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.