Usually, more is better than less. However, in terms of healthcare, the opposite is often true. More healthcare is not necessarily better healthcare…in fact, it’s the other way around. The concept of low-value care is not a new one, it is something we in the healthcare field have been wrangling with for years. Also not new is the concept of focusing on quality rather than quantity. In other words, generating less care that is also of higher value, with a heightened focus on ensuring patient health and improved outcomes.

According to the LOWN Institute, a nonpartisan think tank advocating bold ideas for a just and caring system for health, as much as one-third of annual healthcare spending in the U.S. is wasted. That is a significant driver of increased out-of-pocket costs and impacts the sustainability of our healthcare system. Low-value care is a significant portion of that tremendous waste, estimated to be in the range of $100-$700 billion per year. And unlike certain types of healthcare, such as maternal care which I discussed last month, the pervasiveness of low-value care affects ALL patients, regardless of income, race, class, or insurance status.

There are many examples of low-value care, like unnecessary or ineffective procedures, tests, scans, and medications; repeated lab tests; and elective surgeries that could be avoidable. In extreme situations, this care can cause physical harm to patients, in addition to wasting money and resources. A fee-for-service payment model is another driver of low-value care, rewarding quantity instead of quality. Insurers like BCBSRI are working to create a fee-for-value model to try to reduce unnecessary care.

Our prior authorization data regularly shows us things like repeated surgeries, pre-op testing for minor surgeries (which is usually unnecessary), and many others. We believe it’s a systemic issue that should be addressed more. For example, rather than overprescribing medications, overtreatment, overscreening, or overuse of healthcare, why not focus on proven, effective behaviors such as eating better, exercising, losing weight, and quitting smoking – all of which would help reduce a myriad of health issues?

It is possible though to reduce utilization by addressing it specifically. Two years ago, we entered an education-based, alternative payment model partnership with Spine Care Partners and Lifespan (Lifespan Physician Group and Community Physician Partners) whereby 100% of Lifespan PCPs participated and went through training for appropriate back injury care. The focus was on adherence to evidence-based care guidelines, and we saw a significant decrease (nearly 13%) in imaging and treatments for back pain.

As a healthcare provider, how do you recognize low-value care? One of the most trusted sources to refer to for recommendations about potentially unnecessary tests, screenings, or procedures is Choosing Wisely®, an initiative launched in 2012 by the ABIM Foundation. We also recommend Choosing Wisely to our members as a resource for questions to ask their providers before getting any test, treatment, or procedure, or about any medications they are prescribed.

There are many good reasons why guidelines about low-value care may not always be followed. For example, the clinical situation and the potential for complications could be factors. But the important takeaway is that there are instances where care is not appropriate and should be recognized as waste. Patients should feel empowered to ask questions about their care, and as providers, you should welcome these questions. Health plans, providers, and patients all need to work together to recognize this trend and work together to reduce the amount of low-value care in the system. It benefits all of us.

Another critical piece of this for providers is responding to the opportunity to drive change and improve the value of healthcare they provide by helping to redesign it themselves using data, metrics, and other information available to them. Using performance improvement in hospitals and health settings is helping respond to unnecessary tests, treatments, and other care by integrating evidence-based, clinical decision support guidance and educational campaigns into their systems and workflows. Motive Practicing Wisely Solutions is a great resource to learn more about using best practices and evidence-based guidance to help create higher-quality care, less waste, and lower costs.

In August, we observe National Immunization Awareness Month, National Breastfeeding Month, and Summer Sun Safety Month. As always, thank you for your partnership and all you do to help our members stay safe and healthy.