Thursday, May 15, 2014

Fwd: qotd: Measuring low-value care in Medicare

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Subject: qotd: Measuring low-value care in Medicare
Date: Thu, 15 May 2014 11:08:05 -0700
From: Don McCanne <>
To: Quote-of-the-Day <>

JAMA Internal Medicine
May 12, 2014
Measuring Low-Value Care in Medicare
By Aaron L. Schwartz, BA; Bruce E. Landon, MD, MBA; Adam G. Elshaug,
PhD, MPH; Michael E. Chernew, PhD; J. Michael McWilliams, MD, PhD


Importance: Despite the importance of identifying and reducing wasteful
health care use, few direct measures of overuse have been developed.
Direct measures are appealing because they identify specific services to
limit and can characterize low-value care even among the most efficient

Objectives: To develop claims-based measures of low-value services,
examine service use (and associated spending) detected by these measures
in Medicare, and determine whether patterns of use are related across
different types of low-value services.

Design, Setting, and Participants: Drawing from evidence-based lists of
services that provide minimal clinical benefit, we developed 26
claims-based measures of low-value services. Using 2009 claims for 1 360
 908 Medicare beneficiaries, we assessed the proportion of beneficiaries
receiving these services, mean per-beneficiary service use, and the
proportion of total spending devoted to these services. We compared the
amount of use and spending detected by versions of these measures with
different sensitivity and specificity. We also estimated correlations
between use of different services within geographic areas, adjusting for
beneficiaries' sociodemographic and clinical characteristics.

Main Outcomes and Measures: Use and spending detected by 26 measures of
low-value services in 6 categories: low-value cancer screening,
low-value diagnostic and preventive testing, low-value preoperative
testing, low-value imaging, low-value cardiovascular testing and
procedures, and other low-value surgical procedures.

Results: Services detected by more sensitive versions of measures
affected 42% of beneficiaries and constituted 2.7% of overall annual
spending. Services detected by more specific versions of measures
affected 25% of beneficiaries and constituted 0.6% of overall spending.
In adjusted analyses, low-value spending detected in geographic regions
at the 5th percentile of the regional distribution of low-value spending
($227 per beneficiary) exceeded the difference in detected low-value
spending between regions at the 5th and 95th percentiles ($189 per
beneficiary). Adjusted regional use was positively correlated among 5 of
6 categories of low-value services (mean r for pairwise,
between-category correlations, 0.33; range, 0.14-0.54; P ≤ .01).

Conclusions and Relevance: Services detected by a limited number of
measures of low-value care constituted modest proportions of overall
spending but affected substantial proportions of beneficiaries and may
be reflective of overuse more broadly. Performance of claims-based
measures in supporting targeted payment or coverage policies to reduce
overuse may depend heavily on how the measures are defined.

Excerpts from the Discussion

In this national study of selected low-value services, Medicare
beneficiaries commonly received care that was likely to provide minimal
or no benefit on average. Even when applying narrower versions of our
limited number of measures of overuse, we identified low-value care
affecting one-quarter of Medicare beneficiaries. These findings are
consistent with the notion that wasteful practices are pervasive in the
US health care system.

Although these findings suggest that direct approaches to measuring
wasteful care may be tractable and informative, other findings
underscore potential challenges in developing and applying direct
measures of overuse. In particular, the amount of low-value care we
detected varied substantially with the clinical specificity of our
measures. Estimates of the proportion of Medicare beneficiaries
receiving at least 1 measured low-value service decreased from 42% to
25% when we used more restrictive definitions that traded off
sensitivity for specificity, and the contribution of low-value spending
to total spending decreased from 2.7% to 0.6%.

Thus, the performance of administrative rules to reduce overuse through
coverage policy, cost sharing, or value-based payment (eg, pay for
performance) may depend heavily on measure definition. Such strategies
may be appropriate for select services whose value is invariably low or
whose low-value applications can be identified with high reliability.
For other services, however, more sensitive measures could result in
unintended restriction of appropriate tests and procedures by coverage
and payment policies, whereas more specific measures could substantially
limit the effect of these strategies. Provider groups seeking to
minimize wasteful spending — for example, in response to global budgets
— may be able to distinguish appropriate from inappropriate practices at
the point of care without having to use rigid rules derived from
incomplete clinical data.

Although our analysis suggests that common drivers of low-value care
exist, our study did not identify specific determinants of wasteful
care. Factors associated with low-value care may also be associated with
high-value care.


Comment by Don McCanne

As we look for methods of slowing the increases in health care spending,
much attention is being given to devising methods of identifying and
reducing the amount of unnecessary care provided today. This article
contributes to that discussion by showing the potential impact of
measuring low-value care in Medicare patients. The results are quite

When more sensitive versions of the measures were used, a very large
number of Medicare beneficiaries were found to be receiving services
categorized as low-value, but they were unable to determine whether or
not the care provided was actually wasteful in the various clinical
circumstances. Thus policies that would reduce these services could
result in "unintended restriction of appropriate tests and procedures by
coverage and payment policies."

When more specific versions of the measures were used, the potential
cost savings were very small, thus "substantially limit(ing) the effect
of these strategies." Adjusting between sensitivity and specificity
trades off the inappropriate labeling of beneficial care as being of
low-value, with the failure to identify enough of the clinical instances
that were truly of low-value. Regardless of the sensitivity or
specificity, mistakes will be made in classifying what truly is or is
not low-value care.

As a cost saving measure, it would appear that such an approach would be
administratively complex with costs that could offset a significant
proportion of the very modest gains in recovery of charges for low-value

The authors note that health care professionals working within global
budgets "may be able to distinguish appropriate from inappropriate
practices at the point of care without having to use rigid rules derived
from incomplete clinical data." Clinical judgement trumps empirical
computer algorithms.

It is not as if the policy community does not already know how to
recover some of the profound waste in our system. Just the
administrative savings alone recovered by adopting a single payer system
would be enough to pay for the care that people are not now receiving
that they should be. But our policymakers don't seem to be giving up in
their anything-but-single-payer pursuit of cost containment in health
care. Their obsession is pathological.

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