Matthew J. Collins, M.D., M.B.A., BCBSRI executive vice president and chief medical officer

The concept of low-value care is not a new one; it is something we in the healthcare field have been wrangling with for years. Also not new is the concept of focusing on quality rather than quantity. In other words, generating less care that is also of higher value, with a heightened focus on ensuring patient health and improved outcomes.

According to the LOWN Institute, a nonpartisan think tank advocating bold ideas for a just and caring system for health, as much as one-third of annual healthcare spending in the U.S. is wasted. That is a significant driver of increased out-of-pocket costs and impacts the sustainability of our healthcare system. Low-value care is a significant portion of that tremendous waste, estimated to be in the range of $100-$700 billion per year. The pervasiveness of low-value care affects ALL patients, regardless of income, race, class, or insurance status.

There are many examples of low-value care, like unnecessary or ineffective procedures, tests, scans, and medications; repeated lab tests; and elective surgeries that could be avoidable. In extreme situations, this care can cause physical harm to patients, in addition to wasting money and resources. A fee-for-service payment model is another driver of low-value care, rewarding quantity instead of quality. Insurers like Blue Cross & Blue Shield of Rhode Island are working to create a fee-for-value model to try to reduce unnecessary care.

For example, rather than overprescribing medications, overtreatment, overscreening, or overuse of healthcare, why not focus on proven, effective behaviors such as eating better, exercising, losing weight, and quitting smoking – all of which would help reduce a myriad of health issues?

It is possible, though, to reduce utilization by addressing it specifically. Two years ago, we entered an education-based, alternative payment model partnership with Spine Care Partners and Lifespan (Lifespan Physician Group and Community Physician Partners) whereby 100% of Lifespan PCPs participated and went through training for appropriate back injury care. The focus was on adherence to evidence-based care guidelines, and we saw a significant decrease (nearly 13%) in imaging and treatments for back pain.

One of the most trusted sources to refer to for recommendations about potentially unnecessary tests, screenings, or procedures is Choosing Wisely®, an initiative launched in 2012 by the ABIM Foundation. We recommend Choosing Wisely to our members as a resource for questions to ask their providers before getting any test, treatment, or procedure, or about any medications they are prescribed.

A critical piece of this for providers is responding to the opportunity to drive change and improve the value of healthcare they provide by helping to redesign it themselves using data, metrics, and other information available to them. Using performance improvement in hospitals and health settings is helping respond to unnecessary tests, treatments, and other care by integrating evidence-based, clinical decision support guidance and educational campaigns into their systems and workflows.

There are many good reasons why guidelines about low-value care may not always be followed. For example, the clinical situation and the potential for complications could be factors. But the important takeaway is that there are instances where care is not appropriate and should be recognized as waste. Patients should feel empowered to ask questions about their care, and providers should welcome these questions. Health plans, providers, and patients all need to work together to recognize this trend and work together to reduce the amount of low-value care in the system. It benefits all of us.