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Original Investigation
Less Is More
June 2017

Low-Value Medical Services in the Safety-Net Population

Author Affiliations
  • 1Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Intern Med. 2017;177(6):829-837. doi:10.1001/jamainternmed.2017.0401
Key Points

Question  How often do patients with Medicaid or without insurance receive low-value care compared with privately insured patients; are there any differences related to the physicians treating these patient groups?

Findings  Analyses of nationally representative survey data from 2005 to 2013 show that low-value care was delivered in nearly 1 in 5 visits, with no overall difference between Medicaid or uninsured patients vs privately insured patients. Rates of low-value care were similar between safety-net physicians and non–safety-net physicians.

Meaning  Overuse of low-value care is just as common among patients with Medicaid or without insurance as among privately insured patients.


Importance  National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined.

Objective  To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non–safety-net physicians.

Design, Setting, and Participants  This multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics.

Exposures  Comparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non–safety-net physicians (seeing 1%-10%).

Main Outcomes and Measures  Delivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit.

Results  Overall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non–safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services.

Conclusions and Relevance  Overuse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.