Industry still determining what services are worth doing

Inova Health System’s quest to rid itself of wasteful care started small with posters and handouts scattered about the exam and waiting rooms of its primary-care clinics in Northern Virginia. Following the Choosing Wisely campaign’s blueprint, Inova hoped these would spark conversations between patients and doctors about avoiding care that has little or no value, such as MRIs for some lower back pain or antibiotics for certain upper respiratory infections. 

Progress was slow.

Inova executives then ramped up efforts to reduce low-value care in 2016 by incorporating hundreds of best practice recommendations into its electronic health record system. Any time a clinician orders a test or medication considered low-value, an alert pops up asking them to reconsider. 

These alerts have helped change doctor behavior and saved Inova about $1.6 million over 2½ years, said Dr. Neeta Goel, medical director of quality and population health in Inova’s medical group.

“We’re really trying to improve the quality of care, reduce harm to the patient and of course trying to eliminate all the waste and high cost,” Goel said. 

But Inova leaders think they can do better. Starting in July, the health system and five others in Virginia will participate in a statewide three-year pilot to reduce use of seven procedures considered low value by 25%. Some of those include preoperative testing for low-risk surgeries and annual electrocardiograms for patients without symptoms. 

The pilot project has been a long time coming. The not-for-profit Virginia Center for Health Innovation, whose mission is to accelerate the adoption of value-based healthcare, is spearheading the project with a $2.2 million grant after spending years collecting data from the state’s all-payer claims database and analyzing it to pinpoint wasteful spending. In 2017 alone, its analysis revealed Virginia spent $600 million to $700 million on 42 low-value care services, though that reflects only 5 million of the state’s 8 million residents, due to differing reporting requirements.

Each health system in the pilot will soon get a report detailing its clinicians’ spending on the seven low-value tests and procedures, chosen either because of excessive spending on those services or because they are driven by clinician decisions. While the center will provide regular performance data, monthly webinars and access to expert faculty, it’s up to the hospital systems as to how they want to tackle those services. 

“We feel like we’ve gotten pretty good at the data piece. … What we don’t know yet is what works best in improving. Is it alerts on the EHR? Is it participating in continuing education? Is it financial incentives? We’re hoping to learn in this process what is effective in addressing the (low-value) care,” said Beth Bortz, CEO of the Virginia Center for Health Innovation.

Virginia is hardly alone in the battle against wasteful spending, but it is ahead of the pack in the attention it’s devoting to the issue and its pursuit of tackling the problem on a statewide basis. 

With healthcare costs eating up a larger and larger share of the nation’s gross domestic product, the race is on to figure out how to spend less. In recent years, health insurers and employers have hiked plan deductibles, but that strategy proved to reduce all care, even the necessary kind. Some state and federal lawmakers have turned their sights toward reducing reimbursement rates by tying commercial payment to Medicare, but clinicians argue that will put them in the red and make it harder for patients to get the care they want and need. 
Other experts say that a better way forward is eliminating all the care that patients don’t really need.

“If you believe that healthcare is becoming more and more unaffordable, then it becomes worthwhile to ask if there are things we shouldn’t be doing anymore because there’s no evidence to support it and it might cause harm. It’s easier to say than ‘We might need to cut 5% out of this budget,’ ” said Nancy Giunto, executive director of the Washington Health Alliance, which is similarly analyzing its state’s all-payer claims database to identify waste but hasn’t yet conducted a wide-scale experiment to reduce it.

Low-value care is just what it sounds like: healthcare that provides minimal or no clinical benefit to patients. It comprises tests and procedures that could potentially do more harm than good. One example is providing opioids for minor muscle pain that could be treated with ibuprofen. 

Clinicians provide these tests, procedures and medications out of habit or fear that by not providing, say, that X-ray, they might miss something. Sometimes a hospital or ambulatory surgery center requires a barrage of preoperative testing, even though the primary-care physician knows it’s unnecessary. Other times, unnecessary lab tests are performed as part of a bundled lab contract. Some patients also demand an antibiotic or an MRI, and time-pressed physicians see no harm in acquiescing. Moreover, the U.S. healthcare system still rewards clinicians for doing more, not less. 

For these reasons, the nation spends mountains of money on wasteful services. Several studies estimate 10% to 30% of the $3.3 trillion in U.S. healthcare spending is wasteful. Depending on how the data is sliced, Medicare alone spent $2.4 billion to $6.5 billion on 34 to 72 low-value services in 2014, the Medicare Payment Advisory Commission wrote in a June 2018 report. 

But tallying up low-value care is easier than eradicating it. The Choosing Wisely campaign started by the ABIM Foundation in 2012 focused national attention on low-value care by asking specialty societies to come up with lists of wasteful tests and procedures and ended up with more than 500. It sought to promote conversations between patients and their doctors about unnecessary healthcare but did little to reduce use of those services.

Some consider the national Task Force on Low-Value Care, of which Virginia’s Bortz is a member, to be the next generation that’s turning talk into action. The task force boiled Choosing Wisely’s recommendations down to five relatively inexpensive but common tests or procedures that it considers to be easy targets. The task force aims to bring the employers, insurers and other payers to the table to figure out the best ways to reduce waste.

Some studies have hinted at promising strategies. A review of different experiments by Dartmouth University researchers found that multiprong interventions that get at both the patient and clinician roles in wasteful care have the most potential. Those include clinician decision support and performance feedback and patient education. Value-based pay-for-performance arrangements, risk-sharing and emerging benefit designs to reduce low-value care haven’t been tested as widely, according to the review.

A study published in JAMA in March reported significant reductions in the percentage of patients undergoing preoperative tests before cataract surgery at a Los Angeles County safety-net system after a quality improvement nurse made it her mission to reduce these needless tests. She gathered data on cases of unnecessary EKGs, chest X-rays and lab testing before cataract surgery, got the anesthesiology and ophthalmology department chiefs on board, and then worked from the bottom up to educate nurses, residents and other staff. 

The quality-improvement team and a resident champion distributed new preoperative guidelines and ultimately, the percentage of patients who received pre-op tests decreased from 93% to 24%.

“If you want to be nuanced about how you change health services and how you reduce only low-value care, you’ve got to get local,” said Dr. John Mafi, a University of California at Los Angeles assistant professor who authored the JAMA study. “You’ve got to allow clinicians, nurses and doctors to be the leaders in tackling low-value care, and you’ve got to let local clinicians have autonomy in how they measure it and how they reduce it. Otherwise you are going to get these problems of spillover where you take out both necessary and unnecessary care.”

Health insurers have been reluctant to join hospitals in reducing low-value care. Several experts said that while insurance companies could have a role in using their financial leverage to influence clinicians, they are largely content with the status quo. But that’s starting to change. 
 

Cigna Corp. stopped paying for vitamin D testing in early 2018 after the Endocrine Society a few years earlier determined it isn’t appropriate for all patients. Dr. John Keats, Cigna’s national medical director for affordability and specialty partnerships, said the insurer has seen savings and physicians are ordering the test less often. Cigna has so far seen a 4.8% decrease in claims submissions for vitamin D screenings, and the company estimates that it has saved more than $20 million annually since implementing the guidelines. Keats said the number of appeals Cigna has received for the testing has been well below what he anticipated.
 

Cigna is also working with a vendor called Evicore to 
prior-authorize high-cost MRIs and CT scans for lower back pain and is working with its accountable care organization partners to boost the prescribing of generic drugs by providing those ACOs with performance feedback. Cigna is analyzing data to find out if it can identify instances of unnecessary preoperative testing for minor procedures.

“It really behooves us to pay attention to low-value care and try to eliminate that or certainly steer physicians away from prescribing those things, steer patients away from receiving those types of care, and then those dollars could be spent more productively elsewhere,” Keats said.

Other plans, including Emblem Health in New York, are following Cigna’s lead. Dr. Mark Fendrick, director of the Center for Value-Based Insurance Design at the University of Michigan, noted that Emblem Health is moving ahead with plans to reduce vitamin D screenings and unnecessary preoperative testing, but the insurer said it was too early in the process of its work to comment for this story.

The Pacific Business Group on Health, which includes big employers like Boeing, Bank of America and Microsoft, is pushing its health plans to hold providers accountable. Lauren Vela, the group’s senior director of member value who helped bring Cigna to the table, said large employers depend on their health plans to administer benefits and set up their networks.

“We need the health plan to intervene on this and say wait a minute, there are things you’re paying for here that are very low value. Let’s change that system,” she said.

That’s also why the second phase of Virginia’s pilot is creating an employer task force to prompt their health plans to create benefit designs that reward hospitals for limiting unnecessary care in favor of more high-value care.

In a fee-for-service environment, hospitals will lose money if they provide fewer low-value tests and procedures. In Virginia, the six health systems signed on to the statewide pilot anyway because they felt that value-based contracting is the direction the country is moving toward and they want to be out in front, Bortz explained. In the long term, financial incentives will have to change to hold providers’ interest.

“Once we figure out if we can actually do this, if we can significantly reduce the provision, the next big book of work is going to be figuring out the financing of it,” Bortz said.