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The 5 lowest-value care services and what providers can do about them

Expensive branded drugs, diagnostic testing and imaging prior to low-risk surgery and population-based vitamin D screening, all make the list.

Beth Jones Sanborn, Managing Editor

Diagnostic testing and imaging for low-risk patients prior to low-risk surgery leads the five lowest-value care services, according to a new blog post from Health Affairs that outlines what providers can and should be doing to reduce their frequency to lower costs.

Diagnostic testing and imaging for low-risk patients prior to low-risk surgery usually does not end with the patient's risk category being reclassified, can cause unnecessary care delays, additional low-value testing and costs, according to the Society of General Internal Medicine.

[Also: Low-value health services fuel $586 million in wasteful spending, Health Affairs study says]

Population-based vitamin D screening came in second, with the SGIM saying it is really only needed for higher risk patients when results will be used to institute more aggressive therapy. Otherwise, over-the-counter supplements generally do the trick.

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Prostate-specific antigen screening in men ages 75 years old or above Came in third, with the U.S. Preventative Services Task Force giving the service a "D" rating. The group recommends against the service, as there is "no net benefit or the harms outweigh the goods."

Fourth was imaging for acute low-back pain in the first six weeks after onset. SGIM said that in the absence of red flags like trauma history, unintentional weight loss or history of cancer, among others, this imaging did not improve outcomes, but did raise costs. 

Finally, the use of more expensive branded drugs when generics with identical active ingredients are available rounded out the list.

According to Health Affairs, healthcare purchasers spend $25 billion a year for these services alone, and that figure does not include downstream complications or services.

For providers, population-based, "supply-side incentives" where outcomes are monitored may be the best bet at stemming the tide of low-value care. Accountable care contracts could reduce low-value care through partial capitation or shared savings paired when coupled with meaningful outcome monitoring and broad quality measurement.

"Accountable care contracts encourage physicians to consider value, since incentives are explicitly aligned with quality and cost. In a national survey, 92 percent of physicians said they felt responsible for ensuring that patients avoid unnecessary tests and procedures, and 58 percent believed that physicians were best positioned to do so. Thus, physicians may be ready for a stewardship role in an environment where quality and payments are aligned," NEJM said.

Accountable care contracts may boost investment in practice policy setting as well as other potentially useful tools like patient decision aids, clinical decision support, and clinician education and feedback.

Other areas where there is potential to reverse the trend of low-value care included strengthening of risk-adjusted outcome measurement and creating new measures that help cut down low-value care, like decision quality, NEJM said.

"To address overuse, we now need to work against the current of culture and payment models that still largely reward volume over value. Accountable care contracts encourage providers to tackle overuse, but few providers currently share risk with payers for substantial numbers of patients. Providers participating in accountable care contracts should prioritize internal strategies for reducing use of low-value care."

Health Affairs pointed to other means such as accountable justification, or "gentle shaming" by prompting physicians to publicly justify inappropriate use in the electronic health record to reduce low-value care services and using system defaults to the advantage of generics. Setting system defaults such that generic medications are the top choice in the EHR boosts rates of generic prescribing, Health Affairs said.

"But more generally, there is a deeper need for a change in the culture of medicine toward one that promotes greater clinician engagement in delivering high-value care. Sense-making conversations with frontline clinicians, rigorous performance measurement, and performance feedback are among the essential components of this work."

Twitter: @BethJSanborn
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