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

Health Care Current | May 8, 2018

This weekly series explores breaking news and developments in the US health care industry, examines key issues facing life sciences and health care companies and provides updates and insights on policy, regulatory, and legislative changes.

My Take

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.

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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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In the news

Survey reveals ACO concerns about Medicare Shared Savings Program (MSSP)

The National Association of Accountable Care Organizations (NAACOS) has released the results of an April 2018 web survey of Medicare Shared Savings Program (MSSP) Track 1 Accountable Care Organizations (ACOs) about assuming risk for losses and plans to continue participation in the program. NAACOS surveyed the 82 ACOs that began the MSSP in 2012 or 2013 and remain in Track 1. Beginning in 2019, these ACOs must transition to a two-sided risk model, assuming financial risk for overspending relative to the benchmark as well for sharing in any savings. More than 40 percent of the contacted Track 1 ACOs responded to the survey.

More than 70 percent of responders indicated they would “likely” leave the MSSP if they have to assume risk for losses. According to NAACOS, the Likely category represents a composite of response options: Completely likely (8.6 percent), very likely (20 percent), moderately likely (11.4 percent), and slightly likely (31.4 percent).

More than 80 percent of Medicare ACOs remain in MSSP Track 1. The survey asked them to report their top barriers and challenges to assuming risk for losses. Almost 40 percent of responders selected the following answers:

  • The amount of risk is too great (39.4 percent)
  • Concerns about unpredictable changes to the ACO model/CMS rules (39.4 percent)
  • Desire for more reliable financial projections (39.4 percent)

In the past, NACCOS has advocated for CMS to allow ACOs that meet certain performance criteria to continue in Track 1.

Related: As of May 1, a proposed rule regarding the MSSP and ACOs is pending review at the Office of Management and Budget (OMB).

Azar outlines priorities and initiatives for HHS

Health and Human Services Secretary Alex Azar spoke at the 2018 World Health Care Congress (WHCC) in Washington, D.C. on May 2. There, he discussed the agency’s top four goals:

  • Maximizing health IT
  • Improving transparency in price and quality
  • Pioneering new models in Medicare and Medicaid
  • Removing artificial regulatory barriers to care coordination

Azar discussed updates to the Blue Button 2.0 app, which will use an open application programming interface (API) to give patients the ability to connect their Medicare data to apps developed by private companies. Blue Button is part of a larger, administration-wide effort called MyHealthEData Initiative, which aims to provide patients with greater access to their health care data.

Azar also noted that on May 6, the National Institutes of Health (NIH) will open enrollment for the All of Us Research Program, which aims to advance prevention, treatment, and care for people of all backgrounds. Data will include everything from lifestyle and nutrition to genetics and health care outcomes. All adults are encouraged to participate.

Related: During her keynote address at the World Health Care Congress, Seema Verma, director of the Centers for Medicare and Medicaid Services (CMS), explained how the newly launched MyHealthEData Initiative will give patients greater control over their health records. Like Azar, Verma discussed the recent release of Blue Button 2.0. She also spoke about CMS’s efforts toward price transparency in health care, such as proposing that hospitals post service charges online.

Uninsured rates are up among nearly all groups of working-age adults, study finds

According to the seventh installment of The Commonwealth Fund’s Affordable Care Act (ACA) Tracking Survey, the uninsured rate is up across the board, likely reflecting the administration’s changes to the ACA.

Between February and March of this year, researchers sampled 2,403 adults between the ages of 19 and 64. Overall, 15.5 percent were uninsured. This is the second-highest uninsured rate this survey has found since the first installment during the summer of 2013, when the rate was 19.9 percent.

This year’s study finds that the greatest drop in insurance coverage occurred among people with the lowest incomes. More than a quarter (25.7 percent) of adults living below 250 percent of the federal poverty level lacked health insurance—a 3.3 percent increase from last year. Among adults with higher incomes, the uninsured rate declined slightly, from 6.2 percent to 5.8 percent.

Without the individual mandate penalty, 5 percent of all adults surveyed said they intend to drop their coverage in 2019. This rate was 9 percent among people who have coverage through the individual market enrollees.

Proposed CMS rule would revise quality reporting measures

CMS proposed a rule on April 27 that would update the measures it uses for the Quality Reporting Program (QRP) for skilled nursing facilities (SNFs). The agency explained it would like to remove measures that are unnecessary, unhelpful, and unreliable. The proposed rule would also display information about the measures for two years, rather than just one year. If adopted, these provisions would go into effect in 2020.

CMS proposes coverage of gene-therapy cancer drugs

CMS recently proposed revisions to its payment policies and rates under the Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) for fiscal year 2019 (see the May 1, 2018 Health Care Current). Under these two systems, CMS sets baseline payment rates for inpatient stays, based on a patient’s diagnosis and severity of illness. A hospital will receive a single payment for a patient case, contingent on the classification assigned at discharge.

Each year in the proposed rule, CMS addresses the applications for new technology add-on payments under IPPS and seeks comments, which are considered when determining final-rule provisions. This year’s proposed rule includes 15 applications for new technology add-on payments, including applications for Chimeric Antigen Receptor (CAR) T-cell therapy. Currently, payments for (CAR) T-cell therapies are bundled with other billings. CMS is proposing to pay for (CAR) T-cell treatment in the same manner as bone marrow transplants, which would confer higher payments as CMS considers a separate billing code for these therapies.

(CAR) T-cell therapy is used in cancer treatment. A patient’s blood is drawn and the T-cells are separated. In a laboratory, the patient’s T-cells are genetically engineered, using the CAR process to bind onto and attack certain cancerous cells. These (CAR) T-cells are then administered to the patient via infusion. The first two (CAR) T-cell therapy drugs were approved for use in the US in August 2017.

New Indiana program to target opioid addiction among mothers and newborns

On Monday, April 30, Indiana Governor Eric Holcomb (R) joined state and local leaders at an Indianapolis hospital to announce a new program, the Community Health Network Neonatal Opioid Addiction Project. This project was designed to address opioid use disorder in expectant mothers and to treat neonatal abstinence syndrome (NAS), the medical condition experienced by babies born addicted to drugs. The Indiana Family & Social Services Administration’s (FSSA) Department of Mental Health and Addiction (DMHA) provided about $600,000 towards this initiative.

A recent press release from Holcomb’s office outlines the goals of the hospital’s Neonatal Opioid Addiction Project, which include:

  • Conducting screenings for all expectant mothers to identify those who need support for depression or drug use.
  • Providing care for expectant mothers who test positive for opioids throughout their pregnancies and after their children are born.
  • Offering specialized care for newborns who have been exposed to addictive substances.
  • Developing a Maternal and Neonatal Center of Excellence for the Treatment of Drug Use Symptoms (TODUS).
  • Enhancing data collection, analysis, and reporting on health outcomes, costs, and best practices, as well as ways to identify and remove barriers to addiction treatment and recovery.

The Neonatal Opioid Addiction Project builds upon the Indiana State Department of Health’s (ISDH) pilot project. In 2015, four Indiana hospitals launched an ISDH program to treat pregnant women and babies with substance use disorders (SUDs). The initial results of the pilot project were encouraging: Among mothers who tested positive when they first went to the hospital, about half tested negative for drug use when they came to deliver their babies.

IRS lowers, then increases, permissible 2018 contributions to HSAs

For the 2018 tax year, families with high-deductible health plans (HDHP) will be able to contribute up to $6,900 in pre-tax dollars to a health savings account (HSA), the Internal Revenue Service (IRS) said in a statement on April 26.

The announcement clears up some confusion about this year’s maximum contribution amount. In March, the IRS announced that the $6,900 annual limit would be $50 lower because of inflation-adjustment calculations in the new tax-reform law. However, the final rule keeps the limit at $6,900.

An HSA-compatible family HDHP must have an annual deductible of at least $2,700 ($1,350 for individual coverage) and a maximum out-of-pocket limit of $13,300 ($6,650 for individual coverage). The maximum HSA contribution for single HDHP for 2018 is $3,450.

Background: The administration and Republican Congressional leadership support expanding use of HSA policies across all markets—with the goal of reducing costs and putting more responsibility for health care costs into consumers’ hands. The Deloitte Center for Health Solutions recently explored the state of HSAs in the employer, Medicaid, and individual markets. The research showed that HDHPs combined with HSAs hold the promise of encouraging people to shop for coverage, but employers have found they’ve needed to invest in tools and education to help people use these options. Health plans might need to consider enhancing tools and support to consumers as HDHPs and HSAs become more prevalent in the individual market.

Related: On April 27, the IRS issued guidance to make it easier for some small employers to claim a 2017 tax credit. The Small Business Health Care Tax Credit, which was created by the Affordable Care Act (ACA) offers a tax credit to small employers that purchase employee health coverage through the Small Business Health Options Program (SHOP) marketplace. Small employers can claim the credit for two consecutive years. In some counties, however, small-group health coverage is no longer available through SHOP. The guidance allows employers who claimed the credit for all or part of 2016, or a later taxable year, to continue to claim the credit for offering qualified health coverage purchased outside of a SHOP marketplace.

Breaking Boundaries

Stakeholders are finding creative ways to get real-time data on opioid use

Deloitte’s upcoming paper, Strategies for stemming the opioid crisis: How data analytics can help health plans and PBMs chart their course, discusses the ways in which health plans and pharmacy benefit managers (PBMs) are using data analytics and other technologies to combat the opioid crisis. Our research highlights the many different data sources health plans and PBMs are using, as well as the many limitations in using the data to its full potential. These include privacy regulations that many say need to be modernized and data siloes that exist within organizations and across the health care system. There are also challenges in accessing real-time data from in Prescription Drug Monitoring Programs (PDMPs)—state databases that are used to track prescriptions for controlled substances.

There is broad consensus among health care stakeholders that there is a lack of detailed, real-time data on the opioid epidemic, and some stakeholders are getting creative in their search for new data sources.

City sends robots into the sewers

The city of Cary, North Carolina, is mining data from the sewage system. Cary is the first city to employ a relatively new technology called sewage-based drug epidemiology, which can find traces of substances such as opioids in human waste. Cary is using a grant to partner with a company called Biobot Analytics to use small robots to collect waste samples directly from the city’s sewage system. The researchers aim to develop a baseline of opioid consumption from the samples. They can then identify opioid “hot spots” in the city, as well as determine what kinds of opioids are being used (e.g., prescription drugs vs. illegal substances). Researchers can combine this information with other data, such as demographics, unemployment rates, insurance rates, and others to try to identify trends. The goal is to make the results public in case other cities want to replicate the work.

Maryland project tracks bed availability at treatment centers

Recent data show that states might have undercounted opioid deaths by 20 to 35 percent between 1999 and 2015. Potential reasons include variations in how death certificates are filled out in different states. Data drives policy, and better data could help policymakers and planners determine spending and other initiatives to combat the opioid crisis in their communities.

Other states are exploring diverse solutions to the crisis. In Maryland, the shortage of beds at treatment centers spurred the city to pilot a Substance Use Disorder Bed Finder project—an effort to map all available beds in and around the city in real-time. Officials are working with six centers, and are aiming to expand to as many as 70 centers across the region. Data about bed and staff availability come from surveys collected through a mobile app and are transmitted to a dashboard that is accessible to first responders and crisis teams.

(Source: Linda Poon, The Race to Learn what’s Really Happening in the Opioid Crisis, CityLab, April 30, 2018)

West Virginia uses data to determine risk factors

In West Virginia, opioid-related death rates are higher than the national average. Public Health Commissioner Rahul Gupta directed his staff to do an in-depth analysis of all 887 people who had died of an overdose in the state in the preceding year. From the data, the department was able to develop a targeted list of risk factors. It found that men were twice as likely as women to die of an overdose. People in construction and those who served time in prison were also at higher risk. From these findings, the team recommended policy proposals that made it into legislation, which was recently signed into law. Other findings were used to develop county-level programs aimed at curbing drug abuse. In the latter half of 2017, death rates have begun to slow by about 25 percent. Overdose rates also declined.

(Source: Brianna Ehley, The Immigrant Doctor Who’s Solving West Virginia’s Opioids Crisis, POLITICO Magazine, May 2, 2018)

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