Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018 | Health Care Economics, Insurance, Payment | JAMA Network Open | JAMA Network
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1.
Mafi  JN, Parchman  M.  Low-value care: an intractable global problem with no quick fix.   BMJ Qual Saf. 2018;27(5):333-336. doi:10.1136/bmjqs-2017-007477 PubMedGoogle ScholarCrossref
2.
Kerr  EA, Kullgren  JT, Saini  SD.  Choosing wisely: how to fulfill the promise in the next 5 years.   Health Aff (Millwood). 2017;36(11):2012-2018. doi:10.1377/hlthaff.2017.0953 PubMedGoogle ScholarCrossref
3.
Institute of Medicine.  Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. The National Academies Press; 2013.
4.
Berwick  DM, Hackbarth  AD.  Eliminating waste in US health care.   JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362 PubMedGoogle ScholarCrossref
5.
Shehab  N, Lovegrove  MC, Geller  AI, Rose  KO, Weidle  NJ, Budnitz  DS.  US emergency department visits for outpatient adverse drug events, 2013-2014.   JAMA. 2016;316(20):2115-2125. doi:10.1001/jama.2016.16201 PubMedGoogle ScholarCrossref
6.
Schwartz  AL, Landon  BE, Elshaug  AG, Chernew  ME, McWilliams  JM.  Measuring low-value care in Medicare.   JAMA Intern Med. 2014;174(7):1067-1076. doi:10.1001/jamainternmed.2014.1541 PubMedGoogle ScholarCrossref
7.
Mafi  JN, Russell  K, Bortz  BA, Dachary  M, Hazel  WA  Jr, Fendrick  AM.  Low-cost, high-volume health services contribute the most to unnecessary health spending.   Health Aff (Millwood). 2017;36(10):1701-1704. doi:10.1377/hlthaff.2017.0385 PubMedGoogle ScholarCrossref
8.
Barnett  ML, Linder  JA, Clark  CR, Sommers  BD.  Low-value medical services in the safety-net population.   JAMA Intern Med. 2017;177(6):829-837. doi:10.1001/jamainternmed.2017.0401 PubMedGoogle ScholarCrossref
9.
Mafi  JN, Wee  CC, Davis  RB, Landon  BE.  Association of primary care practice location and ownership with the provision of low-value care in the United States.   JAMA Intern Med. 2017;177(6):838-845. doi:10.1001/jamainternmed.2017.0410 PubMedGoogle ScholarCrossref
10.
Colla  CH, Morden  NE, Sequist  TD, Schpero  WL, Rosenthal  MB.  Choosing wisely: prevalence and correlates of low-value health care services in the United States.   J Gen Intern Med. 2015;30(2):221-228. doi:10.1007/s11606-014-3070-z PubMedGoogle ScholarCrossref
11.
Mafi  JN, May  FP, Kahn  KL,  et al.  Low-value proton pump inhibitor prescriptions among older adults at a large academic health system.   J Am Geriatr Soc. 2019;67(12):2600-2604. doi:10.1111/jgs.16117 PubMedGoogle ScholarCrossref
12.
Mafi  JN, Wee  CC, Davis  RB, Landon  BE.  comparing use of low-value health care services among U.S. advanced practice clinicians and physicians.   Ann Intern Med. 2016;165(4):237-244. doi:10.7326/M15-2152 PubMedGoogle ScholarCrossref
13.
Mafi  JN, Edwards  ST, Pedersen  NP, Davis  RB, McCarthy  EP, Landon  BE.  Trends in the ambulatory management of headache: analysis of NAMCS and NHAMCS data 1999-2010.   J Gen Intern Med. 2015;30(5):548-555. doi:10.1007/s11606-014-3107-3 PubMedGoogle ScholarCrossref
14.
Mafi  JN, McCarthy  EP, Davis  RB, Landon  BE.  Worsening trends in the management and treatment of back pain.   JAMA Intern Med. 2013;173(17):1573-1581. doi:10.1001/jamainternmed.2013.8992 PubMedGoogle ScholarCrossref
15.
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 PubMedGoogle ScholarCrossref
16.
MedPAC.  Use of low-value care in Medicare is substantial. MedPAC Blog. Accessed June 4, 2020. http://www.medpac.gov/-blog-/medpacblog/2015/05/21/use-of-low-value-care-in-medicare-is-substantial
17.
Damberg  CL, Silverman  M, Burgette  L, Vaiana  ME, Ridgely  MS.  Are value-based incentives driving behavior change to improve value?   Am J Manag Care. 2019;25(2):e26-e32.PubMedGoogle Scholar
18.
Haverkamp  MH, Peiris  D, Mainor  AJ,  et al.  ACOs with risk-bearing experience are likely taking steps to reduce low-value medical services.   Am J Manag Care. 2018;24(7):e216-e221.PubMedGoogle Scholar
19.
McWilliams  JM, Landon  BE, Rathi  VK, Chernew  ME.  Getting more savings from ACOs — can the pace be pushed?   N Engl J Med. 2019;380(23):2190-2192. doi:10.1056/NEJMp1900537 PubMedGoogle ScholarCrossref
20.
McWilliams  JM, Chernew  ME, Landon  BE, Schwartz  AL.  Performance differences in year 1 of Pioneer accountable care organizations.   N Engl J Med. 2015;372(20):1927-1936. doi:10.1056/NEJMsa1414929 PubMedGoogle ScholarCrossref
21.
Roberts  ET, McWilliams  JM, Hatfield  LA,  et al.  Changes in health care use associated with the introduction of hospital global budgets in Maryland.   JAMA Intern Med. 2018;178(2):260-268. doi:10.1001/jamainternmed.2017.7455 PubMedGoogle ScholarCrossref
22.
Roberts  ET, Hatfield  LA, McWilliams  JM,  et al.  Changes in hospital utilization three years into Maryland’s global budget program for rural hospitals.   Health Aff (Millwood). 2018;37(4):644-653. doi:10.1377/hlthaff.2018.0112 PubMedGoogle ScholarCrossref
23.
Segal  JB, Bridges  JF, Chang  HY,  et al.  Identifying possible indicators of systematic overuse of health care procedures with claims data.   Med Care. 2014;52(2):157-163. doi:10.1097/MLR.0000000000000052 PubMedGoogle ScholarCrossref
24.
Hong  AS, Ross-Degnan  D, Zhang  F, Wharam  JF.  Small decline in low-value back imaging associated with the ‘Choosing Wisely’ campaign, 2012-14.   Health Aff (Millwood). 2017;36(4):671-679. doi:10.1377/hlthaff.2016.1263 PubMedGoogle ScholarCrossref
25.
Carter  EA, Morin  PE, Lind  KD.  Costs and trends in utilization of low-value services among older adults with commercial insurance or Medicare Advantage.   Med Care. 2017;55(11):931-939. doi:10.1097/MLR.0000000000000809 PubMedGoogle ScholarCrossref
26.
Rosenberg  A, Agiro  A, Gottlieb  M,  et al.  Early trends among seven recommendations from the Choosing Wisely campaign.   JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441 PubMedGoogle ScholarCrossref
27.
Oakes  AH, Chang  HY, Segal  JB.  Systemic overuse of health care in a commercially insured US population, 2010-2015.   BMC Health Serv Res. 2019;19(1):280. doi:10.1186/s12913-019-4079-0 PubMedGoogle ScholarCrossref
28.
Reid  R, Damberg  C, Friedberg  MW.  Primary care spending in the fee-for-service Medicare population.   JAMA Intern Med. 2019;179(7):977-980. doi:10.1001/jamainternmed.2018.8747 PubMedGoogle ScholarCrossref
29.
Milliman.  MedInsight health waste calculator. Accessed February 20, 2020. https://milliman-cdn.azureedge.net/-/media/medinsight/pdfs/medinsight-health-waste-calculator.ashx
30.
Brown  DL, Clement  F.  Calculating health care waste in Washington state: first, do no harm.   JAMA Intern Med. 2018;178(9):1262-1263. doi:10.1001/jamainternmed.2018.3516 PubMedGoogle ScholarCrossref
31.
US Centers for Disease Control and Prevention. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Accessed January 15, 2021. https://www.cdc.gov/nchs/icd/icd9cm.htm
32.
US Centers for Disease Control and Prevention. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Accessed January 12, 2021. https://www.cdc.gov/nchs/icd/icd10cm.htm
33.
Virginia Health Information.  Virginia APCD MedInsight health waste calculator results version 2.0. Accessed June 2, 2017. http://www.vahealthinnovation.org/wp-content/uploads/2016/10/Virginia-APCD-MedInsight-Health-Waste-Calculator-Results-v2.0.pdf
34.
Washington Health Alliance.  Drop the pre-op! Accessed April 18, 2019. https://wahealthalliance.org/wp-content/uploads/2018/10/Drop-the-Pre-op-Info-Sheet-09.14.pdf
35.
Reid  RO, Mafi  JN, Baseman  LH, Fendrick  AM, Damberg  CL.  Waste in the Medicare program: a national cross-sectional analysis of 2017 low-value service use and spending.   J Gen Intern Med. 2020. doi:10.1007/s11606-020-06061-0 PubMedGoogle Scholar
36.
Research Data Assistance Center.  Definitions of ‘cost’ in Medicare utilization files. Accessed May 26, 2020. https://www.resdac.org/videos/definitions-cost-medicare-utilization-files
37.
US Bureau of Labor Statistics.  Consumer Price Index inflation calculator. Accessed November 24, 2020. https://www.bls.gov/data/inflation_calculator.htm
38.
Health Care Cost Institute.  2018 Health care cost and utilization report. Accessed January 7, 2020. https://healthcostinstitute.org/images/pdfs/HCCI_2018_Health_Care_Cost_and_Utilization_Report.pdf
39.
Chua  K-P, Fischer  MA, Linder  JA.  Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study.   BMJ. 2019;364:k5092-k5092. doi:10.1136/bmj.k5092 PubMedGoogle ScholarCrossref
40.
Gjelstad  S, Høye  S, Straand  J, Brekke  M, Dalen  I, Lindbæk  M.  Improving antibiotic prescribing in acute respiratory tract infections: cluster randomised trial from Norwegian general practice (Prescription Peer Academic Detailing (Rx-PAD) study).   BMJ. 2013;347:f4403. doi:10.1136/bmj.f4403 PubMedGoogle ScholarCrossref
41.
Meeker  D, Linder  JA, Fox  CR,  et al.  Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial.   JAMA. 2016;315(6):562-570. doi:10.1001/jama.2016.0275 PubMedGoogle ScholarCrossref
42.
Barnett  ML, Linder  JA.  Antibiotic prescribing to adults with sore throat in the United States, 1997-2010.   JAMA Intern Med. 2014;174(1):138-140. doi:10.1001/jamainternmed.2013.11673PubMedGoogle ScholarCrossref
43.
US Centers for Disease Control and Prevention.  Measuring outpatient antibiotic prescribing. Accessed November 30, 2020. https://www.cdc.gov/antibiotic-use/community/programs-measurement/measuring-antibiotic-prescribing.html#annual-report
44.
King  LM, Bartoces  M, Fleming-Dutra  KE, Roberts  RM, Hicks  LA.  Changes in US outpatient antibiotic prescriptions from 2011-2016.   Clin Infect Dis. 2020;70(3):370-377. PubMedGoogle Scholar
45.
Gidengil  CA, Mehrotra  A, Beach  S, Setodji  C, Hunter  G, Linder  JA.  What drives variation in antibiotic prescribing for acute respiratory infections?   J Gen Intern Med. 2016;31(8):918-924. doi:10.1007/s11606-016-3643-0 PubMedGoogle ScholarCrossref
46.
Cuevas  MA, Wachter  ND, Reyes  C,  et al.  Seeking care for back pain or upper respiratory infections: survey results to inform a safety net hospital Choosing Wisely intervention.   Healthc (Amst). 2020;8(3):100424. doi:10.1016/j.hjdsi.2020.100424 PubMedGoogle Scholar
47.
Colla  CH, Mainor  AJ, Hargreaves  C, Sequist  T, Morden  N.  Interventions aimed at reducing use of low-value health services: a systematic review.   Med Care Res Rev. 2017;74(5):507-550. doi:10.1177/1077558716656970 PubMedGoogle ScholarCrossref
48.
Sharp  AL, Hu  YR, Shen  E,  et al.  Improving antibiotic stewardship: a stepped-wedge cluster randomized trial.   Am J Manag Care. 2017;23(11):e360-e365.PubMedGoogle Scholar
49.
Zhu  W, Chernew  ME, Sherry  TB, Maestas  N.  Initial opioid prescriptions among U.S. commercially insured patients, 2012-2017.   N Engl J Med. 2019;380(11):1043-1052. doi:10.1056/NEJMsa1807069 PubMedGoogle ScholarCrossref
50.
Awadalla  R, Gnjidic  D, Patanwala  A, Sakiris  M, Penm  J.  The effectiveness of stewardship interventions to reduce the prescribing of extended-release opioids for acute pain: a systematic review.   Pain Med. 2020;21(10):2401-2411. doi:10.1093/pm/pnaa139 PubMedGoogle ScholarCrossref
51.
Ladapo  JA, Larochelle  MR, Chen  A,  et al.  Physician prescribing of opioids to patients at increased risk of overdose from benzodiazepine use in the United States.   JAMA Psychiatry. 2018;75(6):623-630. doi:10.1001/jamapsychiatry.2018.0544 PubMedGoogle ScholarCrossref
52.
Moride  Y, Lemieux-Uresandi  D, Castillon  G,  et al.  A systematic review of interventions and programs targeting appropriate prescribing of opioids.   Pain Physician. 2019;22(3):229-240.PubMedGoogle Scholar
53.
US Centers for Disease Control and Prevention.  Prescription Opioid Data. Accessed November 30, 2020. https://www.cdc.gov/drugoverdose/data/prescribing.html
54.
Rich  EC.  Barriers to Choosing Wisely in primary care: it’s not just about “the money.”   J Gen Intern Med. 2017;32(2):140-142. doi:10.1007/s11606-016-3916-7 PubMedGoogle ScholarCrossref
55.
Schlesinger  M, Grob  R.  Treating, fast and slow: Americans’ understanding of and responses to low-value care.   Milbank Q. 2017;95(1):70-116. doi:10.1111/1468-0009.12246 PubMedGoogle ScholarCrossref
56.
Schwartz  AL, Chernew  ME, Landon  BE, McWilliams  JM.  Changes in low-value services in year 1 of the Medicare Pioneer accountable care organization program.   JAMA Intern Med. 2015;175(11):1815-1825. doi:10.1001/jamainternmed.2015.4525 PubMedGoogle ScholarCrossref
57.
Kullgren  JT, Krupka  E, Schachter  A,  et al.  Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial.   BMJ Qual Safe. 2018;27(5):355-364. doi:10.1136/bmjqs-2017-006699 PubMedGoogle ScholarCrossref
58.
Ouayogodé  MH, Meara  E, Chang  CH,  et al.  Forgotten patients: ACO attribution omits those with low service use and the dying.   Am J Manag Care. 2018;24(7):e207-e215.PubMedGoogle Scholar
59.
Colla  CH.  Swimming against the current—what might work to reduce low-value care?   N Engl J Med. 2014;371(14):1280-1283. doi:10.1056/NEJMp1404503PubMedGoogle ScholarCrossref
60.
Fendrick  AM, Smith  DG, Chernew  ME.  Applying value-based insurance design to low-value health services.   Health Aff (Millwood). 2010;29(11):2017-2021. doi:10.1377/hlthaff.2010.0878 PubMedGoogle ScholarCrossref
61.
Henderson  J, Bouck  Z, Holleman  R,  et al.  Comparison of payment changes and choosing wisely recommendations for use of low-value laboratory tests in the United States and Canada.   JAMA Intern Med. 2020;180(4):524-531. doi:10.1001/jamainternmed.2019.7143 PubMedGoogle ScholarCrossref
62.
Gruber  J, Maclean  JC, Wright  B, Wilkinson  E, Volpp  KG.  The effect of increased cost-sharing on low-value service use.   Health Econ. 2020;29(10):1180-1201. doi:10.1002/hec.4127 PubMedGoogle ScholarCrossref
63.
Mafi  JN, Godoy-Travieso  P, Wei  E,  et al.  Evaluation of an intervention to reduce low-value preoperative care for patients undergoing cataract surgery at a safety-net health system.   JAMA Intern Med. 2019;179(5):648-657. doi:10.1001/jamainternmed.2018.8358 PubMedGoogle ScholarCrossref
64.
Colla  CH, Morden  NE, Sequist  TD, Mainor  AJ, Li  Z, Rosenthal  MB.  Payer type and low-value care: comparing Choosing Wisely services across commercial and Medicare populations.   Health Serv Res. 2018;53(2):730-746. doi:10.1111/1475-6773.12665 PubMedGoogle ScholarCrossref
65.
Lee  VS, Kawamoto  K, Hess  R,  et al.  Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.   JAMA. 2016;316(10):1061-1072. doi:10.1001/jama.2016.12226 PubMedGoogle ScholarCrossref
66.
Angiolillo  J, Rosenbloom  ST, McPheeters  M, Seibert Tregoning  G, Rothman  RL, Walsh  CG.  Maintaining automated measurement of Choosing Wisely adherence across the ICD 9 to 10 transition.   J Biomed Inform. 2019;93:103142. doi:10.1016/j.jbi.2019.103142PubMedGoogle Scholar
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    Original Investigation
    Health Policy
    February 16, 2021

    Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018

    Author Affiliations
    • 1Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles
    • 2RAND Health Care, RAND Corporation, Santa Monica, California
    • 3RAND Health Care, RAND Corporation, Boston, Massachusetts
    • 4Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
    • 5Harvard Medical School, Harvard University, Boston, Massachusetts
    • 6Department of Internal Medicine, University of Michigan, Ann Arbor
    • 7Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
    • 8Division of Geriatrics, David Geffen School of Medicine at the University of California, Los Angeles
    • 9Geriatric Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
    JAMA Netw Open. 2021;4(2):e2037328. doi:10.1001/jamanetworkopen.2020.37328
    Key Points

    Question  Have low-value care use and spending decreased over time with increasing focus on reducing waste in the US health care system?

    Findings  In this cross-sectional study of more than 21 million individuals with fee-for-service Medicare, the percentage receiving any of 32 measured low-value services decreased marginally from 2014 to 2018. Claim line–level spending on low-value care per 1000 individuals did not decrease substantially over this period.

    Meaning  This study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign to address low-value care and increased attention on reducing health care waste.

    Abstract

    Importance  Low-value care, defined as care offering no net benefit in specific clinical scenarios, is associated with harmful outcomes in patients and wasteful spending. Despite a national education campaign and increasing attention on reducing health care waste, recent trends in low-value care delivery remain unknown.

    Objective  To assess national trends in low-value care use and spending.

    Design, Setting, and Participants  In this cross-sectional study, analyses of low-value care use and spending from 2014 to 2018 were conducted using 100% Medicare fee-for-service enrollment and claims data. Included individuals were aged 65 years or older and continuously enrolled in Medicare parts A, B, and D during each measurement year and the previous year. Data were analyzed from September 2019 through December 2020.

    Exposure  Being enrolled in fee-for-service Medicare for a period of time, in years.

    Main Outcomes and Measures  The Milliman MedInsight Health Waste Calculator was used to assess 32 claims-based measures of low-value care associated with Choosing Wisely recommendations and other professional guidelines. The calculator designates services as wasteful, likely wasteful, or not wasteful based on an absence of indication of appropriate use in the claims history; calculator-designated wasteful services were defined as low-value care. Spending was calculated as claim-line level (ie, spending on the low-value service) and claim level (ie, spending on the low-value service plus associated services), adjusting for inflation.

    Results  Among 21 045 759 individuals with fee-for-service Medicare (mean [SD] age, 77.4 [7.9] years; 12 515 915 [59.5%] women), the percentage receiving any of 32 low-value services decreased from 36.3% (95% CI, 36.3%-36.4%) to 33.6% (95% CI, 33.6%-33.6%) from 2014 to 2018. Uses of low-value services per 1000 individuals decreased from 677.8 (95% CI, 676.2-679.5) to 632.7 (95% CI, 632.6-632.8) from 2014 to 2018. Three services comprised approximately two-thirds of uses among 32 low-value services per 1000 individuals: preoperative laboratory testing decreased from 213.8 (95% CI, 213.4-214.2) to 166.2 (95% CI, 166.2-166.2), while opioids for back pain increased from 154.4 (95% CI, 153.6-155.2) to 182.1 (95% CI, 182.1-182.1) and antibiotics for upper respiratory infections increased from 75.0 (95% CI, 75.0-75.1) to 82 (95% CI, 82.0-82.0). Spending per 1000 individuals on low-value care also decreased, from $52 765.5 (95% CI, $51 952.3-$53 578.6) to $46 921.7 (95% CI, $46 593.7-$47 249.7) at the claim-line level and from $160 070.4 (95% CI, $158 999.8-$161 141.0) to $144 741.1 (95% CI, $144 287.5-$145 194.7) at the claim level.

    Conclusions and Relevance  This cross-sectional study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign in collaboration with clinician specialty societies and increased attention on low-value care. While most use of low-value care came from 3 services, 1 of these was opioid prescriptions, which increased over time despite the harms associated with their use. These findings may represent several opportunities to prevent patient harm and lower spending.

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