Overuse, or low-value care, refers to health services that have little or no clinical benefit for patients. Overuse puts millions at risk of unnecessary harm from complications, cascade events, financial toxicity, and more. Not to mention, it wastes at least $100 billion each year.
Over the past decade, initiatives like the Lown Institute Hospitals Index, the Right Care Alliance, and Choosing Wisely have made doctors and patients more aware of overuse than ever. But has the prevalence of overuse actually changed? That’s what Dr. John Mafi, primary care physician and assistant professor at UCLA, and colleagues set out to find in their new analysis in JAMA.
In 2018, about one third of Medicare beneficiaries were still receiving at least one low-value service.
They looked specifically at 32 low-value services in the Medicare fee-for-service population, including overuse of medications, tests, and invasive procedures. They found that from 2014 – 2018, the proportion of Medicare beneficiaries receiving any low-value service declined — but only by 2.7%. In 2018, about one third of Medicare beneficiaries were still receiving at least one low-value service. For every 1000 people, about $145,000 was spent on unnecessary services– that’s $5.5 billion for the Medicare population, just for these 32 services.
The small decrease in overused services was not universal across all types of overuse. While low-value preventive screenings like annual cardiac screenings and Vitamin D screenings decreased, prescriptions of opioids for back pain increased, as did antibiotics for colds.
In 2018, more than 121,000 Medicare beneficiaries had carotid artery ultrasounds done unnecessarily.
Many of this overuse takes place in hospitals, which is why the Lown Institute Hospitals Index measures how well hospitals avoid overuse for Medicare fee-for-service patients. Mafi et al. find that several of the low-value services measured on the Lown Hospitals Index are on the rise. Specifically, the prevalence of head imaging for fainting, EEG for headache, and renal artery stenting all increased slightly from 2014-2018. Carotid artery imaging for fainting, which can lead to invasive procedures, became significantly more prevalent from 2014-2018, which is concerning. In 2018, more than 121,000 Medicare beneficiaries had this test done unnecessarily.
How do we get hospitals and other providers to stop doing these low-value procedures? The lack of significant improvement shows that we need to go beyond culture and tackle the incentives that push doctors to overuse. In a recent white paper from the Leonard Davis Institute of Health Economics (LDI), Dr. Rachel Werner, LDI’s executive director, and colleagues argue that it’s time to move faster on value-based payment initiatives. The authors call on the Centers for Medicare and Medicaid Services (CMS) to do three things:
1) Align incentives across all public payers. Even with the value-based payment programs that exist, most public payers are still fee-for-service, making it difficult for providers to fully transition to “value over volume.” For example, the Medicare Incentive Payment System (MIPS) emphasizes value, but it is a small program within the larger fee-for-service system, which is likely not enough of an incentive to stop doing more procedures overall. Hospitals get reimbursed from a lot of different payers (Medicare, Medicaid, Medicare Advantage, etc, Obamacare plans, etc). Creating incentives for value across all of these payers would have a large impact, and make the system less confusing for doctors and hospitals.
2) Use both carrots and sticks. Currently most value-based payment programs offer “upside-only shared savings,” meaning that providers get a benefit if they avoid overuse, but no penalty if they don’t avoid overuse. CMS should move toward risk-bearing, population-based payment models, Werner and colleagues write, and make it harder for providers to “opt out” of value-based models.
3) Incorporate equity into the equation. Some value-based payment models have been rightly criticized for punishing providers that care for more low-income people of color, because it’s harder for them to meet the clinical targets. Most value-based models do not have an explicit goal of reducing health disparities, which needs to change. Alternative payment models should include funding specifically earmarked for caring for patients with social risk factors, which could be used for things like community health workers, community-based services, integration of social services and health. Additionally, CMS should create financial incentives for hospitals or practices to reduce racial health disparities within their patient population.
Patient engagement is an essential element to reducing overuse as well. CMS should consider creating a public awareness campaign on overuse, to inform people — particularly older adults at high risk of complications from overuse– about overuse shared decision making. As our late founder Dr. Bernard Lown wrote, “Fully informed patients, trusting their physicians, do not insist on tests or procedures.” Engaging patients and families is necessary to increase awareness not only about cost and waste from overuse, but the potential harms to patients as well.