June 23, 2020
Now Is the Time to Nip Low-Value Care in the Bud
The coronavirus pandemic exposed flaws in the U.S. health system that we knew existed but weren’t in a rush to do anything about because everyone (other than patients) was profiting off the status quo.
One of the biggest flaws is low-value care. A consequence of fee-for-service medicine, low-value care is care that offers patients little or no therapeutic benefit and may, in fact, harm them. Yet, health plans reimburse for it, and providers provide it because that’s what they’ve always done and, hey, why not?
Then along came COVID-19, and patients stopped going to the hospital and to the doctor. Many of those patients had acute- or chronic illnesses. Guess what? Many of them were OK. They got better or at least didn’t get any sicker. Some patients did—and do—better with less care.
Health plans already knew that. So did hospitals and doctors. And drug companies and medical device manufacturers, too. No one other than some health services researchers ever said anything. COVID-19 forced everyone to come clean, and now people are tripping over themselves to tell us all about it.
For example, in May, two physicians published an op-ed for CNN that noted that many patients who skipped medical care because of COVID-19 are doing just fine. They said, “We need physician researchers willing to ask hard questions about services they deliver—questions that may threaten their own professional/financial self-interests.”
Earlier this week, a physician published an op-ed in the New York Times that noted that “a vast majority of patients seem to have fared better than what most doctors expected.” He rhetorically wondered, “Perhaps Americans don’t require the volume of care that their doctors are used to providing.”
Sandwiched in between those two op-eds was a new study in JAMA Internal Medicine that shows why identifying and reducing low-value care is so important.
Researchers from the University of Toronto and the University of Michigan studied a group of healthy or otherwise low-risk patients in Canada who underwent annual physicals with their primary-care doctors in Ontario over a four-year period from 2012 through 2016.
The researchers wanted to know if three low-value diagnostic tests that the physicians ordered for their patients as part of their physicals led to higher use of medical services later compared with patients who didn’t have the three tests. The three low-value tests were:
- Chest x-rays for adult patients age 18 or older at low risk for heart or lung diseases
- Electrocardiograms for adult patients age 18 or older at low risk for heart disease
- Pap smears for female patients age 13-20 or older than 69 at low risk for cervical cancer
When the researchers compared the patients who had the tests with the same number of patients who didn’t have the tests, they found that the patients who had the tests had even more stuff done to them later. They had more visits with medical specialists like cardiologists and pulmonologists. They had more diagnostic tests like CT scans and heart stress tests. And they had more procedures like follow-up pap smears and colposcopies.
And here’s the kicker. The patients who had the initial tests and then all the downstream care had the same clinical outcomes as the patients who didn’t have the initial tests and all that other stuff done. For example, hospitalization, emergency room visit and mortality rates were pretty much the same. Same for the rates of procedures like heart bypasses, lung resections and hysterectomies.
“Seemingly low-risk screening tests may lead to physician visits or tests that could inconvenience the patient and, in some instances, expose the patient to potential harm,” the researchers said.
Yeah, I’d say so.
The COVID-19 outbreak revealed to patients and payers that that a lot of what providers do and health plans pay for is unnecessary. Many patients do just as well if not better, and payers can save money by not spending it on things that don’t really work. This latest study on low-value care shows us where we can start rooting out unnecessary care, and that’s at the primary-care level where low-value diagnostic tests set off a chain of costly and needless medical events.
Less is more. And less is less.
Let’s create new market-based care delivery and payment models that support those two truisms.
Thanks for reading.
Stay home, stay healthy, stay alive.