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    • Translating Shades of Gray: How can we accelerate value in health care?

      Published Apr 04 2018, 1:35 PM
      • Health care
      • Value
      • AARP

      By Margot Walthall, MHA, and Darshak Sanghavi, MD, OptumLabs

      Change is hard, particularly as our country focuses more on value — not volume — in health care.

      Getting paid based on number of tests or procedures has led to over-treating patients, exposing them to unnecessary health complications and higher costs. By focusing instead on the most effective treatments based on research, we can deliver the highest quality care, while saving money for the health system — and for patients.

      We know some medical tests and procedures are more harmful than helpful for certain patients. They may create additional health risks, cost a lot, have unpleasant side effects and, in some instances, lead to a cascade of unnecessary or unsafe follow-on services.

      These “low-value” medical services are more common than you might realize. With the input of more than 70 medical specialty societies, the Choosing Wisely campaign has identified hundreds of low-value services (LVS) to help improve care decisions between providers and patients

      For instance, we think of cancer screenings as generally useful preventive measures (the sooner you catch something, the better) that saves many lives. However, these experts found that colonoscopies for patients older than 75 can be more harmful than helpful. In these patients, colonoscopies can put them at risk for intestinal tears, dehydration and fainting. Combine this fact with additional out-of-pocket costs, time and stress associated with the screening and ask: Are these tests worth the costs if the patient does not have specific risk factors for colon cancer?

      It can be challenging to reconcile population-based recommendations when treating an individual person. Moreover, our research with AARP reveals that reducing the use of some of these LVS is easier said than done. This suggests that while our health care system has made some progress in transitioning to high value tests and procedures, we have a long way to go.

      Some low value services are easier to reduce than others

      The appropriate use of health care services is an important issue for AARP, OptumLabs’ founding consumer advocate partner, and its nearly 38 million members. We wanted to see whether efforts to reduce low value services were having an impact on the health system

      Using de-identified OptumLabs claims data, researchers from AARP and OptumLabs analyzed trends in use of 16 low-value services from 2009, before the creation of Choosing Wisely, to 2014 among adults ages 50-plus with commercial insurance and adults ages 65-plus with Medicare Advantage.

      Overall, we found that since the Choosing Wisely campaign and other efforts to increase value in health care began, there continues to be a lot of variation — clear successes and additional opportunities — in the use of specific LVS.

      Here are some examples.

      Declines in chest x-rays before surgery

      For decades, it’s been common for doctors to routinely give patients chest x-rays before surgery as a safety measure. Because these x-rays expose patients to radiation, can cause many false alarms and cost extra money, Choosing Wisely recommends that only patients with relevant risks should get them, such as those who:

      • Have signs or symptoms of a heart or lung condition
      • Have heart or lung disease
      • Are over 70 years old and haven’t had a chest X-ray within the last six months
      • Are having surgery on the heart, lungs or any other part of the chest.

      Based on our research, it appears many doctors have gotten the message and researchers found chest x-rays before surgery have fallen considerably across all populations over the six years.

      Figure 1. Pre-operative chest x-ray, 2009-2014

      Line graph shows steep declines in pre-op chest x-rays across all commercial and MA enrollees.
      From 2009-2014, pre-operative chest x-rays declined at the following rates: By 26.8% among commercial enrollees aged 50-64 (COM 50-64), by 21.3% among commercial enrollees aged 65+ (COM 65+), and by 13.1% among Medicare Advantage enrollees aged 65+ (MA 65+).


      Declines in cervical cancer screening for women over 65

      According to American Cancer Society Guidelines, women over 65 who have had regular pap smears over the past 10 years should not be screened for cervical cancer unless they have a serious cervical pre-cancer. This recommendation is because the risk of cancer is low at those ages and the testing can lead to unnecessary treatments.

      Reassuringly, researchers found a substantial decline in cervical cancer screening for women over 65 who had commercial insurance. Initially, the rates of over-testing were markedly higher in the Medicare Advantage subgroup compared to commercial enrollees, but over time, that gap has dramatically improved.

      Figure 2. Cervical cancer screening, 2009-2014

      Line graph shows steep decline starting in 2011 for cervical cancer screening among women over 65.
      From 2009-2014, cervical cancer screening in women over 65 declined by 45.2% for commercial enrollees (COM >65) and by 34.5% for Medicare Advantage enrollees over 65 (MA >65).


      Little reduction in MRIs for low back pain

      Use of MRI to help diagnose low back pain, one of the most common conditions among adults, had a much more subtle decline. A recent Health Affairs study showed similar findings. Why is this type of imaging more difficult to reduce, despite evidence that many patients with uncomplicated low back pain do not get better faster with imaging?

      Figure 3. MRI for low back pain, 2009-2014

      Line graph shows little change in rates of MRI for low back pain across commercial and MA enrollees.
      From 2009-2014, MRIs for low back pain declined very little for Commercial enrollees age 65+ (1.8%) and Medicare Advantage enrollees aged 65+ (11.4%). MRIs declined slightly more among Commercial enrollees aged 50-64 (20.6%).


      To determine if an MRI for low back pain is warranted — and it is in certain situations — doctors need to have careful conversations with their patients about all of their symptoms and health history instead of just ordering the imaging “to be safe.” MRIs are expensive and may be associated with higher rates of unnecessary surgery. But, doctors may not have enough time or may feel pressure from their patient to do the imaging. Therefore, reducing MRI scans in this setting appears to be more challenging.

      How can we accelerate change?

      The results of our work with AARP show that curtailing some low value services is more difficult than others. Awareness alone is not always enough for change. But there are some additional tactics that can help push change. These include reducing barriers to patient-provider conversations, rewarding a de-implementation culture of LVS and encouraging bundles of related — and potentially unnecessary — services for common patient situations.

      Reduce conversation barriers

      Thoughtful provider-patient conversations about which services are recommended, and when, are core to ensuring value in health care. However, a recent survey of providers suggests it has become more difficult to have these discussions with patients. Reasons cited include limited time during office visits, a lack of data to make confident choices, patient insistence and a desire to keep patients happy, as well as malpractice concerns and wanting to do certain things “just to be safe.”

      To solve this, we need to start having broader conversations with patients about what treatments are and are not appropriate so that both doctors and patients feel confident about the choices they make together.

      Create a culture for change

      According to the same provider survey, a cultural change within an organization is required to prioritize the de-implementation of wasteful services as much as the implementation of new treatments. Experts highlight four key actions for organizations to reduce LVS:

      • Ensure leaders prioritize the change.
      • Create a culture of trust, innovation and improvement.
      • Establish a shared purpose and language.
      • Commit resources to the measurement of value.

      Take it to the bundle

      Financial incentives have been blamed for a lot of overuse. Under fee-for-service models, the more doctors treat, the more they are paid. Some bundled payment models that focus on a collection of services rather than individual services have been shown to motivate higher quality health care at lower cost. For example, a possible “Low back pain service bundle” could offer the opportunity to address the overuse of imaging, opioids, surgeries and more. This could lead to fewer MRI scans that result in unnecessary surgery, yielding lower costs and better care.

      As a society, we’ve accepted the fact that many patients receive low value medical services, which continues to take its toll on the health care in America. To move forward in studying and translating what works for de-implementation, we have to focus on better methods that measure clinically meaningful outcomes and unintended consequences for patients.


      *Margot Walthall, MHA, is vice president of integrated programs and translation at OptumLabs
      *Darshak Sanghavi, MD, is chief medical officer and senior vice president of translation at OptumLabs