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Looking at the link of payer type and low-value care

Researchers from The Dartmouth Institute for Health Policy and Clinical Practice examined the connection between payer type and low-value care to determine what effect that insurance design (commercial insurance vs. Medicare) may have on medical overuse and waste.

Among their findings:

  • “The tendency to deliver or avoid low-value care appears largely independent of payer type (Medicare or commercial) and patient population attributes. (Researchers note that the finding suggests that either the difference in anticipated reimbursement is unimportant to providers or that they are ‘unwilling or unable to discriminate by payer type at the point of care.’)
  • “Regions with a high specialist to primary care ratio have more overuse.
  • “Some Hospital Referral Regions may deliver more overuse either as a direct result of higher physician group competition or as an indirect result (more competition results in more fragmentation and redundancy).
  • “The use of the seven low-value services remained relatively consistent over time. However, Vitamin D screening increased substantially during the study period (perhaps as a result of increased public awareness and the promotion of Vitamin D deficiency as a medical concern). In contrast, the use of cervical cancer screening in the over 65 population decreased substantially.
  • “The rate of prescription of opioids for migraine patients is similar in both commercially insured and Medicare populations, but is much more commonly provided than the other Choosing Wisely services examined in the study. (The study’s authors note that study data may not reflect the slight decline in prescription opioid use in response to growing concerns over opioid abuse.)
  • “Finally, the study found that the use of low-value services in both payer types was greater among {groups with} higher proportions of black patients. The researchers note that their finding suggests a concerning ‘potential for double jeopardy in health services receipt among black Americans.’”

To read more, please hit this link.


Choosing Wisely, Consumer Reports team up



The “Choosing Wisely” initiative of the American Board of Internal Medicine (ABIM) Foundation has asked more than 70 medical societies, associations and other  groups to list common medical tests/procedures that are often clinically unnecessary and that can even cause harm in some cases.

To promote its mission of reducing unneeded medical activity, Choosing Wisely has  now partnered with Consumer Reports to create a Web site as well as videos and downloadable materials for patients and providers covering most of the Choosing Wisely recommendations. They have also have launched an iOS app for patients for easy access to these materials on the go. The app includes drugs as well as tests and procedures.

Hit this link to get to the new Consumer Reports/Choosing Wisely Web site.

Hit this link to get to the Choosing Wisely Web site.

Hit this link to read a Med Page Today article on this topic.


Trying to define and reduce low-value care


A  new Health Affairs article is based on discussions with 13 experts on how to reduce  low-value care.  Little consensus was found.

The authors noted: “Solutions to measure, identify, and eliminate low-value care … are challenging and complex. To date, most efforts aimed at reducing low-value care, such as the Choosing Wisely Initiative, have been limited to areas where there is high degree of consensus that the care rendered is low value.”

The authors said they focused on “overuse/overtreatment, failures of care delivery and coordination, and pricing failures. We proposed working definitions of low-value care and explored how participants considered defining and measuring low-value care.”

Findings include:

  • “There is a healthy skepticism of consensus methods, such as Choosing Wisely, in identifying low-value care beyond obvious ‘low-hanging fruit.’ There was not clear consensus on how to use components such as patient preferences, health-related quality of life, or competing risks and risk-benefit tradeoffs (e.g., at what age to initiate and terminate certain preventive screenings) to define and measure low-value care.
  • “There was little consensus on the validity, practical application, and priority for using cost-effectiveness analysis to inform coverage and pricing decisions.”
  • “Although there was agreement that price and cost should be included, particularly unjustified price variation, (e.g., price at freestanding versus facility-adjoined surgical or infusion therapy center) in efforts to reduce low-value care, there was not clear agreement on how that should be done.”

Still, the interviewees agreed  on elements of low-value care that need immediate attention. Among them: medical errors and pricing failures.

The writers proposed the following actions:

  • Looking into incorporating “Choosing Wisely, USPTF, and similar lists into performance and quality measurement for alternative payment programs.”
  • Expanding current low-value care lists “beyond nearly universal low-value care to include items where value is circumstance-dependent. Given concerns about limiting access to appropriate care, we recommend a tiered approach that takes into account both the magnitude and certainty of low-value care use. This effort would need to incorporate patient protections.”

T0 read the article, please hit this link.

Why U.S. can’t control healthcare costs


Ryan Gamlin, a former healthcare-management consultant and currently a medical student at the University of Cincinnati, has written a very useful and insightful commentary  in Medical Economics on  why the U.S. can’t control healthcare costs and has mediocre outcomes compared to other developed democracies.

He concludes:

“New reimbursement structures, like shared savings and ACOs, will draw provider and payer incentives closer to one another – and it is within these highly aligned arrangements that the efforts of physician stewardship organizations, such as Costs of Care and Choosing Wisely, will likely be most effective.

“But with 53% of physician reimbursement  {still} tied to fee-for-service, the majority of dollars saved through these efforts are still subject to recapture by insurers, administrators, or other entities, rather than making their way back to patients in the form of lower out-of-pocket costs.

“As Holman W. Jenkins  {of The Wall Street Journal} pointed out in a recent, devastating satire of the  Epi-Pen scandal, many of the incentives in the current healthcare system are aligned only with growing the total scale of healthcare expenditures, not shrinking them.

“Until we create a system that rewards investment in wellness and healthcare dollars not spent, there is reason to fear that the negative effects of healthcare excesses will continue to be borne by households, businesses, and governments.”

To read his whole piece, please hit this link.


Making Choosing Wisely efforts work

This article looks at the importance of physicians’ communication skills in reaching the goals of the Choosing Wisely campaign, which is aimed at resisting the push for medical interventions not backed by strong evidence.

This is a good look at communications strategies that might work.

‘Choosing Wisely’ may not win some malpractice suits


18th Century Statute of Lady Justice, at Castellania,  Italy. Her sword signifies the coercive power of a court,  her scales represent an objective standard by which competing claims are weighed, and her blindfold indicates that justice should be impartial and meted out objectively without fear or favor.

William Sullivan, D.O., and also a lawyer, discusses why “Choosing Wisely” won’t necessarily protect providers from malpractice suits.

He concludes:

“{Treatment} guidelines are created for many purposes. The intent of a guideline significantly affects whether the guideline will protect a physician against medical malpractice risk. Guidelines relating to payment issues should not be used for clinical or medicolegal purposes without strong clinical research supporting their conclusions. While clinical practice guidelines may be useful for both clinical and medicolegal purposes, the recommendations should be compared with current medical literature to determine whether the guidelines constitute appropriate medical care.

“Statutory guidelines and safe harbors significantly reduce a practitioner’s malpractice risk and also provide a strong deterrent to frivolous lawsuits. However, the decreased risk must be weighed against the inference of negligence that occurs if a statutory guideline is not followed, and against the potential transition of medical practice from a healing art to an exercise in checking all of the appropriate boxes to avoid liability.”

Review of the ‘Choosing Wisely’ campaign


Here’s a review of the  successes and disappointments so far of the ABIM  Foundation’s “Choosing Wisely” campaign aimed at getting patients and clinicians to talk more thoroughly and honestly  with each other about medical, financial, psychological and other issues that should be addressed in healthcare decision-making. The aim is better care and tighter cost control.

It’s by Daniel Wolfson, M.D., of the ABIM Foundation, which is part of the American Board of Internal Medicine empire.

His remarks in a long HealthAffairs piece include:

Choosing Wisely has been criticized for focusing on conversations instead of measures and implementation. It has also been criticized by some who said the content of the lists of unnecessary tests and procedures compiled by various specialties do not address more challenging areas of overuse. These are valid concerns.”


“Efforts to develop additional lists of wasteful tests and procedures are already happening at the grassroots level, such as the Journal of Hospital Medicine’s new series: Choosing Wisely: Things we do for no reason. Group practices have also begun these conversations. We welcome more and more communities to work together to discuss what unnecessary tests and procedures they may be ordering and performing.”



Study: ABIM’s Choosing Wisely campaign disappointing so far



The American Board of Internal Medicine’s Choosing Wisely campaign aimed at reducing the incidence of unneeded and sometimes clinically dangerous care has not had much of an impact so far.

A study  in JAMA Internal Medicine found that, for seven treatment and testing services listed by the Choosing Wisely campaign as usually unnecessary, use of only two had declined, but use of the other five either didn’t change or increased.

A  possible caveat:  All the investigators in the study are affiliated with Anthem, the big health insurer, and led by Alan Rosenberg, M.D., the firm’s vice president for clinical pharmacy and medical policy .

The researchers recommended new measures to  achieve substantial  change in physician knowledge and behavior.

Many, though not all, of the services covered by Choosing Wisely are related to diagnostic imaging.

The study said:  “The relatively small use changes suggest that additional interventions are necessary for wider implementation of Choosing Wisely recommendations in general practice. Some of the additional interventions needed include data feedback, physician communication training, systems interventions (e.g., clinical decision support in electronic medical records), clinician scorecards, patient-focused strategies, and financial incentives.”

‘Choosing Wisely’ in the Alps


Herewith an article on the Swiss version of the American Board of Internal Medicine’s “Choosing Wisely” program to reduce the number of treatments that evidence-based medicine suggests are unneeded or worse and by so doing control costs.

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