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August 17, 2018

The Challenge of Defining Low-Value Care

Laura Joszt
Most efforts to reduce low-value care have so far been focused on areas where there is general agreement, and more discussions are needed to reach a consensus on additional aspects of care that are considered low value.
Interviews with 13 stakeholders found a profound lack of consensus on defining and measuring low-value care.

Most efforts to reduce low-value care have been focused on areas where there is general agreement, according to a blog post published in Health Affairs and written by Beth Beaudin-Seiler, PhD, Health Research Analyst at Altarum Institute; Michael Ciarametaro, MBA, Director of Research at the National Pharmaceutical Council; Robert W. Dubois, MD, PhD, Chief Science Officer and Executive Vice President of the National Pharmaceutical Council; Jim Lee, MS, Vice President Director at Altarum Institute; and A. Mark Fendrick, MD, Director of the University of Michigan Center for Value-Based Insurance Design.

“Further discussions must take place in order to reach consensus on the exact aspects of care that are considered low value,” Fendrick, who is also the co-editor-in-chief of The American Journal of Managed Care (AJMC), said in a statement. “In time and with further research, we will agree on the causes of care that do not provide clinical benefit, diminish the patient experience and contribute to the overall rising costs of care.”

The interviewees reported a healthy skepticism in the ability of methods such as Choosing Wisely to identify low-value care.

In a May 2016 study published in AJMC, researchers found that knowledge of Choosing Wisely was limited, with primary care physicians more aware of the campaign than specialists. Only 1 in 5 primary care physicians said the campaign has empowered them to reduce use of unnecessary tests and procedures, and even fewer specialists expressed this sentiment.

The researchers note that the Choosing Wisely campaign had only been in place for less than 2 years when the survey gauging awareness had been administered. Daniel B. Wolfson, MHSA, executive vice president and chief operating officer of the ABIM Foundation, which created the Choosing Wisely initiative, wrote in a follow-up editorial that awareness has been growing. He noted that more than 450 recommendations have been published.

“As the number of campaign partners and activities has grown, we believe awareness of Choosing Wisely, as well as physicians’ comfort level in engaging conversations with their patients, has increased beyond what is reported in the authors’ article—particularly in areas where local efforts are underway,” Wolfson wrote.

The blog post in Health Affairs did point out that there were elements of low-value care that the interviewees agreed need immediate attention: medical errors, pricing failures, and overuse/overtreatment.

“Our work highlights the importance of reducing low value care to the overall healthcare system in the United States,” Beaudin-Seiler said. “With a deeper understanding and agreement around what constitutes low-value care, we can make meaningful change to the healthcare landscape.”

JAMA Internal Medicine recently reported that the cost savings generated from reducing use of low-value medical services has the potential to be considerable. RAND researchers analyzed spending on 28 low-value services for more than 1.46 million American adults and reported that spending on these services totaled $32.8 million in 2013 with 7.8% of patients receiving low-value services.

The Health Affairs interviews revealed that reducing low-value care through the use of interventions, such as denying low-value care when requested, was a low priority. However, eliminating low-value care can create opportunities to enhance patient experience, improve quality, and lower costs.

“While there is still a lot of work to be done on better defining and measuring this phenomenon, what we learned through these interviews is key to reducing harm to patients and the high spending associated with it,” Ciarametaro said. “In time, consensus around the other aspects of low-value care will develop, further reducing its harmful effects.”

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