Low-Value Services Given to Many Medicare Patients

Marcia Frellick

May 13, 2014

Medicare spent $1.9 billion in 2009 on procedures considered to be of little to no value to patients, according to researchers' analysis of claims data.

Aaron Schwartz, BA, from the Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, and colleagues developed 26 measures of potentially wasteful tests and found that between 25% and 42% of almost 1.4 million Medicare beneficiaries they studied had received at least one of them.

The study was published online May 12 in JAMA Internal Medicine.

Authors considered tests that have been deemed to be of low value by the American Board of Internal Medicine Foundation's Choosing Wisely initiative, the US Preventive Services Task Force "D" recommendations, the National Institute for Health and Care Excellence "do not do" recommendations, the Canadian Agency for Drugs and Technologies in Health Assessments, and peer-reviewed medical literature.

Among the potentially wasteful tests were cervical cancer screening for women aged 65 years and older, computed tomography scanning of the sinuses for acute rhinosinusitis (inflammation of the sinuses), preoperative stress testing, back imaging for patients with low back pain, and prostate-specific antigen testing for men aged 75 years and older.

The low-value services accounted for 0.6% to 2.7% of overall spending, depending on the level of sensitivity in the measure, but the authors say their findings may be representative of a much bigger problem. They used a narrower definition of wasteful services because defining "wasteful" may be different, depending on the patient and circumstances. For instance, lower back imaging is of little use for general muscle soreness but can be lifesaving if used to identify cancer or a spinal abscess.

The researchers excluded some tests deemed of low value, such as imaging for pulmonary embolism without moderate or high pretest probability, because of the difficulty in separating inappropriate from appropriate in claims data, the researchers said.

The study did not identify specific determinants of wasteful care, but the authors calculate that using a broader definition, potentially wasteful measures added up to $8.5 billion.

"We suspect this is just the tip of the iceberg," lead author J. Michael McWilliams, MD, PhD, associate professor of health care policy from the Department of Health Care Policy, Harvard Medical School, and the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, said in a statement.

This large-scale study's tools for identifying and monetizing waste can be used in evaluating the effectiveness of reform efforts such as the Affordable Care Act, the authors say.

Previous attempts to measure waste in Medicare and other health systems have relied on comparing spending rates among matched patient populations in different geographical areas.

In an accompanying editor's note, JAMA Internal Medicine Deputy Editor Mitchell H. Katz, MD, and colleagues write: "This article highlights the opportunity for eliminating unnecessary care, and we hope that others will use and improve the methods developed by the authors. Most important, we hope that development of better measures of low-value care will ultimately spur development of interventions to reduce unnecessary care."

This study was supported by the Beeson Career Development Award Program, National Institute on Aging, American Federation for Aging Research, Doris Duke Charitable Foundation, Agency for Healthcare Research and Quality Institutional Training, and Australian National Health and Medical Research Council Sidney Sax Public Health Fellowship. One author has reported he is a partner in VBID Health, LLC, which has a contract with Milliman to develop and market a tool to help insurers and employers quantify spending on low-value services. Another author has reported he provides advice to the Australian Government Department of Health on policy responses to low-value healthcare. The other authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online May 12, 2014. Abstract

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