Low-Value Heath Care and Overuse of Services: Choosing Wisely

Many policy initiatives are focused on payment reform and identifying better ways of organizing and delivering health care. Little attention has been paid to the elimination of overuse of low-value services, in part because of the politics associated with rationing. The elimination of low-value care as a cost control strategy has appeal because of the opportunity to improve quality while lowering costs. One of the difficulties with studying potential waste or creating incentives for improving efficiency is that there is little accepted wisdom on which treatments are of low value.

            With the intent of filling this gap, Choosing Wisely is part of a multi-year effort of the ABIM Foundation and physician specialty societies to help physicians be better stewards of health care resources by publishing evidence-based lists of health services that patients and physicians should discuss in detail before undertaking. These lists provide an opportunity to identify spending on treatments of low-value using recommendations endorsed by physician groups. There are currently no estimates of how broadly these services are used in practice, how much is spent on them, or what health system factors or policy initiatives might reduce use of these services. 

Using Medicare claims for hospital and physician services with prescription drug data, we estimate the prevalence of use of low-value services as defined by the Choosing Wisely program at the market-level using hospital referral regions. For each market, we estimate rates of use of the following CW measures: cardiac screening in low-risk patients (mean prevalence 12.2%), DXA screening in an interval shorter than two years (10.1%), use of antipsychotics in dementia patients (68.7%), use of feeding tubes in advanced dementia patients (9.0%), preoperative cardiac imaging assessment for low-risk non-cardiac surgery (48.6%), screening for 25-OH-Vitamin D deficiency (8.8%), opioid treatment for migraine (20.7%), upper-tract imaging for patients with benign prostatic hyperplasia (BPH, 1.2%), screening women older than 65 years of age for cervical cancer (3.1%), and imaging for low-back pain (22.5%).

We create an index for overuse by hospital referral regions and study correlates of overuse at a local level. We find that areas with higher proportions of minority groups (Hispanic, black), worse health, higher overall Medicare spending, and a greater concentration of specialists use more low-value tests and treatments. Rural areas, areas with a greater proportion of the population in poverty, and a greater density of primary care physicians are less likely to use low-value tests and services. Utilization-based quality measures are positively associated with overuse.

Stewardship and educational campaigns, such as Choosing Wisely, may reduce use of low-value tests and services. Measurement of overuse is a critical first step towards reducing waste. Armed with information on which services are low-value, health care professionals and policymakers need to develop and test appropriate guidelines, interventions, quality measures and payment reforms that reduce utilization of these tests and procedures while minimizing any unintended consequences.