and Reducing Overuse Task Force on Low-Value Care April 27, 2017 - - PowerPoint PPT Presentation
Defining, Measuring, and Reducing Overuse Task Force on Low-Value Care April 27, 2017 Outline Defining waste (and its several varieties) (1) Significance of waste and overuse (2) Examples of overuse (3) Reducing overuse: what works? (4)
Task Force on Low-Value Care April 27, 2017
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(1) (2) (3) (4)
deliver benefits
expensive alternatives with identical or better benefits
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DEFINING WASTE
Administrative Waste
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Bentley TGK, Effros RM, Palar K, Keeler EB. Waste in the U.S. Health Care System: A Conceptual Framework. Milbank Q. 2008;86(4):629-659.
DEFINING WASTE
Administrative Waste Operational Waste
delivery
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Bentley TGK, Effros RM, Palar K, Keeler EB. Waste in the U.S. Health Care System: A Conceptual Framework. Milbank Q. 2008;86(4):629-659.
DEFINING WASTE
Administrative Waste Operational Waste
related
management
delivery
inputs
Clinical Waste
deliver net benefit (overtreatment)
benefit over less costly alternatives
benefit, but does not meet standards of cost-effectiveness
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Bentley TGK, Effros RM, Palar K, Keeler EB. Waste in the U.S. Health Care System: A Conceptual Framework. Milbank Q. 2008;86(4):629-659.
DEFINING WASTE
Waste Clinical Waste Overuse
Clinical Waste
deliver net benefit (overtreatment)
benefit over less costly alternatives
benefit, but does not meet standards of cost-effectiveness
Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516.
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DEFINING WASTE
Waste Clinical Waste
(a) Overuse
(b) Overuse of treatment (c) Treatment of over- diagnosed disease
Morgan DJ, Dhruva SS, Wright SM, Korenstein D. 2016 update on medical overuse: a systematic review. JAMA Intern Med. 2016;176(11):1687-1692.
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DEFINING WASTE
extrapolating from:
SIGNIFICANCE
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The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, D.C.: National Academies Press; 2010.
Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516.
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SIGNIFICANCE
Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012;307(14):1513-1516.
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SIGNIFICANCE
EXAMPLES OF OVERUSE
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US Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening.
Percent of Male Medicare FFS Beneficiaries Age 75+ With Screening PSA Test (2014) National Average: 18.2%
EXAMPLES OF OVERUSE
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Dartmouth Atlas of Health Care. Screening PSA Tests. http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=72. US Preventive Services Task Force. Final Recommendation Statement: Prostate Cancer: Screening. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening.
% % %
20% 28% 34% 36% 41% 42% 46% 48% 49% 51% 56% 62% 64% 66% 67% 73% 74% 75% 78% 83% 84% 85% 87% 91% 97% 80% 72% 66% 64% 59% 58% 54% 52% 51% 49% 44% 38% 36% 34% 34% 27% 26% 25% 22% 17% 16% 15% 13% 9% 3%
25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
VA System
Adherence to Colonoscopy Interval Guidelines in 25 VA Systems
Share of Patients with Guideline-Concordant Care Share of Patients with Care Not Guideline-Concordant
Screened Too Soon (95%)
EXAMPLES OF OVERUSE
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Johnson MR, Grubber J, Grambow SC, Maciejewski ML, Dunn-Thomas T, Provenzale D, Fisher DA. Physician non-adherence to colonoscopy interval guidelines in the veterans affairs healthcare system. Gastroenterology. 2015;149(4):938-951.
Distribution Of Cesarean Rates in US Hospitals Among Lower-Risk Pregnancies (2009)
EXAMPLES OF OVERUSE
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Kozhimannil KB, Law MR, Virnig BA. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality and Cost Issues. Health Aff. 2013;32(3):527-535.
societies
recommendations
MEASURING OVERUSE
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American Board of Internal Medicine Foundation, Consumer Reports. Choosing Wisely Infographic. http://www.choosingwisely.org/wp-content/uploads/2017/04/Choosing-Wisely-Infographic-Update0317.pdf. Published April 2017.
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Milliman and VBID Health. MedInsight Health Waste Calculator. http://vbidhealth.com/docs/Health-Waste%20Calculator-VBID.pdf
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MEASURING OVERUSE
9.6% 23.0% 14% 38%
Commercial Peds (2014) Commercial Adults (2013) Medicare FFS (2013)
Share of Population Receiving 1+ Choosing Wisely (or Similar) Service, Per Year
More Specific More Sensitive 11.4%
MEASURING OVERUSE
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Charlesworth CJ, Meath THA, Schwartz AL, McConnell KJ. Comparison of Low-Value Care in Medicaid vs Commercially Insured Populations. JAMA Intern Med. 2016;176(7):998-1004. Chua K-P, Schwartz AL, Volerman A, Conti RM, Huang ES. Use of Low-Value Pediatric Services Among the Commercially Insured. Pediatrics. November 2016:e20161809. Medicare Payment Advisory Commission. Health Care Spending and the Medicare Program: A Data Book.; 2016. http://www.medpac.gov/docs/default-source/data-book/ june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0. Accessed April 11, 2017.
$2.6 $7.1
Medicare FFS (2013)
Population-Level Cost of Choosing Wisely (or Similar) Services, Per Year (Billions)
More Specific More Sensitive 20
Medicare Payment Advisory Commission. Health Care Spending and the Medicare Program: A Data Book.; 2016. http://www.medpac.gov/docs/default-source/data-book/ june-2016-data-book-health-care-spending-and-the-medicare-program.pdf?sfvrsn=0. Accessed April 11, 2017.
MEASURING OVERUSE
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Schwartz AL, Zaslavsky AM, Landon BE, Chernew ME, McWilliams JM. Low-Value Service Use in Provider Organizations. Health Serv Res. November 2016.
100 200 300 400 500
21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99 102 105
Number of Provider Organizations Low-Value Services per 100 Medicare Beneficiaries
Distribution of Provider Organizations by Count of Low-Value Services Delivered per Medicare Beneficiary Per Year
20 40 50 60 80 100 90 70 30
MEASURING OVERUSE
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Errors and Sub-optimal Decision- Making Poor Organization and Coordination Poor Incentives for Providers and Consumers Intentional Deception
Unintentional Deliberate 23
ADDRESSING OVERUSE
Provider-Facing Interventions (Supply) Incentives P4P Prior authorization Risk sharing (ACOs, bundles, etc.) Information Clinical decision support Clinician education Clinician feedback Patient-Facing Interventions (Demand) Incentives Cost-sharing Value-based Insurance Design (V-BID) Information Patient education Provider report cards
ADDRESSING OVERUSE
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Colla CH. Swimming against the Current — What Might Work to Reduce Low-Value Care? New England Journal of Medicine. 2014;371(14):1280-1283.
Intervention Choosing Wisely Campaign Population 29 million commercially insured Americans Measures Use of x-ray, MR, and CT imaging associated with visits for low-back pain Key Findings
decrease)
Notes
ADDRESSING OVERUSE
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Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low-Value Back Imaging Associated With The “Choosing Wisely” Campaign, 2012–14. Health Aff. 2017;36(4):671-679.
ADDRESSING OVERUSE
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Hong AS, Ross-Degnan D, Zhang F, Wharam JF. Small Decline In Low-Value Back Imaging Associated With The “Choosing Wisely” Campaign, 2012–14. Health Aff. 2017;36(4):671-679.
$10,301 $9,842
$- $2,000 $4,000 $6,000 $8,000 $10,000 $12,000
Baseline (2009-2011) Pioneer Y1 (2012) Differential Change in Spending on Low-Value Services Per 100 Beneficiaries
Intervention Pioneer ACO participation Population Medicare FFS beneficiaries Measures 31 claims-based measures of CW-type services Key Findings Significant differential reductions of:
services Notes
historically high rates of low-value care
ADDRESSING OVERUSE: SUPPLY
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Schwartz AL, Chernew ME, Landon BE, McWilliams JM. Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program. JAMA Intern Med. 2015;175(11):1815-1825.
ADDRESSING OVERUSE: SUPPLY
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Weingarten S. Evidence Based Medicine. Published March 17, 2017. https://www.youtube.com/watch?v=jMo0YEYVo4w. Weingarten S. Reducing Unnecessary Tests and Treatments via E-Alerts at Cedars-Sinai. https://www.hfma.org/leadership/choosingwisely/. Published January 27, 2015.
Intervention Alerts in EHR for 180 Choosing Wisely services Population Patients of Cedars Sinai Measures Ordering of CW services Key Findings
from 8%-27%
Notes
0%
Opioid/Butalbital in Migraine Vitamin D Screening RBC Units in Transusions Antispychotics in Dementia Benzodiazepines for Pts 65+Changes in Ordering Associated with Implementation of Decision Support
Opioid/Butalbital in Migraine Vitamin D Screening RBC Units in Transfusions Antipsychotics in Dementia Benzodiazepines for Patients 65+
ADDRESSING OVERUSE: SUPPLY
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Weingarten S. Evidence Based Medicine. Published March 17, 2017. https://www.youtube.com/watch?v=jMo0YEYVo4w. Weingarten S. Reducing Unnecessary Tests and Treatments via E-Alerts at Cedars-Sinai. https://www.hfma.org/leadership/choosingwisely/. Published January 27, 2015.
17 20 55 42 35 26 34 73 61 59
20 40 60 80
Total Calcium Ionized Calcium Chloride Magnesium Phosphorus
Tests Ordered/1,000 Patient Days Pre Post
Intervention
frequently overused laboratory tests
residents tied to appropriate use Setting Large academic medical center Measures Laboratory tests ordered Key Findings
targeted tests
Notes
ADDRESSING OVERUSE: SUPPLY
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Han SJ, Saigal R, Rolston JD, Cheng JS, Lau CY, Mistry RI, McDermott MW, Berger MS. Targeted Reduction in Neuro-surgical Laboratory Utilization: Resident-Led Effort at a Single Academic Institution. J Neurosurg. 2014;120(1):173-177.
Tests Ordered/1,000 Patient Days
for high-value services
assessing V-BID for low-value services
ADDRESSING OVERUSE: DEMAND
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Intervention
for specialty care office visits
unchanged Population Employees of Mayo Clinic Measures Use of specialty visits, imaging, and
Key Findings
sustained after four years Notes
0%
Specialty OVs Imaging ProceduresObserved Changes in Utilization Relative to Expected Changes
ADDRESSING OVERUSE: DEMAND
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Shah ND, Naessens JM, Wood DL, Stroebel RJ, Litchy W, Wagie A, Fan J, Nesse R. Mayo Clinic Employees Responded To New Requirements For Cost Sharing By Reducing Possibly Unneeded Health Services Use. Health Affairs. 2011;30(11):2134-2141.
Specialty Office Visits Imaging Procedures
Intervention Contact with coaches offering shared decision making Population Patients with any of 6 preference- sensitive conditions Measures Claims Key Findings Significant reductions in:
Notes
$5,233 $4,953
$- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000
Usual Care Enhanced Support
Annual Medical Costs
ADDRESSING OVERUSE: DEMAND
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Veroff D, Marr A, Wennberg DE. Enhanced Support For Shared Decision Making Reduced Costs Of Care For Patients With Preference-Sensitive Conditions. Health Aff. 2013;32(2):285-293.
Intervention Exposure to messaging on low-value care Population Survey panel Measures Preferences for hypothetical clinician Key Findings Only one message – emphasizing threat of harm from overuse – led to statistically significant changes in preferences Notes
benefits to individual, not benefit to society
changes in mock clinician choice
35% 39% 46% 41%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Type of Messaging Presented
Prefer Clinician Who Avoids Low-Value Care (Percent)
ADDRESSING OVERUSE: DEMAND
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Schlesinger M, Grob R. Treating, Fast and Slow: Americans’ Understanding of and Responses to Low-Value Care. The Milbank Quarterly. 2017;95(1):70-116. .
ADDRESSING OVERUSE
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MacColl Center for Health Care Innovation Taking Action on Overuse Framework https://takingactiononoveruse.org National Alliance of Healthcare Purchaser Coalitions Choosing Wisely Employer Toolkit http://www.nationalalliancehealth .org/choosing-wisely-employer- toolkit American Board of Internal Medicine Foundation/Consumer Reports Choosing Wisely Resource Directory http://www.choosingwisely.org/re sources Washington Health Alliance Statewide Choosing Wisely Task Force http://wahealthalliance.org/allianc e-reports-websites/choosing- wisely/washington-state-choosing- wisely-task-force/