Payment policies may be needed to reduce low-value services
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Recommendations endorsed by the American Board of Internal Medicine Foundation’s Choosing Wisely initiative to discontinue the use of two low-value screening services had a minimal impact in practice, suggesting policy changes to remove coverage of such services may be needed to reduce unnecessary screening, researchers reported in JAMA Internal Medicine.
“These findings suggest that recommendations alone may be insufficient to significantly reduce use of low-value services and that pairing recommendations with policy changes may be more effective,” James Henderson, PhD, a consultant for the University of Michigan’s Consulting for Statistics, Computing and Analytics Research program, and colleagues wrote.
Recent research has shown that low-value services and overtreatment lead to $75.7 billion to $101.2 billion of wasted health care spending in the United States annually.
To address waste, the Choosing Wisely initiative has campaigned against the use of population-based vitamin D screening for not demonstrating improved outcomes and triiodothyronine (T3) testing in patients with hypothyroidism in favor of thyroid-stimulating hormone level tests since 2012. In Ontario, Canada, a policy eliminating reimbursement for population-based vitamin D screening was implemented in 2010 to reduce low-value services.
Henderson and colleagues examined how often the tests were used in Canada and the United States prior to and following the Choosing Wisely program and Ontario’s payment policy using administrative claims from Ontario, the U.S. Veteran’s Health Administration and a large database of commercial insurance claims in the U.S.
The study included claims from 54,223,448 people aged 18 to 64 years who had a primary care visit with vitamin D screening between January 2010 and June 2015 or had established hypothyroidism between January 2012 and June 2015.
Henderson and colleagues found that Ontario’s 2010 policy eliminating low-value vitamin D testing reimbursement was associated a relative reduction in vitamin D screening of 92.7% (95% CI, 92.4-93).
The reductions in vitamin D screening associated with the Choosing Wisely campaign were significantly smaller. Researchers found that the campaign was associated with reductions of 4.5% (95% CI, 2.6-6.3) for claims in Ontario, 13.8% (95% CI, 11.8-15.9) for claims in the U.S. VA, and 14% (95% CI; 12.8-15.2) for U.S. employer-sponsored insurance.
For T3 testing, researchers did not identify significant changes in Ontario (relative marginal effect [RME] = 0.3%; 95% CI, –1.4 to 2) or the VA (RME = 0.7%; 95% CI, –4.7 to 6.4). For U.S. employer-sponsored insurance, they found that the campaign was associated with an increase in T3 testing (RME = 3%; 95% CI, 1.6-4.4).
Henderson and colleagues noted that if the rate of vitamin D screening in the U.S. was the same as the highest rate in Ontario after it eliminated reimbursement, an average of 213,000 screenings in the VA and 4.4 million in the U.S. commercial market would have been avoided each year.
In an editor’s note published alongside the study, Sanket S. Dhruva, MD, MHS, and Rita F. Redberg, MD, MSc, assistant professor and professor, respectively, of the School of Medicine at the University of California, San Francisco, explained that the implementation of these policies will “require courage,” as people will initially resist the idea of a service being taken away even if it is not beneficial.
“However, noncoverage of low-value care is necessary to ensure thoughtful stewardship of limited health care resources and to ensure that patients do not receive nonevidence-based care for which the harms likely outweigh the benefits,” they wrote. – by Erin Michael
Disclosures: Dhuvra, Henderson and Redberg report no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.