Abbreviations: CKD, chronic kidney disease; CT, computed tomography; DVT, deep vein thrombosis; ED, emergency department; EEG, electroencephalogram; EKG, electrocardiogram; HPV, human papillomavirus; IVC, inferior vena cava; MR, magnetic resonance; 1,25-OH Vitamin D, dihydroxycholecalciferol; PE, pulmonary embolism; PFT, pulmonary function test; PTH, primary hyperparathyroidism; T3, triiodothyronine; TB, tuberculosis; TIA, transient ischemic attack; VTE, venous thromboembolism.
a All patients aged 18 to 64 years continuously enrolled in 2013 with complete sociodemographic information (excluding those with unknown census division, sex, or education).
b The number of unique patients receiving at least 1 low-value service was 114 723 (7.8%) equaling 32.8 million US dollars in spending (0.5%).
c Attributed costs include entire inpatient stay in which service took place.
d Attributed costs include service plus narrow set of related procedure codes occurring on the same day.
e Inpatient associated: occurring during an inpatient stay; ED associated: ≤14 d after an ED visit.
f Attributed costs include all procedures on same day in which service took place.
g Attributed costs include only service itself.
h Exclusion diagnoses include epilepsy, stroke/TIA, history of stroke, head trauma, convulsions, altered mental status, nervous system symptoms (eg, hemiplegia), and speech problems.
i Exclusion diagnoses include those immediately above and giant cell arteritis, cancer, and history of cancer.
j Includes inflammation of eyelid or orbit, orbital cellulitis, and visual problems.
k Exclusion diagnoses include cancer, trauma, intravenous drug abuse, neurologic impairment, endocarditis, septicemia, TB, osteomyelitis, fever, weight loss, loss of appetite, night sweats, and anemia.
l Includes breast procedures, colectomy, cholecystectomy, transurethral resection of the prostate, hysterectomy, orthopedic surgical procedures other than hip and knee replacement, corneal transplant, cataract removal, retinal detachment, hernia repair, lithotripsy, and arthroscopy.
m Includes procedures listed immediately above as well as coronary artery bypass graft, aneurysm repair, thromboendarterectomy, percutaneous transluminal coronary angioplasty, and pacemaker insertion.
Abbreviations: HSA, health savings account; HRA, health reimbursement arrangement.
a In Optum data this is either from public records, self-reported surveys or a derived KBP group ethic code table.
b In Optum data this is derived from a demographic-based analytical model.
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Reid RO, Rabideau B, Sood N. Low-Value Health Care Services in a Commercially Insured Population. JAMA Intern Med. 2016;176(10):1567–1571. doi:10.1001/jamainternmed.2016.5031
More than $750 billion of US health care spending annually represents waste, including approximately $200 billion in overtreatment.1 Reducing overuse could improve quality and access while reducing spending and has been championed by clinicians through the Choosing Wisely initiative, as well as payers and policymakers. Indirect assessments of waste based on geographic spending variation reveal the scale of the problem, but cannot concretely inform methods of improvement. Direct assessments of low-value care have thus far focused on Medicare only, a limited set of measures, or a specific geographic area.2-5 We assessed low-value health care and spending in a large, national, commercially insured population.
We assessed low-value services in 2013 using a 25% random sample of the 2011 to 2013 Optum Clinformatics Data Mart of UnitedHealthcare commercial claims for patients aged 18 to 64 years from across the United States.
Adapting 28 previously published low-value service measures,3-6 we assessed the number of unique patients receiving each service in 2013 and patients’ 2013 standardized costs for each service, winsorizing at the 5th and 95th percentiles.
We assessed predictors of disproportionate low-value spending using a 2-part model, adjusting for patient and plan characteristics. The first part, a probit model, estimated the probability of any low-value spending, while the second part, a generalized linear model with a γ-distribution and a log-link function, estimated low-value spending per $10 000 in total spending, conditional on having any low-value spending. Analyses were performed using Stata statistical software (version 14, StataCorp LP).
Of 1 468 689 patients, 114 732 (7.8%) received low-value services in 2013, resulting in $32.8 million in spending ($22.32 per capita), or 0.5% of total spending. The most commonly received services included: triiodothyronine measurement in hypothyroidism (1.5%), imaging for nonspecific low back pain (1.3%), and imaging for uncomplicated headache (1.0%). The greatest proportion of spending was for spinal injection for lower-back pain at $12.1 million (37.0%), head imaging for uncomplicated headache at $3.6 million (11.0%), and imaging for nonspecific low back pain at $3.1 million (9.4%) (Table 1).
Low-value spending per $10 000 in total spending was less among patients who were older, male, black or Asian, lower-income, or enrolled in a Consumer-Directed Health Plan (CDHPs). Regionally, the Southern, Middle Atlantic, and Mountain regions had greater proportionate low-value spending (Table 2).
In this commercially insured population, we found modest use of the low-value services assessed, but considerable corresponding potential savings.
Compared with prior studies of low-value care, ours showed comparable overall care patterns using more measures or a broader geographic area than others in commercial insurance, and reflected a younger healthier patient population than that in Medicare.2-5
Low-value spending was less among nonwhite and lower-income patients, reflecting potential reverse disparities and underscoring the dichotomous contributions of disparities to waste in health care. Underuse among less advantaged groups and overuse among more advantaged groups both warrant attention.
While CDHP enrollees’ lesser low-value spending could suggest that this insurance benefit design may reduce overuse, given the potential for selection bias and prior evidence of parallel reductions in both high- and low-value care in CDHPs, this finding warrants further study.
Direct measures of low-value care face dual limitations of inclusivity. They can be overinclusive, potentially capturing instances where care was appropriate and high-value; to minimize this, we used measures with narrow, specific definitions. Conversely, they can be underinclusive; our 28 measures address multiple clinical areas of professional consensus, but only represent a small portion of all low-value care delivered. Predictors of spending on other low-value services, especially those of controversial value, may differ.
Efforts to reduce waste in health care may be bolstered by measure development efforts that focus on overtreatment, insurance designs that discourage overuse, and programs that target groups and regions at greater risk of low-value care.
Corresponding Author: Rachel O. Reid, MD, MS, RAND Corporation, 20 Park Plz, Ste 920, Boston, MA 02116 (email@example.com).
Published Online: August 29, 2016. doi:10.1001/jamainternmed.2016.5031
Author Contributions: Dr Sood and Mr Rabideau had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Reid, Sood.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Reid, Rabideau.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Obtaining funding: Sood.
Administrative, technical, or material support: Rabideau.
Study supervision: Sood
Conflict of Interest Disclosures: None reported.
Funding/Support: Funding from the Leonard D. Schaeffer RAND-USC Initiative in Health Policy and Economics and the National Institutes of Health (Grant Number R01AG043850) contributed to this research.
Role of the Funder/Sponsor: The RAND Corporation and the National Institutes of Health had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
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