By Surabhi Dangi-Garimella, PhD
Can health care services have low value? Turns out, they do! A service or a treatment that provides no or little benefit to the patient—or worse, might harm the patient—is a low-value service. While we might quickly jump to conclusions on who should be blamed for providing the low-value service, multiple factors influence low-value care delivery:
- Traditional/well-established clinical practices
- Workflows/prompts within electronic health records
- Patient expectations
- Knowledge gaps
- Fee-for-service payment system
For years now, our health system has been grappling with ways to reduce spending. While drug pricing remains a hot target, eliminating inefficiencies in care delivery at various levels is one approach to tackle unnecessary spending, which can also protect the patient from harm. According to the Center for Value-Based Insurance Design, low-value care devours more than $340 billion annually in the U.S.
Typical examples of low-value care delivery include:
- Over-prescription: Overprescribing medications such as antibiotics, opioids, anti-anxiety medications, diabetes medications, can be harmful. Many of these drugs are associated with serious side effects that add another level of complication to the patient’s health. Many older patients are on multiple medications—what is known as polypharmacy—and can face adverse effects due to drug-drug interactions.
- Over-screening: Over-screening can often lead to a series of investigations and unnecessary treatments or procedures. Consider lung cancer screening as an example. Low-dose CT scan over five years can prevent death among one in 320 patients at high-risk of lung cancer. However, the high false-positive rate of this screening procedure results in about 2.5% of high-risk patients who do not have cancer to undergo unnecessary invasive procedures such as a lung biopsy or bronchoscopy that may lead to other complications. The overdiagnosis rate with this screening process is 20% and consequently, patients may receive very strong treatments with severe side effects but no benefit.
It’s important to realize what triggers this chain of events. Physician members of the American Medical Association who participated in an online survey stressed the following reasons:
- Malpractice (~85%)
- Patient pressure (59%)
- Difficulty accessing medical records (~38%)
They recommended training residents on appropriateness criteria (which is a score that considers examination, indication, gender and age), easier access to outside health records, and more practice guidelines as solutions to resolving the issue of low-value care.
- Unnecessary procedures: A fallout of patient expectations of receiving some form of care when they visit a clinic or hospital with a health-related complaint is unnecessary procedures. This issue has been talked about for a while now but was particularly highlighted during the COVID-19 pandemic. Delays or cancellations of various tests and treatments as a result of the pandemic found no harm done to certain patient populations, meaning the following can be safely avoided:
- Colonoscopies conducted in those over 85 years
- Hemoglobin measurement in type 2 diabetes patients
- Yearly dental X-rays
Surgeries are often planned that may have alternatives: c-sections in women who have a low-risk pregnancy or a hysterectomy instead of an alternative treatment for ovarian cancer. This can burden the patient with avoidable cost and, more importantly, avoidable health risks.
Do We Have a Solution to Reduce Low-Value Services?
Health economists and health care researchers have presented solutions that can have a real impact on this conundrum.
- Raising awareness among both patients and providers and encourage shared decisions. The Choosing Wisely campaign developed by the ABIM Foundation has taken the lead to promote this effort at the national level.
- Measuring low-value care in claims data from Medicare and private payers
- Updating clinical decision support tools at the point of care so clinicians can be on top of the latest clinical recommendations and guidelines
These solutions are showing results, but our health system has a long way to go to see more widespread adoption.
Surabhi Dangi-Garimella, Ph.D. is a biologist with academic research experience, who brings her skills and knowledge to the health care communications world. She provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.