LOW-VALUE CARE is defined as care that is of “little benefit to patients, have potential to cause harm, incur unnecessary costs to patients or waste limited health resources.”

Low Value Care

V-BID Center (Value-based Design Insurance Center, University of Michigan ) is leading initiatives to reduce the utilization of  LOW-VALUE CARE, which they define as care that is of “little benefit to patients, have potential to cause harm, incur unnecessary costs to patients or waste limited health resources.”

Chapter I addressed health care quality and a variety of measurements employed by Medicare, commercial insurers, and health care systems with partnerships of hospitals/doctor groups. The measurements that provider organizations use matter to the doctors and other ancillary care providers based on the selected quality metrics and outcomes that providers achieve in their care delivery. What matters to patients, however, is often less experienced as high-value care.

Numerous healthcare experts have outlined wastefulness in the fee-for-service (FFS) payment system. A landmark article in New Yorker by Dr. Atul Gawande wrote an article in the New Yorker stating that  Medicare spent $15,000.00 per Medicare beneficiary in McAllen, Texas, whereas it spent $7500 per Medicare beneficiary in  El Paso, Texas. Despite strikingly different expenditures in similarly located geographical areas, outcomes were not different. There was across-the-board overuse of medical services in McAllen that had no benefit to patients. Dartmouth Researchers also found patients having more excessive treatments of marginal value in high-cost areas of the country- also from payments to providers based on the FFS system.

There is a significant and increasing effort on the provider/payer side in the USA to replace the current predominant payment model based on volume of care (e.g., in a fee-for-service payment system), which incentivizes unnecessary care. The new payment models are based on the value of care, which would not only reduce unnecessary care but also aim to reduce overall costs of care.

Value-based care (VBC) is a healthcare reimbursement model based on quality rather than quantity of care. The goal of this model is not just to provide care, but to provide better care for individuals, better health for populations, and lower cost of care. This goal is what drives the shift from the Fee-for-Service model to VBC.

There are different models of VBC currently in practice, as stated below:

* Accountable Care Organization (ACO)-Accountable Care Organizations (ACOs) are groups of healthcare organizations, physicians, and other providers working together to provide care to patients. These organizations use reimbursement based on capitation  ( some with risk adjustment for sicker patients) -an agreed-upon amount per patient per year, and the organization has to provide all necessary care for all the patients enrolled in this plan. 

*Population-Based Payment Model -Population-based payment model (PBP) or global budgeting is used by sizeable integrated health groups like Intermountain Health Care ( 2 million patients in Utah, Idaho ) or Kaiser Permanente. (12.5 million people in 9 states ). This model sets a fixed budget for the total care of a defined population over a specific period, usually a year. Integrating evidence-based health care and prepaid coverage financing drives care coordination across all settings and care teams. It enables quality outcomes by ensuring that providers deliver proper care at the right time and in the right setting. The plan avoids unnecessary costs by eliminating unneeded or duplicate tests or procedures that occur when fragmented care is eliminated through teamwork and coordination among its array of providers. Even with reduced revenues received per PBP model compared to the FFS model, Intermountain Health Care has been able to innovate and expand additional services with high patient satisfaction rates.

*Bundled payments- This payment model uses a single price for an episode of care, such as total knee or total hip replacement, for all the patient’s services (pre-operative, operative, and postoperative care ).  The price paid is usually slightly lower than the historic prices based on the fee-for-service payment model. This payment is akin to a single flat-rate DRG  ( Diagnosis Related Group ) payment to hospitals, including all physician fees and costs of related treatments, complications, or hospital readmissions within 90 days of the original operation or medical complications such as pneumonia. It is important to note that it is still volume-based. Also, the payment model is on a per-case basis, unlike global capitation, which is the case in ACO. Bundled payments for specific disease management like Diabetes or Congestive Heart Failure are sometimes called ‘disease capitation,’ which means the payment is based on the expected costs of managing a specific disease over a defined period of time. In the above examples, payers are at financial risk if they do not eliminate wasteful care that does not contribute to desired outcomes and patient satisfaction.

Low-value care is pervasive, as noted by Dr.Bricker.  In one of his educational videos, Dr. Eric Bricker said the following: He was expanding on an editorial in the Journal of American Association, making the case that Low-Value Care remains a problem even in the absence of fee-for-service.

” I always assumed if you fixed Fee-for-Service, you would fix the perverse incentive to do too much and therefore fix healthcare.” Not entirely, and he gave the following examples.

1. Canada does not have FFS, and still, 30% of Seniors in Alberta receive at least one of 10 low-value services
2. Maryland has Global Budgets for hospitals-not FFS – and there are still high rates of 19 Low values services
3. VA does not have FFS, and yet 5%-21 % of Vets still receive Low-Value testing

The article also pointed out that the type of Low-Value Service is very different from one hospital or physician group to another, essentially unique microenvironments of waste. The authors spell out a bottom-up rather than top-down solution to low-value care.In  the above examples payers are at financial risk if they do not  eliminate care that is wasteful and does not contribute to desired outcomes and patient satisfaction.

In addition to the payers, professional organizations like the American Board of Internal Medicine recognize widespread low-value care in the US and other countries and have launched their own efforts to reduce low-value care. 

In collaboration with Consumer Reports, the American Board of Internal Medicine (ABIM) launched a campaign in April 2012, CHOOSING WISELY. This campaign aims to reduce unnecessary tests and procedures and promote more effective use of health care resources. Each medical society was invited to develop a “Top Five “ list of unnecessary tests, treatments, or procedures. More than 70 societies comprising over one million clinicians are now partners of the Choosing Wisely campaign. Choosing Wisely USA has made 550 recommendations. There are numerous examples- unwarranted CT scan, MRI, or EEG in a patient with headache and no other neurologic symptoms or signs, imaging for low back pain without red flags,  ER visits for non-emergency care, inappropriately prescribed antibiotics in as many as half the cases, unnecessary surgical procedures when simple measures like Physical therapy could suffice with equivalent results. There is significant geographic variation in the provision of low-value care. Two examples of excessive low-value care are in areas with higher specialty physicians to primary care ratio and regions with a higher proportion of minority beneficiaries. 

The global movement that began in the United States in 2012  has now spread its influence to 20 countries across five continents, uniting healthcare professionals and patients in a shared mission to reduce low-value care.

Choosing Wisely Canada was launched on April 2, 2014, and is organized by a small team from the University of Toronto, the Canadian Medical Association, and St. Michael’s Hospital (Toronto).  Up to 30% of tests, treatments, and procedures in Canada are potentially unnecessary. Choosing Wisely Canada has made 330 recommendations.

Choosing Wisely Canada, launched a campaign a patient or healthcare professional, can actively participate in, provides patient resources and widely distribute cards with five questions patients should ask their physicians regarding any test, procedure, or treatment.

1. Do I need this? 2. What are the risks? 3. Are there simpler, safer options? 4. What happens if I don’t do anything?  5. What are the costs?

Since its inception in 2012, the Choosing Wisely campaign has made significant strides in elevating the quality of medical care in many countries. Its expansion into new programs like Nurses Improving Care for Healthsystem Elders (NICHE) within the past year is a testament to its promising future.

However, it is important to note that specialty organizations choose initiatives that are mostly low-hanging fruits. As per the article in PubMed in  (JBJS)Journal Bone Joint Surgery ( peer-reviewed highly regarded organization of orthopedic surgeons) by Nicholas A. Badard et al.,  just over a million patients with knee osteoarthritis were identified in the Humana database from 2007 to 2015. 405101  (38%) received a corticosteroid injection, and 137,005 (13%) received a hyaluronic acid injection. Two clinical practice guidelines from JBJS  stated inconclusive evidence for benefit from these interventions. Although the trend in using hyaluronic acid injections by orthopedic surgeons and pain specialists decreased a little after guidelines were published, there was no change in practice from primary care physicians or nonoperative musculoskeletal providers. The authors concluded that, given the high costs of these injections and their questionable clinical efficacy, clinical practice guidelines did not substantially reduce the volume of steroid or hyaluronic acid injections. They stressed the need for additional measures to encourage higher-value care for patients with knee osteoarthritis, highlighting the urgency of the situation and prompting the reader to consider potential solutions.

The review of epidural corticosteroid injections for lumbosacral radicular pain by the Cochrane Collaboration (a global network of over 40,000 volunteer physicians in 130 countries)on April 9, 2020, delivered a stark conclusion: Injections of anti‐inflammatory steroids did not offer any long-term benefit compared to standard pain management and physical therapy. This finding underscores the need for a reevaluation of current practices, especially considering the widespread use of these injections.