MedPAC Tackles Complex Issue of Low-value Medical Services

Commissioners Weigh How to Match Policy to Key Research Findings

April 07, 2015 03:01 pm Michael Laff Washington, D.C. –

Cancer screenings and diagnostic imaging are essential tools for physicians but they are frequently overused, making up the highest percentage of low-value care services, according to Medicare Payment Advisory Commission (MedPAC) research findings.

[Radiologist holdling x-ray at desk with patient]

During the commission's April 2-3 meeting,( members discussed which medical services are considered low value and possible measures to minimize their use. Low-value services were defined as procedures that carry little or no clinical benefit and those for which the risk of patient harm outweighs the potential benefit.

According to a presentation by MedPAC staff,( the total cost of low-value services to Medicare in 2012 was estimated at $5.8 billion. Services that are considered low value include imaging for low back pain, colon cancer screening for older patients and MRI or CT scans for uncomplicated headache. Together, imaging studies and cancer screenings accounted for 70 percent of volume of low-value services. Most of the spending on low-value care went to cardiovascular testing and procedures.

Among research findings and other information sources about low-value care that were cited during the meeting was the American Board of Internal Medicine Foundation's Choosing Wisely campaign,( which, to date, has identified more than 300 tests and procedures that are considered low value. The AAFP is an original member organization of Choosing Wisely.

Story highlights
  • The total cost of low-value health care services to Medicare in 2012 was estimated at $5.8 billion.
  • Low-value services were defined as procedures that carry little or no clinical benefit and those for which the risk of patient harm outweighs the potential benefit.
  • Identifying low-value care through Medicare claims data is difficult because downstream costs aren't accounted for.

"I think it's about time we retire the flawed paradigm that more services lead to better health," MedPAC Commissioner Craig Samitt, M.D., M.B.A., said during the meeting.

Commission staff noted in their presentation that identifying low-value care through Medicare claims data is difficult and leads to conservative cost estimates for these services because they do not account for downstream follow-up tests or screenings.

Members of the commission wrestled with how to translate the findings into a policy that would reduce the rate at which low-value services are performed.

Among the recommendations considered were suggestions that Medicare continue to publish research results on low-value services, change coverage rules to conform with evidence that demonstrates low value, and increase or introduce cost-sharing obligations for beneficiaries who receive such services.

Regarding the latter suggestion, said MedPAC Chair Glenn Hackbarth, J.D., "Cost-sharing will be unpopular and a politically difficult thing to do."

On the other hand, he added, "I have a problem using taxpayer dollars to pay for services that are proven to be of low value."

Hackbarth noted that such spending could be reallocated for essential health costs, such as subsidies for low-income individuals to receive better care. Samitt cautioned that by focusing on low-value services, policymakers are avoiding a discussion about what Medicare does not cover, such as preventive care.

"There (is) a whole bucket of services we provide that are of low value or no value, and I think there are an equal number of services that we should be providing that we don't," said Samitt. The focus, he added, should be on reallocating resources that are not improving health to those that do.

But identifying a low-value service is just the start of the debate. Some commissioners asked whether a service that leads to a better outcome for just one out of dozens of patients should be considered low value. Cutting off payment for such a service carries considerable risk.

"Medicare is always afraid of this," said Commissioner Kathy Buto, M.P.A. "There might be one person who needs this service."

Another hurdle to any policy change would be informing the patient about the value of particular medical services and any accompanying cost-sharing responsibilities.

"Before we ask them (beneficiaries) to pay more I think they need to know these are low-value services," said Commissioner Mary Naylor, Ph.D., R.N.

Patients and physicians might make different decisions about ordering a diagnostic test if the patient was responsible for the cost, yet such conservations are not routine. The AAFP offers videos to help physicians have those conversations.

Finally, one commissioner pointed out that many research findings are not new, yet awareness among the various medical specialties remains low.

"Virtually all societies in medicine now have put out these Choos(ing) Wisely guidelines, but we don't share them very much among ourselves," said Commissioner William Hall, M.D.

Hall, a geriatrician, said his physician specialty organization changed tactics by assessing the findings of other specialty groups in terms of how members of his group could apply them, instead of relying solely on their own data.

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