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February 5, 2018

This state had $282M in low-value care—in just 1 year, report finds

Daily Briefing

    More than 622,000 Washington residents received unnecessary medical care over one year at an estimated cost of $282 million, according to a new report that industry experts say shines a light on the problem of overuse.

    Here are 15 tactics to reduce avoidable ED use

    For the report, Washington Health Alliance (WHA) researchers reviewed commercial insurance claims from WHA's All Payer Claims Database for services and procedures delivered from July 2015 to June 2016. They identified about 1.3 million commercially insured Washington residents who received at least one of 47 medical services or procedures considered commonly overused by the American Board of Internal Medicine Foundation's Choosing Wisely campaign and the U.S. Preventive Services Task Force.


    Overall, the researchers found 622,341 Washington residents—or 47.9% of the sample—received low-value services at a total cost of $282 million.

    According to the report, 11 of the 47 procedures and services accounted for 93% of the low-value care provided from July 2015 to June 2016. The 11 procedures and services included:

    • Annual electrocardiograms (EKGs) or cardiac screening;
    • Cervical cancer screenings in women;
    • Imaging for eye disease;
    • Population-based screening for OH-Vitamin D deficiency
    • Preoperative lab studies prior to low-risk surgery; and
    • Prostate-Specific Antigen (PSA) screening for prostate cancer.

    For example, the researchers found 166,860 women received an annual cervical cancer screening at estimated cost of $25.8 million. Of those women, 121,014—or 73%—received wasteful cervical cancer screenings at an estimated cost of $19 million. The researchers also found that of the 108,037 individuals who received preoperative lab studies prior to a low-risk surgery, 85% received wasteful were deemed wasteful studies, costing an estimated $86 million.

    Call to action

    The researchers in the report wrote that the medical community's pledge to "First, do no harm" should include avoiding financial as well as physical and emotional harm. They wrote that "overuse must become central to honest discussions of health care value in Washington state." The researchers urged clinical leaders to drive "provider efforts to incorporate reduction of overuse into local practice culture" and to make "the concepts of 'choosing wisely' and shared decision-making … the bedrock of provider-patient communications."

    They also called on the health care industry to continue the "transition from paying for volume to paying for value in health care." However, they noted that value-based care models "must include measures of overuse, and not just measures of access and underuse."


    Susie Dade, the report's primary author and deputy director of WHA, said many low-cost tests do not get a second look when they are ordered, but "little things add up." Dade said physicians can help mitigate the use of unnecessary procedures and tests by bringing up costs when they speak to patients about the benefits and risks of procedures. "We don't think of harm (to patients) in terms of financial harm," but "doing things that are unnecessary and then sending patients big bills is financial harm," Dade said. "Given the advent of high-deductible health plans where people have much more out-of-pocket exposure, I think we need to have those conversations."

    H. Gilbert Welch, a professor at the Dartmouth Institute who has authored books on overuse, said the problem goes back to simple economics: Current payment models compensate providers for conducting more tests and performing more procedures. Welch said, "Incentives matter," and "[a]s long as people are paid more to do more they will tend to do too much."

    According to ProPublica, officials from Washington's hospital and medical associations largely agreed with the report's findings, but noted that patients often contribute to overuse by insisting that providers "do something," such as prescribing a drug or perform a test.

    Jennifer Graves, VP for patient safety at the Washington State Hospital Association, said the report could change how both providers and patients perceive unnecessary care. Graves said sometimes "watching and waiting" might be a better approach than prescriptions or tests, and that the report's findings could help to change both providers' and patients' mindsets regarding unnecessary care (Allen, ProPublica, 2/1; Baker, "Vitals," Axios, 1/2; Castellucci, Modern Healthcare, 2/1; Washington Health Alliance report, 2/1).

    Next, get primers for reducing avoidable ED utilization

    Are specific patient populations making up a significant proportion of your ED visits? Each installment in our Right-Sizing ED Use primer series takes a lens to one of these frequent user subgroups.

    We analyze the reasons these patients seek care in the ED, the business case for intervening, and solutions for reducing unnecessary ED use. The primers also feature in-depth case studies which highlight the operational details of successful and targeted programs from leading health care organizations.

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