Defining, Measuring, and Reducing Overuse Task Force on Low-Value Care April 27, 2017
Outline Defining waste (and its several varieties) (1) Significance of waste and overuse (2) Examples of overuse (3) Reducing overuse: what works? (4) 2
DEFINING WASTE On Waste • OECD: • Services and processes that are either harmful or do not deliver benefits • Costs that could be avoided by substituting less expensive alternatives with identical or better benefits 3 OECD. Tackling Wasteful Spending on Health . Paris: OECD Publishing; 2017.
DEFINING WASTE A Taxonomy of Waste Administrative Waste • Complexity • Transactions-related • Benefit management • Sales/marketing • Compliance • Fraud • Pricing failures Bentley TGK, Effros RM, Palar K, Keeler EB. Waste in the U.S. Health Care System: A Conceptual Framework. Milbank Q . 2008;86(4):629-659. 4 OECD. Tackling Wasteful Spending on Health . Paris: OECD Publishing; 2017.
DEFINING WASTE A Taxonomy of Waste Operational Administrative Waste Waste • Complexity • Inefficiencies in care • Transactions-related delivery • • Unduly expensive inputs Benefit management • • Errors Sales/marketing • • Duplicative services Compliance • Fraud • Pricing failures Bentley TGK, Effros RM, Palar K, Keeler EB. Waste in the U.S. Health Care System: A Conceptual Framework. Milbank Q . 2008;86(4):629-659. 5 OECD. Tackling Wasteful Spending on Health . Paris: OECD Publishing; 2017.
DEFINING WASTE A Taxonomy of Waste Administrative Operational Clinical Waste Waste Waste • Complexity • • Inefficiencies in care Care that does not • Transactions- delivery deliver net benefit related (overtreatment) • Unduly expensive • Benefit • inputs Care that offers no management benefit over less • Errors • Sales/marketing costly alternatives • • Compliance Duplicative services • Care that delivers • Fraud benefit, but does not • Pricing failures meet standards of cost-effectiveness Bentley TGK, Effros RM, Palar K, Keeler EB. Waste in the U.S. Health Care System: A Conceptual Framework. Milbank Q . 2008;86(4):629-659. 6 OECD. Tackling Wasteful Spending on Health . Paris: OECD Publishing; 2017.
DEFINING WASTE A Taxonomy of Waste Clinical Waste Waste • Care that does not Clinical Waste deliver net benefit (overtreatment) • Care that offers no benefit over less costly alternatives Overuse • Care that delivers benefit, but does not meet standards of cost-effectiveness 7 Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA . 2012;307(14):1513-1516.
DEFINING WASTE A Taxonomy of Waste Waste Clinical Waste Overuse (a) Overuse (b) Overuse of of testing treatment (c) Treatment of over- diagnosed disease 8 Morgan DJ, Dhruva SS, Wright SM, Korenstein D. 2016 update on medical overuse: a systematic review. JAMA Intern Med . 2016;176(11):1687-1692.
SIGNIFICANCE Approaches to Estimating Waste • Societal-level estimates can be drawn by extrapolating from: • Comparisons with peer countries • Variation in patterns of practice across regions • Domain-specific expert opinion • Person-level claims/encounter data • Person-level medical record review 9 The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary . Washington, D.C.: National Academies Press; 2010.
SIGNIFICANCE Cost of Waste 10 Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA . 2012;307(14):1513-1516.
SIGNIFICANCE Cost of Waste 11 Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA . 2012;307(14):1513-1516.
EXAMPLES OF OVERUSE PSA Testing in Men 75+ 12 US Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening.
EXAMPLES OF OVERUSE PSA Testing in Men 75+ Percent of Male Medicare FFS Beneficiaries Age 75+ With Screening PSA Test (2014) % % % National Average: 18.2% Dartmouth Atlas of Health Care. Screening PSA Tests. http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=72. 13 US Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening.
EXAMPLES OF OVERUSE Colonoscopy Adherence to Colonoscopy Interval Guidelines in 25 VA Systems Share of Patients with Guideline-Concordant Care Share of Patients with Care Not Guideline-Concordant 1 97% 3% 2 91% 9% 3 87% 13% 4 85% 15% 5 84% 16% 6 83% 17% 7 78% 22% 8 75% 25% 9 74% 26% 10 73% 27% VA System 11 67% 34% 12 66% 34% 13 64% 36% 14 62% 38% Screened 15 56% 44% 16 51% 49% Too 17 49% 51% Soon 18 48% 52% 19 46% 54% (95%) 20 42% 58% 21 41% 59% 22 36% 64% 23 34% 66% 24 28% 72% 25 20% 80% Johnson MR, Grubber J, Grambow SC, Maciejewski ML, Dunn-Thomas T, Provenzale D, Fisher DA. Physician non-adherence 14 to colonoscopy interval guidelines in the veterans affairs healthcare system. Gastroenterology . 2015;149(4):938-951.
EXAMPLES OF OVERUSE Cesarean Sections Distribution Of Cesarean Rates in US Hospitals Among Lower-Risk Pregnancies (2009) 15 Kozhimannil KB, Law MR, Virnig BA. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality and Cost Issues. Health Aff . 2013;32(3):527-535.
MEASURING OVERUSE Low-Value Lists • Launched in 2012 • 75 partnering specialty societies • 490 service-specific recommendations American Board of Internal Medicine Foundation, Consumer Reports. Choosing Wisely Infographic. 16 http://www.choosingwisely.org/wp-content/uploads/2017/04/Choosing-Wisely-Infographic-Update0317.pdf. Published April 2017.
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MEASURING OVERUSE Health Waste Calculator 18 Milliman and VBID Health. MedInsight Health Waste Calculator . http://vbidhealth.com/docs/Health-Waste%20Calculator-VBID.pdf
MEASURING OVERUSE Receipt of Select Overused Services Share of Population Receiving 1+ Choosing Wisely (or Similar) Service, Per Year 38% More Specific More Sensitive 23.0% 14% 11.4% 9.6% Commercial Peds (2014) Commercial Adults (2013) Medicare FFS (2013) Charlesworth CJ, Meath THA, Schwartz AL, McConnell KJ. Comparison of Low-Value Care in Medicaid vs Commercially Insured Populations. JAMA Intern Med . 2016;176(7):998-1004. Chua K-P, Schwartz AL, Volerman A, Conti RM, Huang ES. Use of Low-Value Pediatric Services Among the Commercially Insured. Pediatrics . November 2016:e20161809. Medicare Payment Advisory Commission. Health Care Spending and the Medicare Program: A Data Book .; 2016. http://www.medpac.gov/docs/default-source/data-book/ 19 june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0. Accessed April 11, 2017.
MEASURING OVERUSE Cost of Select Overused Services Population-Level Cost of Choosing Wisely (or Similar) Services, Per Year (Billions) More Specific More Sensitive $7.1 $2.6 Medicare FFS (2013) Medicare Payment Advisory Commission. Health Care Spending and the Medicare Program: A Data Book .; 2016. http://www.medpac.gov/docs/default-source/data-book/ 20 june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0. Accessed April 11, 2017.
MEASURING OVERUSE Variation in Tendency to Overuse Distribution of Provider Organizations by Count of Low-Value Services Delivered per Medicare Beneficiary Per Year 500 Number of Provider Organizations 400 300 200 100 0 20 30 40 50 60 70 80 90 100 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99 102 105 Low-Value Services per 100 Medicare Beneficiaries 21 Schwartz AL, Zaslavsky AM, Landon BE, Chernew ME, McWilliams JM. Low-Value Service Use in Provider Organizations. Health Serv Res . November 2016.
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ADDRESSING OVERUSE Root Causes of Waste Errors and Poor Poor Sub-optimal Organization Incentives for Intentional Decision- and Providers and Deception Making Coordination Consumers Unintentional Deliberate 23 OECD. Tackling Wasteful Spending on Health . Paris: OECD Publishing; 2017.
ADDRESSING OVERUSE Interventions Patient-Facing Interventions (Demand) Provider-Facing Interventions (Supply) Incentives Incentives Cost-sharing P4P Value-based Insurance Design (V-BID) Prior authorization Information Risk sharing (ACOs, bundles, etc.) Patient education Information Provider report cards Clinical decision support Clinician education Clinician feedback 24 Colla CH. Swimming against the Current — What Might Work to Reduce Low-Value Care? New England Journal of Medicine . 2014;371(14):1280-1283.
ADDRESSING OVERUSE Choosing Wisely Campaign Intervention Choosing Wisely Campaign Population 29 million commercially insured Americans Measures Use of x-ray, MR, and CT imaging associated with visits for low-back pain • Significant 1 percentage point reduction in low-value imaging (4% Key Findings decrease) • No significant impact of enrollment in HDHP on receipt of imaging • Rate of high-value imaging unchanged Notes 25 Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low- Value Back Imaging Associated With The “Choosing Wisely” Campa ign, 2012 – 14. Health Aff . 2017;36(4):671-679.
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