Low-Value Health Care Services in a Commercially-Insured Population [PDF]

SLIDE 1

Low-Value Health Care Services in a Commercially-Insured Population

Academy Health Annual Research Meeting – June 28, 2016

Rachel O. Reid, MD, MS1,2; Brendan Rabideau, BA3; Neeraj Sood, PhD3,4

1RAND Corporation; 2Division of General Internal Medicine and Primary Care, Brigham and

Women’s Hospital; 3Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California; 4Department of Health Policy and Management, Sol Price School of Public Policy, University of Southern California

SLIDE 2

Background: Waste in the US Health Care System is Both Common and Expensive

$750 billion of US health care spending annually is waste
$200 billion is for overtreatment or overuse
Reducing waste
Decrease spending while improving quality and access
Championed by providers, policymakers, payers and patients
Choosing Wisely campaign and other initiatives

SLIDE 3

Background: Direct Assessments of Waste in Health Care are Needed

Indirect assessments of spending on waste

Based on geographic variation in spending Provide scale of problem Cannot directly inform improvement

Direct assessments of wasteful, low-value services

Important to understand

pportunities for improvement

Have focused on

Medicare
Narrow set of measures
Limited geographic area

SLIDE 4

Design: Retrospective Analysis of Commercial Insurance Claims

Aim: : Assess utilization of and spending on set of low-value health care services in a large, national commercially insured population

Design: n:

Retrospective analysis of

commercial insurance claims

Assessed care received in 2013

Data: a:

25% random sample of Optum

Cliniformatics Datamart

2011 to 2013

Cohor

rt:
Patients aged 18-64
Continuously enrolled in 2013

SLIDE 5

Analyses: Employed 28 Published Low-Value Health Care Service Measures

Cardio iovas ascu cula lar Testin ing and Proced edures es

Carotid endarterectomy

for asymptomatic adults

IVC filters to prevent PE
Percutaneous coronary

intervention for stable coronary artery disease

Renal artery

angioplasty or stent

Screening for carotid

artery disease for syncope

Screening for carotid

artery disease in asymptomatic adults

Stress testing for stable

coronary artery disease Diagnostic stic and Preven entiv ive e Testin ing

1,25-OH Vitamin D

testing without hypercalcemia or CKD

Homocysteine testing

in cardiovascular disease

HPV testing younger

than 30

Hypercoagulable

testing for VTE

Imaging for adnexal

cysts

PTH test for stage I-III

CKD

T3 testing for

hypothyroidism Head and Neurolo logic ic Testin ing

EEG for headaches
Head imaging for

syncope

Head imaging for

uncomplicated headache

Sinus CT for

uncomplicated acute rhinosinusitis Musculo loske skelet letal al Testin ing and Proced edures es

Arthroscopic surgery

for knee osteoarthritis

Frequent bone density

testing

Imaging for nonspecific

low back pain

Imaging for plantar

fasciitis

Spinal injection for

lower-back pain

Vertebroplasty or

kyphoplasty for

steoporotic vertebral

fractures Preoper erat ativ ive e Testin ing

Chest radiography
Echocardiography
Pulmonary Function

Testing

Routine Stress Tests

SLIDE 6

Analyses: Measuring Low-Value Utilization and Spending in Study

Utilization
Unique patients receiving each low value service in 2013
Spending
Patients 2013 standardized costs for each service
Accounting for spending on related services and procedures
Winsorized at 5th and 95th percentile to reduce impact of outliers

SLIDE 7

Analyses: Regression Analysis to Predict Disproportionate Low-Value Service Spending

Outcome
Low-value spending per

$10,000 in total spending

Regression: 2 Part-Model

1. Probit

Estimate probability of any low-

value spending

2. GLM (γ-distribution, log link function)

Estimate low-value spending per

$10,000 in overall spending

Conditional on having any low

value spending

Adjusting for:
Patient characteristics
Age
Sex
Race
Household Income
Census Division
Plan Characteristics
Health Plan Type
i.e., EPO, HMO, POS, PPO
CDHP Options
i.e., High-Deductible plan with

HRA or HSA

SLIDE 8

Results: Low-Value Service Utilization and Spending in Commercially Insured Patients

Patients in Study Cohort: 1,468,689 Overall Medical Spending: $6.6 Billion

SLIDE 9

Results: Low-Value Service Utilization and Spending in Commercially Insured Patients

Patients Receiving Low-Value Services: 114,732 (7.8%) Patients in Study Cohort: 1,468,689 Overall Medical Spending: $6.6 Billion Low-Value Service Spending: $32.8 Million (0.5%)

SLIDE 10

Results: Low-Value Service Utilization and Spending in Commercially Insured Patients

Cardiovascular 9,007 (0.6%) Diagnostic/Preventive 49,743 (3.4%) Head and Neurologic 20,194 (1.4%) Musculoskeletal 33,028 (2.3%) Preoperative 11,550 (0.8%)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pati atients ents Sp Spen endin ing

Patients Receiving Low-Value Services: 114,732 (7.8%) Patients in Study Cohort: 1,468,689 Overall Medical Spending: $6.6 Billion Low-Value Service Spending: $32.8 Million (0.5%)

SLIDE 11

Results: Low-Value Service Utilization and Spending in Commercially Insured Patients

Cardiovascular 9,007 (0.6%) Cardiovascular $5.5 Million (16.8%) Diagnostic/Preventive 49,743 (3.4%) Diagnostic/Preventive $4.0 Million (12.2%) Head and Neurologic 20,194 (1.4%) Head and Neurologic $5.2 Million (15.9%) Musculoskeletal 33,028 (2.3%) Musculoskeletal $16.8 Million (51.1%) Preoperative 11,550 (0.8%) Preoperative $1.3 Million (4.0%)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pati atients ents Sp Spen endin ing

Patients Receiving Low-Value Services: 114,732 (7.8%) Patients in Study Cohort: 1,468,689 Overall Medical Spending: $6.6 Billion Low-Value Service Spending: $32.8 Million (0.5%)

SLIDE 12

Results: Low-Value Services Accounting for Most Utilization and Spending

Most Commonly Received Low-Value Services

T3 measurement in hypothyroidism

1.5%

Imaging for nonspecific low back pain

1.3%

Imaging for uncomplicated headache

1.0%

Low-Value Services with Greatest Spending

Spinal injection for lower-back pain

$12.1 million (37.0%)

Imaging for uncomplicated headache

$3.6 million (11.0%)

Imaging for nonspecific low back pain

$3.1 million (9.4%)

SLIDE 13

Regression Results: Older, Male, Non-White, Low-Income have Less Low-Value Spending

$20.42**
$11.30**
$18.19**
$3.81**

$0.08

$4.40*

$1.89

$9.12**
$7.42**
$8.10**
$5.25**
$5.12**
$3.35**
$25
$20
$15
$10
$5

$0 $5 $10 $15

Low-Value Service Spending per $10k in T

tal Spending

*p<0.05, **p<0.001

SLIDE 14

Regression Results: Selected Regions and CDHPs have Less Low-Value Spending

$8.01** $11.92** $10.10**

$3.19 -$4.60**

$12.66** $2.35 $14.26** $6.10* $0.98 $2.30

$2.73*
$5.86**
$25
$20
$15
$10
$5

$0 $5 $10 $15

Low-Value Service Spending per $10k in T

tal Spending

SLIDE 15

Summary

In commercially-insured population, found
Modest use of low-value services assessed
Considerable corresponding savings
Compared to prior assessments of low-value services
Comparable care patterns
Similar regional variation
Younger, healthier population
Key groups have disproportionate low-value spending

SLIDE 16

Limitations

Cross-sectional analysis
Direct measures of low-value care can be:
Over-inclusive
Potentially capture instances where care was high-value
Minimized by using narrow, specific measure definitions
Under-inclusive
Set of measure can only address small fraction of all low-value care

delivered and predictors of spending on other service may differ

Minimized by using a broad list of measures across multiple

specialties, settings, and care types

SLIDE 17

Policy Implications

Higher-income and white patients have greater

proportionate spending on low-value services

Could represent reverse disparities
Disparities contribute to waste in 2 ways, both warrant attention
CDHP enrollees less proportionate spending on low value

services

Insurance benefit design could facilitate reduced overuse
However, finding should be weighed against potential for

selection bias and parallel reductions in high-value care

SLIDE 18

Conclusions

Efforts to reduce waste in health care may be bolstered by
Measure development efforts that focus on overtreatment
Insurance benefit designs that discourage overuse
Programs targeting groups and regions at risk of low-value care

SLIDE 19

Acknowledgements

This work was funded by grants from the National Institutes of Health and from the Leonard D. Schaeffer RAND-USC Initiative in Health Policy and Economics.

Thank you! rreid@rand.org

SLIDE 20

Pa Patien ents ts Spending ng

All l Pa Patie ient nts s and d Spend ending ing 1,468,689 $6.6 Billion Patients Reveiving % Patients Low-Value Spending % Low-Value Spending % Overall Spending All l Low-Valu alue e Service vices 114,732 7.81 $32.8 Million

0.50

Preop

per

erat ativ ive e Testin ting 11,500 0.79 $1.3 Million 3.97 0.02 Muscu sculosk loskele eletal al Testin ting g and Proce

cedur

ures es 33,028 2.25 $16.8 Million 51.09 0.25 Head ad and d Neurolo

logic

gic Testing ing 20,194 1.37 $5.2 Million 15.87 0.08 Diagno gnostic tic and Preve eventive tive Testin ting 49,743 3.39 $4.0 Million 12.24 0.06 Cardio diovasc ascula ular Testin ting g and Proce

cedu

dures res 9,007 0.61 $5.5 Million 16.83 0.08

SLIDE 21

Cardio diovasc ascula ular Testin ting g and Proce

cedu

dures res Pts s (10k) 0k) $100k’ ’s % Carot

tid

id endar artere erect ctom

my

y for asym ymptom

mat

atic ic adult ults Carotid endarterectomy, not associated with ED visit, for female patients without history of stroke or TIA and without stroke, TIA, or focal neurologic symptoms in claim 0.1 2.7 0.8 1 IVC VC filter ers s to preve event nt PE PE Any IVC filter placement 1.6 4.4 1.3 6 Pe Percut cutan aneou eous s coron

nar

ary y inter erven ventio tion n for stable ble coron

nary

y arter ery y disea sease se Coronary stent placement or balloon angioplasty, not associated with ED visit, for patients with established diagnosis of acute myocardial infarction (≥3 mo before) 0.6 19.7 6.0 1 Re Rena nal l artery y angiop ioplas lasty ty or stent nt Renal/visceral angioplasty or stent placement with renal atherosclerosis or renovascular hypertension diagnosis in procedure claim 0.2 4.8 1.4 5 Screen eening ing for carot

tid

id arter ery y disea sease se for syncop cope Carotid imaging with syncope diagnosis for patients without stroke or TIA history, and without diagnosis of stroke, TIA, or focal neurologic symptoms in claim 5.2 1.4 0.4 3 Screen eening ing for carot

tid

id arter ery y disea sease se in asym ymptom

matic

tic adult ults Carotid imaging with syncope diagnosis for patients without stroke or TIA history, and without diagnosis of stroke, TIA, or focal neurologic symptoms in claim 51.6 19.2 5.8 4 Stres ress s testin ting for stab able le coron

nary

y arter ery y disea sease se Stress test not associated with inpatient or ED care for patients with an established diagnosis of acute myocardial infarction (≥3 mo before) 3.1 3.0 0.9 2

SLIDE 22

Diagno gnostic tic and Preve eventive tive Testin ting Pts s (10k) 0k) $100k’ ’s % 1,25 25-OH H Vitam amin in D testing ing witho hout ut hy hype percal calcemi cemia a or CKD KD Calcitriol test without hypercalcemia, secondary hyperparathyroidism, or

ther hypercalcemia condition (sarcoidosis, TB, or selected neoplasms) in

claim, or CKD history; no hypercalcemia diagnosis in past 30d 46.7 5.5 1.6 7 Homo mocys cystein eine e testi ting ng in cardiovas diovascular cular disease sease Homocysteine test with no diagnoses of folate or vitamin B12 deficiencies in claim and no folate or vitamin B12 test in prior claims 51.9 2.8 0.8 5 HPV V testin ting g younge nger r than 30 30 HPV test in female patients younger than age 30 91.5 17.4 5.3 Hype yperco coagu agulab lable le testing ing for VTE Hypercoagulable state laboratory test within 30d after lower extremity DVT

r PE diagnosis; no evidence of recurrent thrombosis (i.e., DVT or PE

diagnosis >90 d before claim) 0.7 0.2 0.0 5 Imagin ging g for adne nexal xal cysts ts 2 or more echography procedures within 60d of primary diagnosis of adnexal cyst 14.2 4.0 1.2 2 PTH H test for stage ge I-III II CKD KD PTH test for CKD; no dialysis services before or ≤30 d after test, no hypercalcemia diagnosis during year 15.0 2.1 0.6 4 T3 T3 testing ting for hy hypo poth thyr yroid

idism

ism Total or free T3 measurement in patient with hypothyroidism diagnosis during year 154.1 8.2 2.5 1

SLIDE 23

Head ad and d Neurolo

logic

gic Testing ing Pts s (10k 0k) $100k’ ’s % EEG EEG for heada daches hes EEG with headache diagnosis in claim, and no epilepsy or convulsions in current or prior claims 2.0 1.8 0.5 5 Head ad imagi aging g for synco ncope pe Head CT or MR imaging with syncope diagnosis and no diagnoses in claim warranting imaging 99.5 36.2 11. 05 Head ad imagi aging g for uncom

mplica

licated ed heada dache he Brain CT or MR imaging with non-posttraumatic, non-thunderclap headache diagnosis, and no diagnoses in claim warranting imaging 13.1 3.0 0.9 3 Sinus us CT for uncom

mplica

licated ed acute e rhino nosin sinusit usitis is Maxillofacial CT with sinusitis diagnosis and no sinusitis complications, immune deficiencies, nasal polyps, or head/face trauma in claim and no sinusitis diagnosis 30-365 d before imaging 28.1 11.0 3.3 4

SLIDE 24

Musculosk sculoskele eletal al Testing ting and Proced

cedur

ures es Pts s (10k 0k) $100k’ ’s % Arthr hrosc

scop
pic

ic surger gery y for knee e osteoa eoarth thrit ritis is Knee arthroscopic debridement or chondroplasty with osteoarthritis or chondromalacia diagnosis in procedure claim and no meniscal tears in procedure claim 0.5 6.7 2.03 Frequ quent ent bone ne densit nsity y testin ting Bone density test within 2y of prior bone density test, with established

steoporosis diagnosis

9.0 0.9 0.28 Imagin ging g for nonsp specif ecific ic low back k pain in Back imaging with low back pain diagnosis occurring within 6 wk of initial back pain diagnosis and no diagnoses in claim warranting imaging 126.4 30.7 9.36 Imagin ging g for plan antar ar fasciit ciitis is3 Radiographic or MR imaging with plantar fasciitis diagnosis within 2w of initial diagnosis 53.1 6.6 2.02 Spina inal l inject ectio ion n for lower er- back k pain Outpatient epidural, facet, or trigger point injections for low back pain, excluding etanercept; no radiculopathy diagnoses in claim 42.5 121.3 37.0 1 Verteb ebrop

plas

lasty ty or

r

kyph phop

plas

lasty ty for

steop

eoporot

tic

ic verteb ebral al fract ctur ures es Vertebroplasty or kyphoplasty for vertebral fracture; no bone cancers, myeloma, or hemangioma in procedure claim 0.04 1.3 0.39

SLIDE 25

Preop

per

erat ativ ive e Testin ting Pts s (10k 0k) $100k’ ’s % Chest t radiogr diograph aphy Chest radiograph not associated with inpatient or ED care, ≤30d before low/intermediate risk non-cardiothoracic surgery 67.8 2.8 0.8 5 Echoca

cardiog

iograp aphy Echocardiogram not associated with inpatient or ED care, ≤30d before low/ intermediate-risk non-cardiothoracic surgery 8.3 3.1 0.9 5 Pulm lmon

nar

ary y Fu Functio ction n Testing ing PFT not associated with inpatient or ED care, ≤30d before low/intermediate- risk surgery 3.8 0.4 0.1 1 Ro Rout utine ine Stres ress s Tests Stress EKG, echocardiogram, or nuclear imaging, not associated with inpatient or ED care, ≤30d before low/intermediate-risk non-cardiothoracic surgery 7.4 6.7 2.0 5

SLIDE 26

Average Margin inal Effect Characteris istic ic Low-Value Spending per capita ($) p Low-Value Spending per $10,000 in Total Spending ($) P Age Age 18-34 (ref)

-
-
35-49

7.85 (6.95, 8.75) <0.001

20.42 (-22.03, -18.81)

<0.001 50-64 21.59 (20.39, 22.79) <0.001

11.30 (-12.94, -9.66)

<0.001 Sex Sex Female (ref)

-
-
Male
7.90 (-8.84, -6.96)

<0.001

18.19 (-19.34, -17.03)

<0.001 Race Ethnicit ity White (ref)

-
-
Black
3.02 (-4.49, -1.55)

<0.001

3.81 (-5.68, -1.95)

<0.001 Hispanic

1.09 (-2.65, 0.47)

0.172 0.08 (-1.89, 2.05) 0.935 Asian

8.43 (-10.12, -6.74)

<0.001

4.40 (-7.23, -1.57)

0.002 Unknown

0.36 (-2.77, 2.05)

0.767 1.89 (-1.15, 4.94) 0.223 Household ld Income Unknown

0.66 (-2.14, 0.81)

0.377

9.12 (-10.87, -7.36)

<0.001 <$40k 0.89 (-0.81, 2.59) 0.304

7.42 (-9.39, -5.46)

<0.001 $40-$49K

0.55 (-2.61, 1.52)

0.603

8.10 (-10.55, -5.66)

<0.001 $50-59K 2.08 (-0.08, 4.24) 0.059

5.25 (-7.69, -2.81)

<0.001 $60-$74K

1.06 (-2.67, 0.55)

0.198

5.12 (-7.18, -3.06)

<0.001 $75-$99K 0.60 (-0.82, 2.02) 0.407

3.35 (-5.12, -1.58)

<0.001 $100K+ (Ref)

-
-
Census Divis

isions East North Central (ref)

-
-
East South Central

4.83 (1.79, 7.86) 0.002 8.01 (4.68, 11.33) <0.001 Middle Atlantic 4.94 (2.75, 7.14) <0.001 11.92 (9.40, 14.45) <0.001 Mountain 1.55 (-0.34, 3.43) 0.108 10.10 (7.77, 12.42) <0.001 New England

3.88 (-6.50, -1.27)

0.004

3.19 (-6.48, 0.09)

0.057 Pacific

5.02 (-6.80, -3.24)

<0.001

4.60 (-6.81, -2.39)

<0.001 South Atlantic 2.07 (0.56, 3.59) 0.007 12.66 (10.83, 14.48) <0.001 West North Central

1.67 (-3.50, 0.16)

0.074 2.35 (0.10, 4.61) 0.040 West South Central 7.35 (5.50, 9.22) <0.001 14.26 (12.17, 16.35) <0.001 Healt lth Plan Product Type Exclusive Provider Organization 0.54 (-3.15, 4.23) 0.773 6.10 (1.98, 10.21) 0.004 Health Maintenance Organization

3.11 (-6.93, 0.71)

0.111 0.98 (-3.37, 5.33) 0.659 Point of Service or Other

1.54 (-5.00, 1.91)

0.382 2.30 (-1.51, 6.10) 0.237 Preferred Provider Organization or Indemnity (ref)

-
-
Consumer Directed Healt

lth Plan No HRA/HSA (ref)

-
-

SLIDE 27

Assessing CPT Codes for 95% of Allowed Costs Captured in Spinal Injection Measure:

Codes Directly Related to Injections Make up Vast Majority of Captured Spending

Codes Not Assessed (Each <0.07% of Spending) $1,908,619 5%

$35,686,990 97.7% of assessed spending $726,381 2.0% of assessed spending $99,940 0.3% of assessed spending

Other $36,513,311 95% Codes Directly Relevant to Spinal Injection (e.g., injections, anesthesia, E&M, medications, fluoroscopy) Codes Not Related to Injection, but Common in Back Pain or Pain Clinic Patients (e.g., Drug Testing, Lumbar Imaging, Physical Therapy, Chiropractic, Back Orthoses, Injection of Other Joints/Tendons/Nerves) Code for More Complex Back Procedure (i.e., Laminotomy, CPT 63030)

SLIDE 28

% of Patient nts N=1,4 ,468 68,6 ,689 89 % of Low-Va Value ue Spending ng Mean Sending ng per capita ($) P a Spending ng per $10, 0,000 00 Total Spending ing ($) P a Patient nt Characteris istics Age Age 18-34(ref) 32.7 17.4 11.87 - 56.21 - 35-49 34.3 31.3 20.37 <0.001 40.62 <0.001 50-64 33.0 51.3 34.74 <0.001 50.12 <0.001 Sex Female(ref) 50.5 58.0 25.65 - 60.87 - Male 49.5 42.0 18.93 <0.001 36.60 <0.001 Race/Et Ethnic nicity b White(ref) 70.7 74.2 23.41 - 49.39 - Black 10.0 9.5 21.29 0.014 47.46 0.037 Hispanic 10.4 9.6 20.70 0.001 48.31 0.253 Asian 4.9 2.6 11.95 <0.001 43.40 <0.001 Unknown 4.0 4.0 22.61 0.571 50.99 0.292 Househo hold ld Income c Unknown 13.9 11.6 18.62 <0.001 43.46 <0.001 <$40k 10.0 10.1 22.57 0.495 47.75 <0.001 $40-$49K 5.7 5.4 21.23 0.089 45.32 <0.001 $50-59K 6.3 7.0 24.59 0.275 47.24 <0.001 $60-$74K 9.6 9.0 20.87 0.011 47.10 <0.001 $75-$99K 14.9 15.8 23.64 0.615 48.83 <0.001 $100K+(ref) 39.6 41.2 23.21 - 52.23 - Census us Divisio ions ns East Northcentral(ref) 15.7 14.9 21.06 - 41.82 - East Southcentral 3.6 4.1 25.55 0.011 47.61 <0.001 Middle Atlantic 6.8 7.4 24.25 0.009 54.08 <0.001 Mountain 9.3 9.4 22.41 0.221 51.69 <0.001 New England 3.1 2.4 17.71 0.032 39.40 0.143 Pacific 8.5 5.5 14.58 <0.001 37.00 <0.001 South Atlantic 26.5 27.7 23.37 0.008 54.38 <0.001 West North Central 11.7 10.1 19.42 0.120 45.14 0.003 West South Central 14.8 18.4 27.72 <0.001 54.19 <0.001 Health h Plan n Product Type Exclusive Provider Organization 11.9 13.4 25.08 0.630 55.77 <0.001 Health Maintenance Organization 8.6 7.9 20.52 0.107 46.94 0.217 Point of Service or Other 77.2 76.3 22.04 0.315 48.13 0.038 Preferred Provider Organization or Indemnity (ref) 2.3 2.4 24.05 - 44.39 - Consum umer Directed Health h Plan No HRA/HAS (ref) 74.6 77.0 23.03 - 49.86 - High-Deductible Health Plan with HRA 11.3 11.1 21.86 0.160 48.47 0.121 High-Deductible Health Plan with HSA 14.1 12.0 18.97 <0.001 43.85 <0.001