Reducing Low-Value Care Key to Value-Based Reimbursement Success

February 01, 2018 - Value-based reimbursement success hinges on decreasing low-value care across patient populations, explained Scott Weingarten, MD, MPH, Senior Vice President and Chief Clinical Transformation Officer at Cedars-Sinai Medical Center.

While hospitals and health systems have flocked to value-based care strategies, such as population health management programs and high-risk patient interventions, the non-profit academic healthcare organization in the Los Angeles area has taken a slightly different approach.

In addition to care management initiatives, the health system has focused on reducing low-value care use among its providers and across low to high-risk patient populations over the past four years.

“According to the literature and the information we can find, if we’re really going to make a substantial leap forward in our efforts to both improve quality of care and affordability of care, we have to focus on reducing low-value care,” Weingarten recently told RevCycleIntelligence.com.

“When I say ‘low-value care,’ I mean care, tests, and treatments where the harm exceeds the benefits or there are no to minimal benefits,” he continued. “There are guidelines available to guide these discussions, such as Choosing Wisely, which is an initiative from the American Board of Internal Medicine that encompasses about 70 physician specialty societies that represent about 600,000 physicians. There is also peer-reviewed literature, which helps us define low-value care.”

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The use of low-value care is significantly driving up wasteful spending in hospitals and health systems. The industry spent about $32.8 million on just 28 low-value services in 2013, such as triiodothyronine measure in hypothyroidism, imaging for non-specific back pain, and imaging for non-complicated headaches, a 2016 RAND Corporation and University of South California study revealed.

The services accounted for just 0.5 percent of total healthcare spending, but low-value care added about $22 more per person annually.

Low-value care is also an issue facing both seemingly low-cost, healthy patients and a health system’s highest risk and cost patients. A recent study in the New England Journal of Medicine found that providers performed more low-value care services on low-risk patients, indicating that focusing efforts to reduce low-value care on high-risk populations may miss the mark.

As provider organizations like Cedars-Sinai transition to value-based care, ensuring that all patients receive the highest value care will help hospitals and health systems become cost-efficient and maximize value-based reimbursement.

Decreasing low-value care use can also help hospitals and health systems continue value-based reimbursement success after low-hanging fruit opportunities generate savings and quality improvements.

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But it isn’t always easy to change how providers deliver care, especially since physicians practiced under the fee-for-service system that encouraged them to adopt a “try everything” approach to treatment for so long.

“It’s hard, and a lot of organizations have focused on care management instead, which is also important,” he said. “It’s easier to gain initial support for providing additional care, like care managers seeing patients in their homes, than reducing low-value care.”

To truly shift how providers deliver care in the era of value-based reimbursement, Cedars-Sinai addresses low-value care utilization through clinical decision support tools.

“What we do is integrate information defining low-value care into electronic health records as clinical decision support,” Weingarten explained. “We remind providers when they’re about to do something or order a test or treatment which the sub-specialty societies or peer-reviewed literature would suggest is low-value care. We provide the clinicians with evidence in real time.”

From there, providers can make their own judgment based on the evidence in the reminder and the patient right in front of them. They can either agree with the reminder and not order the test or treatment, or consciously decide to deliver the service because of that particular patient’s characteristics and health needs.

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“For example, let’s say you’re a provider and you’re about to give what’s called a Benzodiazepine to an older patient, let’s say a patient who’s 90-years-old,” he elaborated. “Benzodiazepines are drugs such as Valium, Ambien, and Ativan. That is low-value care because, on one hand, the patient may have insomnia, but on the other hand, Benzodiazepines may increase that older patient’s chance of falling, having a hip fracture, being hospitalized, and dying. So, we alert the provider in real-time about the evidence.”

The prompt also signals for the provider to discuss alternative treatment options with patients.

“We also allow the provider to print material from Consumer Reports to hand to the patient, because the 90-year-old patient might say, ‘I understand that Benzodiazepines aren’t safe. But I can’t sleep and that’s a concern. What can I do instead?’ So Consumer Reports provides ‘do instead’ information or other types of sleep hygiene that are safer.”

Equipped with reliable information on low-value care services and alternative treatments, providers and their patients can jointly decide on the most effective treatment course. As a result, providers either save money by reducing low-value care use or by providing personalized care that could prevent adverse, costly health outcomes.

Cedars-Sinai also aims to reduce low-value care by providing clinicians with feedback on their low-value care use in comparison to their colleagues.

In the four years since the health system targeted low-value care, Weingarten has seen providers start to better understand how the care they deliver impacts value.

“We see orders that are canceled after the provider views clinical decision support,” he said. “So, we know an order was placed, the physician or provider was alerted, and they canceled the order.”

“But more importantly, we can observe an educational effect,” he continued. “The provider knows if they order low-value care that they’re going get an alert, and if it pops up enough times, they know they’re going get feedback. If they agree with the evidence and the sub-specialty physician guidelines, you see the frequency of ordering low-value tests and treatment decrease.”

As low-value care use falls, the health system is finding that all their patients are experiencing improved care delivery and, subsequently, costs are falling.

“There always will be some low-value care, it is impossible to eliminate all low-value care because we have to take into account patient preferences and not all patients are the same,” Weingarten concluded. “We have to respect differences. But I believe that it’s possible to significantly reduce low-value care and thereby improve quality of care, improve patient outcomes, and reduce costs.”