Posted: 08 May. 2018 5 min. read

When health care makes us less healthy: The challenges of low-value care

By Terri Cooper, Global Health Care Sector Leader, Deloitte Consulting LLP

In the United States, we spend hundreds of billions of dollars each year on health care that might not improve a patient’s condition. Some care might even make a condition worse. In the US and around the world, low-value care is pervasive, costly, and difficult to eliminate, according to a new report from the Deloitte Center for Health Solutions.

Examples of low-value care include:

  • An EEG for a patient with a headache, or a CT scan or MRI for a patient with lower-back pain and no signs of a neurological problem
  • Emergency room visits for non-emergencies
  • Surgery when physical therapy would be equally or more effective 
  • Inappropriately prescribed antibiotics
  • Overprescribed pain medication, such as opioids

Education could help reduce low-value care

To reduce the prevalence of low-value care, we should start by considering why it is so entrenched. Our culture often presumes that more translates to better: more prescription drugs, more procedures, and more doctor visits should make us better.

In addition, patients sometimes don’t fully understand the treatment, the risks, or the alternatives. A surgeon, for example, might recommend surgery even if physical therapy could be just as effective, less risky, and far less expensive. We can blame at least part of this on a fee-for-service (FFS) payment system that rewards volume instead of value. But the physician might not be fully aware of alternative treatments.

Artificial intelligence (AI) could give clinicians access to libraries of research and help them stay abreast of the latest clinical developments and alternative courses of action. Some of the most promising, technology-driven safety interventions (e.g., cloud-enabled AI and advanced clinical decision-support systems that predict which patients are most at risk for adverse events) could lead to safer health care in tomorrow’s hospitals, clinics, and physician offices.1

Low-value care in a value-based world

We have been talking about the potential of value-based care for several years now. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) pays Medicare clinicians for patient cost, quality, and other outcomes as well as for the number of services provided. The law creates incentives for clinicians to move away from Medicare’s FFS model and toward alternative payment models that reward value. Outside of Medicare, commercial health plans could help reduce low-value services by reducing payments for them, or by boosting payment for high-value services.

Global awareness of low-value care has been increasing. More than 20 countries have initiated “Choosing Wisely” campaigns, in which physicians and health care specialty societies identify services, tests, or treatments that are inappropriately used.2 The campaign, which was launched in 2012 by the ABIM Foundation and Consumer Reports, now includes more than 80 specialty societies such as nursing, dentistry, physical therapy, and pharmacy. These groups have collectively identified mountains of overused tests and treatments, and have published 520 recommendations, according to the organization’s website.

Three health systems that have reduced low-value care

Health systems in several countries have launched strategies that are helping to ensure more patients get the right care, in the right setting, delivered the right way. Consider these examples of strategies that are reducing low-value care:

  • Cataracts in California: In 2015, the Los Angeles County-University of Southern California Medical Center (LAC+USC), a public teaching hospital, made changes that helped eliminate routine preoperative testing for patients who didn’t need it before routine cataract surgery. The changes were based on Choosing Wisely guidelines.3 Over the six-month trial period, unnecessary preoperative medical visits fell from 76 percent to 12 percent of patients after the program was implemented. Without additional testing, average wait times for the surgery declined by six months.
  • Babies in Brazil: In 2015, a coalition of 26 private and public hospitals across Brazil began a pilot project—Projeto Parto Adequado (PPA)—to reduce the rate of medically unnecessary Caesarian sections. In 2017, more than half of all births in Brazil were by C-section.4 Compared to vaginal births, C-sections have been associated with maternal pelvic floor dysfunction, higher risk of childhood asthma and childhood obesity, and increased risk of complications in future pregnancies.5 Women in the pilot were given appropriate evidence-based information about their options. In Phase I of the project, partner organizations increased the rate of vaginal births from 21.6 percent to 38 percent over 18 months. Phase 2, which launched last August, expanded the program to 137 hospitals.
  • Teleconsultations in Texas: Inappropriate emergency department (ED) visits account for between 12 percent and 32 percent of all ED visits in countries such as the United States, Canada, England, Italy, Portugal, and Australia.6 In 2014, the Emergency Telehealth and Navigation (ETHAN) program in Houston established a system of ambulance-based teleconsultations that reduced ED use and freed emergency medical services (EMS) teams to respond to other calls.6 Patients who call for an ambulance receive on-the-spot referrals to the most appropriate site of care—ED, hospital, home, or urgent-care clinic. The program has reduced unnecessary ED visits by 6.7 percent.7 Each avoidable inappropriate ED visit saves about $2,500, which translates to a savings of about $1 million a year for private and public health insurers. The program also reduced back-in-service times for ambulances by 44 minutes.

In 2013, the US spent $765 billion each year on low-value care, according to an estimate from the Institute of Medicine. Reducing low-value care can be difficult and time-consuming, but it is increasingly important as we shift to a value-based care model. If we can reduce low-value care, we can create opportunities to enhance patient experience, improve quality, and reduce costs. To succeed, patients, providers, and health plans should take an active role in identifying—and in finding alternatives—to low-value care.

Endnotes
1. Current and future perspectives on the management of polypharmacy, BMC Family Practice 18, no. 70 (2017)
2. ABIM Foundation, Choosing Wisely: A special report on the first five years, 2017. 
3. ABIM Foundation, Choosing Wisely list of recommendations: American Academy of Ophthalmology, 2013 
4. Paula Lavoissiere, Number of C-section deliveries going down in Brazil, Agencia Brasil, 2017
5. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990–2014, PLoS ONE 11, no. 2 (2016), Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis, 2018, PLoS Medicine 15, no. 1 (2018)
6. Michael Gonzalez, telephone interview, February 1, 2018.
7. James R. Langabeer et al., Cost-benefit analysis of telehealth in pre-hospital care, Journal of Telemedicine and Telecare, 2016

 

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Terri Cooper

Terri Cooper

Principal | Deloitte Consulting LLP

Terri is currently Deloitte’s Vice Chair of External Diversity, Equity, and Inclusion (DEI) where she focuses on fostering Deloitte’s external brand and helping to drive market facing efforts. Terri has a personal passion and commitment to growing and developing talent at all levels. As chief inclusion officer, Terri drove Deloitte’s strategy to recruit, develop, and advance a diverse workforce and foster an inclusive environment. Terri led Deloitte’s inaugural Inclusion Summit and Day of Understanding, which fostered courageous conversations on DEI topics. She advanced inclusive leadership at all levels and establish inclusion as a core leadership capability. Terri has more than two decades of experience working in various capacities of the life sciences and health care industry, including participating in a broad range of strategic advisory services. She has created new global operating models; supported the integration of development, regulatory, and drug safety functions in a number of Life Sciences company mergers; restructured all aspects of the research and development (R&D) value chain; and driven increased cost and efficiency measures. Terri serves as a frequent speaker on diversity, equity, and inclusion issues and trends. She spearheaded the State of Inclusion annual research as well as represented Deloitte at Davos, Fortune’s Most Powerful Women, and Women Leaders Global Forum. She was named to Crain’s 2019 New York Notable Women in Accounting. She is a board member for the Simmons University Institute for Inclusive Leadership Strategic Board of Advisors. She holds a Joint Honors Bachelor of Science Degree in Chemistry and Pharmacology and a PhD in Pharmacology from the University of London, UK. Connect with her on LinkedIn at www.linkedin.com/in/drterricooper and Twitter @DrTerriCooper.