to Medicare patients. "While Medicare measures hospitals and physicians on quality of care such as flu shots and mammogram rates for breast cancer screening, very little measurement is done on low-value care. I also believe there are many other forces that lead to the status quo prevailing, such as non-evidence-based protocols, force of habit, medical training, and how your colleagues around you practice."

In addition to policymakers continuing to help educate physicians and patients about these risks and continuing with payment reforms that discourage low-value practices, the researchers recommend incorporating more computer-based decision-support tools that can dissuade physicians from exercising low-value care.

"I think it does need to start with physician payment reform and trying to design payment policies that are not overly complex but also do not incentivize the delivery of expensive procedures that may not benefit patients," said Mafi, adding that "ultimately, given the multifactorial nature of this problem, it will require multifaceted solutions as I and others have argued previously, including a combination of physician payment reform, physician education and engagement, and seamless electronic health record decision support tools."

The study takes into account only a small portion of unnecessary care that is amenable to measurement.

The findings were published in JAMA Network Open.