Johns Hopkins study names health systems that provide the most 'unnecessary' care

About 11% of the nation's health systems are big-time over-utilizers of low-value services, according to a Johns Hopkins University study published in JAMA on Friday.

Health systems that employ fewer primary care physicians, have higher bed counts or are investor-owned are associated with more unneeded care, researchers at Johns Hopkins' medical and public health schools found. Unnecessary procedures, tests and screenings are linked to lower quality of care and worse patient and worker safety, and drive up healthcare costs.

Among the top over-users were St. Dominic Health Services of Jackson, Mississippi, Irving, Texas-based USMD Health System, Community Medical Centers of Clovis, California, and Providence, Rhode Island-based Care New England Health System, according to the study.

USMD Health System is the only for-profit health system topping the list of over-users, but others scored above average, such as Nashville, Tennessee-based HCA Healthcare, Tenet Healthcare of Dallas, King of Prussia, Pennsylvania-based Universal Health Services and Community Health Systems of Franklin, Tennessee.

The study analyzes Medicare claims data from 2016-2018 at 3,745 hospitals for 17 services previously identified as unnecessary, such as MRIs for patients with mild traumatic brain injuries, spinal fusions for back pain and pap smears for women over age 65. A health system's usage of these types of services relative to its peers serves as a proxy for whether its hospitals provide unneeded care, according to the study.

"This type of tool has the potential to provide guidance for health systems on which practices they might de-implement," said Rinad Beidas, the director of the Penn Implementation Science Center at the University of Pennsylvania, who was not involved in the research. "Given the immense strain on our [healthcare] system and clinicians over the past two years, identifying practices for de-implementation are even more important to reduce burden on our workforce."

St. Dominic's Health Services, the top over-utilizer named in the report, regularly scrutinizes patient care and quality measures against best-known clinical practices, said Scott Kashman, the president of the health systems' health services market operation. Although health system leaders haven't fully reviewed the Johns Hopkins findings, "we are committed to exploring this study and taking any necessary actions to ensure our patients, community and region receive the most exceptional, safe and effective care," he said.

USMD Health System, Community Medical Center and Care New England Health System didn't respond to requests for comment.

At the other end of the spectrum, the health systems that perform these unnecessary services the least are more likely to be academic medical centers, employ more primary care doctors, provide a disproportionate amount of uncompensated care or utilize integrated delivery models, the study shows.

"Primary care physicians have a role in coordinating care, and making sure that procedures aren't repeated if they've already been done, and that specialists aren't used if it's something that can be managed by primary care doctor," said Dr. Jodi Segal, the lead author and a professor at the Johns Hopkins University School of Medicine.

Large not-for-profit health systems such as Pittsburgh-based Allegheny Health System, Houston Methodist in Texas, and Houston-based Memorial Hermann Health System provided below-average amounts of unneeded care. according to the study.

Dignity Health of San Fransisco, and Danville, Pennsylvania-based Geisinger and Seattle-based Group Health (owned by Kaiser Permanente of Oakland, California, since 2017) fell into the average category. All of those systems are not-for-profit.

The study determined that the more physician groups a health system owns, the more unnecessary care is provided, a finding that could help hospital leaders explore how to expand services while maintaining quality.

"As hospitals restructure themselves into larger and larger systems, senior leadership of hospitals will have to own this problem, said Dr. Vikas Saini, president of the Lown Institute, a healthcare think tank that has studied overuse.

Johns Hopkins researchers plan to continue their studies by examining health systems with average or below-average use of the procedures, particularly those with characteristics more similar to the biggest over-users. Those hospitals' practices could offer insights to their peers with higher usage of unneeded services, the study says. Further research also is necessary to determine what factors contribute to overuse, such as what medical specialists deliver the services, what kinds of patients receive them and what are the rationales behind these practices.

The Johns Hopkins researchers didn't include children's hospitals, behavioral health centers, rehabilitation hospitals or psychiatric hospitals in their analysis.

Correction: An earlier version of this article misidentified the locations of HCA Healthcare's and Tenet Healthcare's headquarters.