One-third of health care in the United States is wasted. Despite this recognition, solutions are sparse. The Optimal Care model combines evidence-based medicine, patient-centered technology, and outcomes reporting to transform health care.
Am J Manag Care. 2022;28(2):51-52. https://doi.org/10.37765/ajmc.2022.88693
A new care model is needed to rescue our struggling health care system. The Optimal Care model propels health care transformation through the use of evidence, technology, and data. It deploys the following strategies to drive improvements in care quality while simultaneously reducing low-value and harmful care:
The US health care system provides suboptimal outcomes at costs that are twice the average of those of other wealthy nations. The 4 major drivers of excess cost are administrative overhead, pharmaceutical pricing, overuse of low-value care, and the cost of medical, hospital, and imaging procedures.1 The first 2 cost drivers may be beyond the control of physicians. However, physicians and other health care providers can have influence over the latter 2 by eliminating low-value care and choosing the most efficient site of service. These last 2 drivers account for 27% of the excess spending in our health care system, although this may be an underestimation, as the Institute of Medicine has suggested that low-value care represents about one-third of all health care expenditures.
A 2018 study of Medicare, Medicaid, and commercial claims in the state of Washington placed the magnitude of low-value care at 44% of all care delivered.2 However, the term “low-value care” diminishes the significance of the problem; in reality, this care is wasted at best and is quite often harmful. Choosing Wisely is a well-intentioned program that attempts to reduce low-value care, but it only begins to address the magnitude of the problem. For example, this program fails to address many invasive, potentially harmful, and costly interventions that do not have supporting data showing improved health outcomes or quality of life. These include, but are not limited to, carotid endarterectomy in asymptomatic carotid artery stenosis, the aggressive treatment of low-risk Gleason score 6 prostate cancer and papillary thyroid cancers, the overuse of lumbar spinal fusion, and the overuse of cardiac catheterization and coronary interventions, to name but a few.
The current reimbursement model creates perverse incentives that foster the persistence of low-value care. Therefore, to eliminate low-value care, providers and health systems must be willing to move to value-based care and quickly transition to risk-based arrangements in which providers and health systems are responsible for the total cost of care. A necessary element of this transition is the development of an infrastructure supporting this new model. The Optimal Care model has been designed to meet this need.
Optum Care is the national, physician-led, ambulatory care delivery system of Optum, and the Optimal Care model is a key component of its care delivery infrastructure. The fundamental tenet of this program is the rapid transition of high-quality evidence-based medicine (EBM) into daily practice, with the simultaneous goals of improving patient outcomes, eliminating low-value and harmful care, and reducing the cost of care. Historically, the delay from publication of high-quality research to practice implementation is 5 to 10 years. The Optimal Care model is designed to reduce this to 12 weeks. The key components of the program include:
The implementation of Optimal Care is not without its challenges.
Part of the challenge also lies outside of the medical group. Most health plan benefit designs are not specifically oriented to align incentives around decreasing the total cost of care. For example, lower patient coinsurance (or shared savings) for optimal care decisions would serve to better align patients with their providers around the choice of high-value care, the best-performing providers, and the most efficient sites of service. Additionally, health systems must be willing to shift tests and procedures to the least expensive site of service with equivalent outcomes and patient safety. More innovative benefit designs are beginning to move to reference-based pricing and service line capitation, both of which will compel providers and health systems to focus on lowering the total cost of care. The Optimal Care model supports providers on this journey.
Collectively, the major stakeholders within our health care delivery system have failed to control rising health care costs. Our patients and employers cannot afford our current health care system, and they deserve one that delivers better outcomes. The tipping point is upon us. The solution relies to a large extent on the willingness of providers and health systems to eliminate low-value care and harmful care. As this occurs, the reduction in total cost of care will be large enough to reverse the trend of continually rising health care costs. Despite the challenges described above, the Optimal Care program has been successfully deployed and has demonstrated improvements in health care outcomes while reducing total cost of care.
Author Affiliations: Optum Center for Research and Innovation, Minnetonka, MN.
Source of Funding: None.
Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; and statistical analysis.
Address Correspondence to: Kenneth Cohen, MD, Optum Center for Research and Innovation, 5995 Opus Pkwy, Minnetonka, MN 55343. Email: firstname.lastname@example.org.
1. Emanuel EJ. The real cost of the US health care system. JAMA. 2018;319(10):983-985. doi:10.1001/jama.2018.1151
2. 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