NEBGH Health and Wellness Conference. Making Sure Low Value Clinical Services Go Down for the Count

Transcription

1 NEBGH Health and Wellness Conference Making Sure Low Value Clinical Services Go Down for the Count

2 Using Value-Based Insurance Design to Reduce Low Value Care A. Mark Fendrick, MD University of Michigan Center for Value-Based Insurance Design

3 Making Health Care Great Again ; ) Innovations to prevent and treat disease have led to impressive reductions in morbidity and mortality Irrespective of these advances, cutting health care spending is the main focus of reform discussions Underutilization of high-value services persists across the entire spectrum of clinical care Our ability to deliver high-quality health care lags behind the rapid pace of scientific innovation

4 Star Wars Science

5 Flintstones Delivery

6 Creating Headroom to Pay for High-Value Care Identifying /Removing Unnecessary Services Discouraging the use of specific low-value services must be part of the strategy

7 Creating Headroom to Pay for High-Value Care Identifying /Removing Unnecessary Services Unlike delay for cost offsets from improved quality, savings from waste elimination are immediate and substantial Identification, measurement, and removal of unnecessary care has proven challenging

8 Reducing Low Value Care: Why so difficult? Clinician factors: e.g., training, fear of lawsuits, time pressures, intolerance of uncertainty Patient factors: lack of knowledge or financial consequences, more is better Healthcare system factors: institutional culture, pricing, fee-for-service payment models

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10 Reducing Low Value Care: Where to Start? Although much of the low-value care discussion has focused on high-cost services, low-cost items are less likely to draw attention by particular clinicians or patient advocacy groups Choose services: Easily identified in administrative systems Mostly low value (little or no clinical nuance) Reduction in their use would be barely noticed

11 Multi-Stakeholder Task Force Identifies 5 Commonly Overused Services Ready for Action 1. Diagnostic Testing and Imaging Prior to Surgery 2. Vitamin D Screening 3. PSA Screening in Men Imaging in First 6 Weeks of Low Back Pain 5. Branded Drugs When Identical Generics Are Available

12 Identifying and Removing Unnecessary Care: Milliman Health Waste Calculator Collaboration between Milliman and V-BIDHealth Measures 47 potentially unnecessary services Analyze cost savings potential Generate actionable reports and summaries

13 My Hope for the Future

14 Case Studies Wasteful Services Milliman Health Waste Calculator Results Suzanne Taranto Principal and Consulting Actuary, Milliman

15 Waste in the Healthcare System Comes From Many Places Category Unnecessary Services Inefficiently Delivered Services Excess Admin Costs Sources Overuse beyond evidence-established levels Discretionary use beyond benchmarks Unnecessary choice of higher-cost services Mistakes, errors, preventable complications Care fragmentation Unnecessary use of higher-cost providers Operational inefficiencies at care delivery sites Insurance paperwork costs beyond benchmarks Insurers administrative inefficiencies Inefficiencies due to care documentation requirements Estimate of Excess Costs % of Waste % of Total $210 billion 27% 9.15% $130 billion 17% 5.66% $190 billion 25% 8.28% Prices that are too high Missed Prevention Opportunities Service prices beyond competitive benchmarks Product prices beyond competitive benchmarks Primary prevention Secondary prevention Tertiary prevention $105 billion 14% 4.58% $55 billion 7% 2.40% Fraud All sources payers, clinicians, patients $75 billion 10% 3.27% Total $765 billion 33.33% SOURCE: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Institute of Medicine (2013)

16 Case Studies Wasteful Services A number of different groups have applied Milliman Health Waste Calculator metrics to their data Early implementers included health plans and large riskbearing entities Employers are now taking advantage of the methodology to identify waste The following slides describe learnings and actions taken in response:

17 Commonwealth of Virginia Unnecessary Care Initiative Among 5.5 million Virginia beneficiaries, 1 in 5 received at least 1 low-value service in 2014 The 44 low-value services were delivered 1.7 million times, which cost $586 million (~2% of healthcare spend)

18 Commonwealth of Virginia Unnecessary Care Initiative Clinical Measure Total Services Measured Low Value Index (%) Low Value Services (#) Unnecessary Spending ($) Baseline labs for patients undergoing low-risk surgery Stress cardiac or advanced noninvasive imaging in the initial evaluation of patients w/o symptoms EKGs or other cardiac screening for low-risk patients w/o symptoms Routine Pap tests in women years of age PSA-based screening for prostate cancer in all men regardless of age 571,600 79% 453,447 $184,781, ,878 13% 27,817 $185,997,938 2,268,194 6% 147,423 $60,499, ,865 81% 161,539 $37,558, ,011 42% 132,793 $31,501,675 49

19 Commonwealth of Virginia Unnecessary Care Initiative Nearly Two-Thirds of Expenditures on Low-Value Services in Virginia were on Little Ticket Items 65% John N. Mafi et al. Health Aff 2017;36:

20 Community Coalition Reporting State of Washington Health Alliance Approximately 1.3 M individuals received one of the 47 services, and almost half (47.9%) received at least one wasteful service Estimated $282 M of wasteful spend Washington State leads the nation in providing integrated, high-value care in largely capitated payment systems: Surprising result 2 0

21 Carrier on Behalf of Large Employers 24% of members had at least one Wasteful Service Paid claim value of wasteful or likely wasteful services was $11.30 PMPM Key results by category: 21

22 Carrier on Behalf of Large Employers High Risk Categories (8% of wasteful spend) Peripherally-inserted central catheters (PICC) in stage III V chronic kidney disease patients without consulting nephrology Revascularization without prior medical management for renal artery stenosis Vertebrolplasty for osteoporotic vertebral fractures Top 3 Medium Risk Categories (18% of wasteful spend) Annual EKGs or any other cardiac screening for low-risk patients without symptoms PSA-based screening for prostate cancer in all men regardless of age Coronary angiography in patients without cardiac symptoms unless high-risk markers present 22

23 Carrier on Behalf of Large Employers Top 5 Low Risk Categories (53% of total wasteful spend) Don t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal Routinely ordering imaging tests for patients with uncomplicated headaches Population based screening for 25-OH-Vitamin D deficiency Routinely ordering imaging tests for patients without symptoms or signs of significant eye disease Routine head CT scans for emergency room visits for severe dizziness 23

24 Taking Action How Do Employer Plans Use these Results? Once wasteful services are identified they are avoided through: Plan Design Care Management Contracting Plan Design challenges not all services in a category are wasteful For example, plan does not cover a service without specific criteria - requires plan documents to be kept up to date with medical protocol Care Management prior authorization on likely wasteful services Practicality for high volume services Contracting - Hold health plan or providers (if directly contracted) responsible for managing likely wasteful services 24

25 Case Study Wasteful Services Questions and Discussion

26 Health Waste Calculator Methodology

27 Clinical Nuance Situational Intelligence Defining Unnecessary or Wasteful Services that research has proven to add no value in particular clinical circumstances and in fact can lead to subsequent unnecessary patient harm not to mention undo costs MedInsight Health Waste Calculator methodology begins with evidence based guidance as prioritized and defined by leading community organizations (e.g. NICE, USPTF Part D, Choosing Wisely ). Due to the limitations of clinical data within claim records the MedInsight Health Waste Calculator approach is very conservative in terms of its definitions of waste. 27

28 47 Measures in Place Today; 400+ Planned ID # Waste Headline Waste Mnemonic 1 Antibiotics for Acute Rhinosinusitis AI01b 2 Coronary Artery Calcium Scoring for known CAD SCCT01 3 Headache Image ACR01 4 Immunoglobulin G/ immunoglobulin E Testing AI02 5 Lower Back Pain Image AFP02 6 PSA URG01 7 Radiographic Imaging for Uncomplicated Acute Rhinosinusitis AOHN04 8 Routine Annual Stress Testing NMMI02 9 Sinus CT AI01a 10 Stress Cardiac Imaging or Advanced Non-Invasive Imaging AC01 11 AnnualEKGs or Cardiac Screening AFP05 12 Antibiotics for Adenoviral Conjunctivitis AO03 13 Colonoscopy GE01 14 CT Head/Brain for Sudden Hearing Loss AOHN01 ID # Waste Headline Waste Mnemonic 16 Dexa AFP03 17 Diagnostics Chronic Urticaria AI03 18 Echocardiography as Routine Follow-Up AC02 19 ED CT Scans For Dizziness JH Electroencephalography (EEG) for Headaches AN01 21 Exercise Electrocadiogram ACPY Imaging of the Carotid Arteries for Simple Syncope Neuroimaging in a Child with Simple Febrile Seizure AN02 AP04 24 NSAIDs for Hypertension, Heart Failure, or CKD SNP04 25 Oral Antibiotics for Uncomplicated Acute External Otitis AOHN03 26 Pap Smear Hysterectomy AFP04 27 Pap Smear Under 21 AFP01 28 Radionuclide Imaging SNC01 29 Routine Pap in Women Years of Age COGY02 15 CT Scans for Pediatric Headache AAP06 30 Syncope Image ACPY01 28

29 HWC Clinical Specification 29

30 Imaging for Uncomplicated Headache Measure Description Unnecessary imaging in adults with a diagnosis of uncomplicated headache Services being measured Radiology services including facility and professional services HWC Degree of Waste Certainty: HIGH VALUE Necessary Inpatient admission within a month of diagnosis of headache Diagnosis of cancer or head trauma within a year prior to the diagnosis of headache Diagnosis of complicated sinusitis Diagnosis of headache in 60 years and older Presence of diagnosis of complicated headache LIKELY LOW VALUE Likely Wasteful MRI or CT for a diagnosis of chronic headache LOW VALUE Wasteful Absence of inpatient admission within a month of diagnosis of headache Absence of a diagnosis of cancer or head trauma within a year prior to the diagnosis of headache Absence of a diagnosis of complicated sinusitis Imaging for headache in less than 60 years old Imaging in the absence of any diagnosis of complicated headache ULTIMATE RISK Summary of Wasteful Imaging Impact False positive results cause worry to patients and lead to unnecessary procedures False reassurance from an inadequate study Potential risks of an allergic reaction to iodine contrast media with CT scanning Risk of over-sedation in claustrophobic patients having MRI scans American College of Radiology ACR Appropriateness Criteria. Headache Available at: 30