The United States spends more on health care than any other country and costs have been rising faster than the rate of inflation for some time. Yet, many policy responses to address rising costs ignore the elephant in the room: waste. According to some estimates, waste accounts for approximately one-quarter of total U.S. health care spending. One major driver of waste is low-value care, defined as the provision of care in which the potential harms outweigh the potential for benefit. It has been estimated that 42 percent of Medicare beneficiaries, 15 percent of Medicaid patients, and 11 percent of commercially insured patients—about 50 million people in total—experience one or more overuse events per year, amounting to $106 billion in wasteful spending.
But high costs are not the only consequence of a health care system that is flooded with inefficient and wasteful services. Overutilization of low-value care can cause real harm to patients, taking the form of unnecessary invasive surgeries, needless side effects, or false positive test results that lead to cascades of additional visits and treatments. The impact of these harms is diverse: physical, psychological, social, and financial.
A unique opportunity, eliminating overuse could improve (or maintain) health outcomes and reduce spending while redirecting important resources toward the delivery of high-value care. Greater efforts are needed to ensure future health care reforms don’t just focus on how much is spent, but instead how well these funds are spent. Identifying and understanding the drivers or determinants of overuse is essential to the development of effective strategies to combat it.
Several academic and research institutions have made significant progress in this area. The Research Consortium for Health Care Value Assessment (Value Consortium) has spent the last few years developing a framework to identify, measure, and ultimately, reduce the prevalence of low-value care throughout the health care system. In doing so, the Value Consortium has also identified future areas in need of more research to better understand the key drivers of low-value care.
The practical application of Consortium’s low-value care framework to the analysis of commercial insurance claims data has yielded important insights about low-value care. These findings support the hypothesis that low-value care is highly prevalent throughout the U.S. health care system, subject to significant geographic variation and that the underlying drivers of it are still not well understood.
Many of the Consortium’s findings are consistent with those of my own research. In recent work, we found that regional differences in overuse persist over time, suggesting that they are the result of systematic, local differences in care delivery rather than random noise. We also found that there is an association between the observable, structural characteristics of the regional health care system and overuse. Tackling low-value care will require purposeful experimentation and collaboration by many different stakeholders.
There are a number of opportunities to drive solutions in this area. First, there is a clear need for more robust generation of evidence on clinical effectiveness of health services to identify top sources of low- value care. Despite comprising only 14 percent of health care spending, approximately 43 percent of recent cost-effectiveness analysis studies evaluated pharmaceuticals. Meanwhile, only 22 percent of recent studies addressed medical and surgical interventions. Researchers and research funders should harness investment in clinical and cost effectiveness analysis and other forms of health technology assessment to identify and address low- value care across the full spectrum of care.
On the policymaking front, options have been put forward to control low-value care and drive higher value care overall. Reducing low-value care will likely require policies and interventions that focus on both the financial and non-financial, behavioral and cultural drivers of overuse. Some researchers have proposed adopting a “screen door” approach to benefit design and payment systems that would deter low-value care, while allowing high-value services to “pass through.” But implementing such a program successfully requires one to reliably disentangle low-value and high-value services from one other, while continuing to provide an appropriate level of access to health care for patients.
A systemic review of interventions found those that addressed both patient and clinician roles in overuse had the greatest potential to reduce low-value care–as did approaches such as clinical decision support, performance feedback, and provider education. Plan incentives in benchmarking or quality measures could also be considered. Regardless of the option, strong patient engagement will be key to ensure low-value care is defined appropriately and tools are in place to drive more patient and clinical engagement to avoid its use. It will also be important to recognize the need for further research to address persistent gaps in the available evidence.
Achieving a higher value health care system will be a multi-stakeholder endeavor. There is no single driver of low-value care — providers, systems, and patients all play a role. But with the right tools, researchers, policymakers, and industry stakeholders can work together to re-align incentives and transform our health care delivery system into one that prioritizes value, eliminates waste and leads to better overall patient outcomes.
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