Perspective: Low-Value Care is Everywhere. What is Driving It and How Can We Intervene?

Commercial payers spent more than $5.5 billion on 20 select low-value health care services in 2015, according to a new study from the Research Consortium for Healthcare Value Assessment, a collaboration between Altarum and VBID Health. We found that the prevalence of low-value care was widespread, with some regional variance, as illustrated on the map below. To reduce it, we need to take a closer look at where it is occurring and why. 

State Frequency of Low-Value Care Services, Privately Insured, 2015

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Although some states (Alaska, North Dakota, Utah, Idaho, and Oregon) performed better than others, none fell below 10 percent of members receiving at least one low-value care service. The worst performing states (Florida, New Jersey, North Carolina, New York, and Alabama) were twice that, with rates exceeding 20 percent of members. And while the study data was limited to the prevalence of low-value care among the privately-insured, prior research suggests that these findings are likely replicated among the publicly-insured, with some proposing that low-value services are even more common among vulnerable populations. 

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If the provision of low-value care is widespread and present regardless of payer type or anticipated reimbursement—what is driving it and how can we curb its use? Clues may be found on closer examination of the three most often-occurring services:  

1. Routine cervical cancer screen in women 30–65 ($782 million). It is unlikely that patient preference is driving a demand for annual Pap tests. A more likely culprit? Providers whose training that is out-of-step with current best practices. 
2. Population-based screening for Vitamin D ($928 million). Here the blame may lay with electronic medical systems programmed to be more efficient through 1-click ordering, yet unintentionally perpetuating a low-value service in bundled laboratory panels. 
3. Use of brand-name drugs over generic equivalents ($1.57 billion). In this case, patient preference may play a role, either through lack of education or financial incentives, for example, discounts and coupons offered for brand-name drugs.

There is no single driver of low-value care—providers, systems, and patients all play a role. To reduce it, our solutions must align incentives appropriately along all three of these areas. Quality improvement CME training could help providers decrease the frequency of Pap tests to align with recommended guidelines.  Improved interoperability and clinical decision support applications could help end blanket ordering of unnecessary panels through EHRs. And patient education and improved insurance plan design could help reduce patient preference for brand-name medications. The good news is that we know how to break down where low-value care is occurring and can begin to take a closer look at designing the correct interventions.

Read the full report.