Measuring Low-Value Care in Medicare
By Aaron L. Schwartz, BA; Bruce E. Landon, MD, MBA; Adam G. Elshaug, PhD, MPH; Michael E. Chernew, PhD; J. Michael McWilliams, MD, PhD
JAMA Internal Medicine, May 12, 2014
Abstract
Importance: Despite the importance of identifying and reducing wasteful health care use, few direct measures of overuse have been developed. Direct measures are appealing because they identify specific services to limit and can characterize low-value care even among the most efficient providers.
Objectives: To develop claims-based measures of low-value services, examine service use (and associated spending) detected by these measures in Medicare, and determine whether patterns of use are related across different types of low-value services.
Design, Setting, and Participants: Drawing from evidence-based lists of services that provide minimal clinical benefit, we developed 26 claims-based measures of low-value services. Using 2009 claims for 1 360 908 Medicare beneficiaries, we assessed the proportion of beneficiaries receiving these services, mean per-beneficiary service use, and the proportion of total spending devoted to these services. We compared the amount of use and spending detected by versions of these measures with different sensitivity and specificity. We also estimated correlations between use of different services within geographic areas, adjusting for beneficiaries’ sociodemographic and clinical characteristics.
Main Outcomes and Measures: Use and spending detected by 26 measures of low-value services in 6 categories: low-value cancer screening, low-value diagnostic and preventive testing, low-value preoperative testing, low-value imaging, low-value cardiovascular testing and procedures, and other low-value surgical procedures.
Results: Services detected by more sensitive versions of measures affected 42% of beneficiaries and constituted 2.7% of overall annual spending. Services detected by more specific versions of measures affected 25% of beneficiaries and constituted 0.6% of overall spending. In adjusted analyses, low-value spending detected in geographic regions at the 5th percentile of the regional distribution of low-value spending ($227 per beneficiary) exceeded the difference in detected low-value spending between regions at the 5th and 95th percentiles ($189 per beneficiary). Adjusted regional use was positively correlated among 5 of 6 categories of low-value services (mean r for pairwise, between-category correlations, 0.33; range, 0.14-0.54; P ≤ .01).
Conclusions and Relevance: Services detected by a limited number of measures of low-value care constituted modest proportions of overall spending but affected substantial proportions of beneficiaries and may be reflective of overuse more broadly. Performance of claims-based measures in supporting targeted payment or coverage policies to reduce overuse may depend heavily on how the measures are defined.
Excerpts from the Discussion
In this national study of selected low-value services, Medicare beneficiaries commonly received care that was likely to provide minimal or no benefit on average. Even when applying narrower versions of our limited number of measures of overuse, we identified low-value care affecting one-quarter of Medicare beneficiaries. These findings are consistent with the notion that wasteful practices are pervasive in the US health care system.
Although these findings suggest that direct approaches to measuring wasteful care may be tractable and informative, other findings underscore potential challenges in developing and applying direct measures of overuse. In particular, the amount of low-value care we detected varied substantially with the clinical specificity of our measures. Estimates of the proportion of Medicare beneficiaries receiving at least 1 measured low-value service decreased from 42% to 25% when we used more restrictive definitions that traded off sensitivity for specificity, and the contribution of low-value spending to total spending decreased from 2.7% to 0.6%.
Thus, the performance of administrative rules to reduce overuse through coverage policy, cost sharing, or value-based payment (eg, pay for performance) may depend heavily on measure definition. Such strategies may be appropriate for select services whose value is invariably low or whose low-value applications can be identified with high reliability. For other services, however, more sensitive measures could result in unintended restriction of appropriate tests and procedures by coverage and payment policies, whereas more specific measures could substantially limit the effect of these strategies. Provider groups seeking to minimize wasteful spending — for example, in response to global budgets — may be able to distinguish appropriate from inappropriate practices at the point of care without having to use rigid rules derived from incomplete clinical data.
Although our analysis suggests that common drivers of low-value care exist, our study did not identify specific determinants of wasteful care. Factors associated with low-value care may also be associated with high-value care.
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Comment:
By Don McCanne, MD
As we look for methods of slowing the increases in health care spending, much attention is being given to devising methods of identifying and reducing the amount of unnecessary care provided today. This article contributes to that discussion by showing the potential impact of measuring low-value care in Medicare patients. The results are quite disappointing.
When more sensitive versions of the measures were used, a very large number of Medicare beneficiaries were found to be receiving services categorized as low-value, but they were unable to determine whether or not the care provided was actually wasteful in the various clinical circumstances. Thus policies that would reduce these services could result in “unintended restriction of appropriate tests and procedures by coverage and payment policies.”
When more specific versions of the measures were used, the potential cost savings were very small, thus “substantially limit(ing) the effect of these strategies.” Adjusting between sensitivity and specificity trades off the inappropriate labeling of beneficial care as being of low-value, with the failure to identify enough of the clinical instances that were truly of low-value. Regardless of the sensitivity or specificity, mistakes will be made in classifying what truly is or is not low-value care.
As a cost saving measure, it would appear that such an approach would be administratively complex with costs that could offset a significant proportion of the very modest gains in recovery of charges for low-value care.
The authors note that health care professionals working within global budgets “may be able to distinguish appropriate from inappropriate practices at the point of care without having to use rigid rules derived from incomplete clinical data.” Clinical judgement trumps empirical computer algorithms.
It is not as if the policy community does not already know how to recover some of the profound waste in our system. Just the administrative savings alone recovered by adopting a single payer system would be enough to pay for the care that people are not now receiving that they should be. But our policymakers don’t seem to be giving up in their anything-but-single-payer pursuit of cost containment in health care. Their obsession is pathological.