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Reducing Low-Value Care May Mean Tough Conversations With Stakeholders

Laura Joszt
The concept of value is a well-known topic among health policy experts, the payer community, and policy makers, but patients do not necessarily have the same idea of what value means. When discussions about removing low-value care from the system to save money come up, patients might get the wrong idea of what is going on and why.
One of the services the panelists gave as an example of a low-value service that is used a lot and can be cut out of the system is vitamin D screening. Cigna defined a population where vitamin D screening was recommended and for any patients who didn’t meet that criteria, it would not pay for the test. According to Keats, a year later, doctors have stopped ordering the test and it has saved $20 million.

“This whole idea of low-value care, I think, is great, but what I see time and again [is]…we have to be on the lookout for low-value physicians,” Keats said. “At the end of the day, this is physician driven.”

Beth Bortz, president and chief executive officer of the Virginia Center for Health Innovation (VCHI), was in the audience and mentioned that some physicians don’t even realize they’re ordering the test as often as they are. She related the story of a member of USPSTF whom VCHI was working with in its quest to identify and measure uses of low-value care, who saw his data on vitamin D screening and thought it must have been wrong because he would never order that many vitamin D screenings. But once he dug into the data, he realized that a vitamin D screening was part of a bundled lab, and he was ordering it far more than he realized.

“I think that’s a big piece of the secret sauce [to reducing use of low-value services],” Bortz said. “They have to sit with [the data], look at it, dig into it.”

Carey admitted that there is pushback even from physicians when it comes removing low-value care, and it’s not because they don’t think low-value care utilization isn’t an issue. Most physicians agree with the concept of removing low-value care, but they worry it will be overinterpreted and that the 5% or 10% who do need the service will miss out on it. The pushback, he clarified, has been on an “inflexible system” that doesn’t allow leeway for someone to step off and provide services that might be low-value for the majority of people but fit for that specific patient.

All this work to remove low-value care can have real benefits for patients, as it saves money that might have been used on unnecessary services and frees those dollars up for high-quality services to be used. Darien used the example of lung cancer, where if money is freed up, everyone can get their tumor sequenced so they are given the right treatment that will work for them instead of being treated “scattershot.”

“That’s removing low-value care to add high-value care,” she said.

In Virginia, VCHI just received $2.2 million to launch a 3-year statewide pilot to reduce the use of low-value care. The pilot will bring together 6 health systems and 3 clinically integrated networks to form a large-scale health system learning community and also create an employer task force that includes employers, the Virginia Chamber of Commerce, and the Virginia Business Coalition. This is the next step after the work Virginia has done to identify and measure low-value care utilization.

“Once we’ve moved the dial, then we’ll explore the headroom,” Carey said. “We need to turn waste into real dollars.”

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