Health system obstacles can prevent the elimination of low-value services

• Health system processes and procedures — not just physician practice patterns — can perpetuate the provision of low-value care. 
• State approaches to eliminating low-value care include either educating or shaming clinicians.
• Health plans and employers are educating clinicians and enrollees about low-value care.

Although approaches to eliminating healthcare services deemed “low value” traditionally have focused on physicians, some leaders of such efforts increasingly are finding that health system processes can pose significant obstacles.

A key to controlling healthcare spending and improving clinical outcomes is targeting the $345 billion in annual low-value care, said Mark Fendrick, MD, director of the University of Michigan Center for Value-Based Insurance Design. High-profile examples, according to the U.S. Preventive Services Task Force (USPSTF), include:

• Vitamin D screening tests
• Diagnostic tests before low-risk surgery
• PSA screening for men older than 69
• Provision of branded drugs when identical generics are available
• Imaging for lower back pain within six weeks of onset

Numerous value-based payment initiatives have been launched in recent years to educate physicians that such healthcare services offer relatively little benefit while adding unnecessary costs for patients and health plans.

Health system obstacles to curtailing low-value care

Beth Bortz, president and CEO of the Virginia Center for Health Innovations (VCHI), has educated physicians across the state about the need to minimize the use of low-value care. However, primary care physicians have objected to her that the surgical teams at their hospitals are required to conduct such low-value pre-op testing as a standing order.

“So, there’s all kinds of system problems that are happening,” Bortz said at a Jan. 29 briefing for congressional staff by the Smarter Health Care Coalition.

As a result of such revelations, Virginia hospital systems where she has helped identify similar practices have targeted system procedures that promote the use of low-value care.

Similarly, a physician member of the USPSTF once asked Bortz to review VCHI’s all-payer claims database to identify whether he prescribed low-value care. He was shocked when she found he ordered high rates of vitamin D testing. The physician investigated and realized the test was part of a standard testing bundle for annual exams created by his health system.

Health systems joined the effort to eliminate low-value care after VCHI identified $539 million in 2018 spending on just 48 low-value services offered by providers and covered by health plans that submit data to the state’s all-payer claims database.

John Keats, MD, national medical senior director for affordability and specialty partnerships for Cigna, said in an interview that state-led efforts like VCHI are the best way to identify and remove system-based obstacles to reducing low-value care. However, the health plan has started to work with health systems that operate its commercial accountable care organizations to find and remove such obstacles.

Different approaches to curtailing low-value care

Health system obstacles to eliminating low-value care may bolster the case for cooperative approaches such as that in Virginia, where clinicians and health systems voluntarily work with VCHI to review their data and identify where a high volume of such care is provided.

It’s a stark contrast to other approaches, such as in Washington state, where such data is posted online to create public pressure on providers to change the practice behavior.

“We go into these conversations assuming clinicians want to do the right thing. This is not [about] shaming them with data; this is a ‘Help us look at your data and help us figure out what might be happening that you look different than your peers,’” Bortz said. “And that has been an effective strategy.”

Meanwhile, some employers are both educating providers on the extent to which they use low-value care and urging enrollees to select providers that the employer has found offer high-value care. Walmart launched a “pretty sophisticated education campaign” during the last open enrollment for its health plan, which covers 1 million lives, to get enrollees to seek surgical care from its preselected centers of excellence, said Amanda Deegan, director of global public policy for Walmart.

That initiative was very well-received by employees, Deegan said, whereas outcomes of an initiative to show providers their data to get them to change their care patterns were a “mixed bag.”