Low-value health care drops only marginally despite effort to curb practices

Spending on low-value health care among fee-for-service Medicare recipients dropped only marginally from 2014 to 2018, despite both a national campaign to better educate clinicians and increasing use of payment revisions that discourage wasteful care, according to a new RAND Corporation study.

Three items accounted for two-thirds of the low-value care. Among these, prescribing opioids for acute back pain increased despite a growing national awareness of the harms caused by the drugs and the role of such prescribing in fueling the nation’s opioid crisis.

The study found that the proportion of study participants receiving any of 32 low-value services decreased from 36.3% in 2014 to 33.6% in 2018. Annual spending per 1,000 individuals on low-value care also decreased, from $52,766 to $46,922 from 2014 to 2018. The findings are published online by the journal

JAMA Network Open.

“Our study highlights several promising opportunities for targeted interventions that may reduce wasteful health care spending while improving the quality of care,” said John N. Mafi, the study’s lead author and an adjunct physician policy researcher at RAND, a nonprofit research organization.

“Given mushrooming deficits and the fact that the Medicare trust fund is running out of cash, there will be enormous pressure to find ways to trim spending in the Medicare program and making significant progress in reducing low value care needs to be a top priority,” said Mafi, who also is an assistant professor of medicine at the David Geffen School of Medicine at UCLA.

An estimated 10% to 20% of health care spending consists of low-value care, defined as patient services that offer no net clinical benefit in specific scenarios. These items include many common treatments such as the prescribing of antibiotics for uncomplicated acute upper respiratory infections.

While low-value care increases costs for both patients and health care payers, it also is associated with harmful outcomes for patients. For example, about 1 in every 1,000 antibiotic prescriptions is associated with serious complications that require a patient to visit a hospital emergency department.

To address the problem, the American Board of Internal Medicine Foundation joined with multiple clinician specialty societies in 2012 to create an initiative called Choosing Wisely, designed to encourage physicians and patients to engage in conversations about evidence-based medical practice and the problem of low-value care.

The new RAND study analyzed information about the care received by more than 21 million Americans enrolled from 2014 to 2018 in traditional fee-for-service Medicare, the nation’s health insurance program for people aged 65 years and older.

Researchers examined claims-based low-value care measures from the Milliman MedInsight Health Waste Calculator, a software program that highlights care designated as wasteful by the Choosing Wisely campaign and other professional physician society guidelines.

The study found that three services accounted for two-thirds of the low-value care. In addition to opioids prescribed for back pain, the other two services were preoperative laboratory testing and the prescribing of antibiotics for upper respiratory infections.

During the study period, preoperative laboratory testing fell, while increases occurred among both opioid prescriptions for back pain and the prescribing of antibiotics for upper respiratory infections.

Researchers caution that the study reflects a small portion of unnecessary care that is amenable to measurement.

“In the midst of ongoing antibiotic overuse and an opioid overdoes crisis, our findings highlight worrisome trends and underscore an urgent need to improve the quality and safety of care delivered to individuals with Medicare,” Mafi said.

The study suggests that policymakers continue efforts to educate both physicians and patients about low-value care and continue with payment reforms that discourage use of the low-value practices. In addition, efforts should increase use of computer-based decision-support tools that can encourage physicians to reduce their use of low-value medical care.

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Support for the study was provided by the federal Agency for Healthcare Research and Quality and the National Institutes of Health.

Other authors of the paper are Rachel O. Reid, Lesley H. Baseman, Scot Hickey, Mark Totten, Denis Agniel and Cheryl L. Damberg, all of RAND, and A. Mark Fendrick of the University of Michigan and Catherine Sarkisian of the David Geffen School of Medicine at UCLA.

RAND Health Care promotes healthier societies by improving health care systems in the United States and other countries.