Blog | Friday, December 15, 2017

Looking in the wrong place?


It is no secret that there is a lot of waste in health care. Even if one leaves aside the most egregious examples such as duplication of tests and patient harm that necessitates more care, we still collectively do a lot of stuff that does not improve health. A recent report in Health Affairs changed my assumptions about what that stuff looks like.

The authors analyzed claims data from an all payer database in Virginia for services provided in 2014. They prospectively defined 44 services that were of “low value” defined as providing no net health benefit in specific clinical circumstances. Their assessments were based on nationally recognized standards, including the “Choose Wisely” campaign of the American Board ofInternal Medicine, the U.S. Preventive Services Task Force, Centers for Medicare and Medicaid Services criteria, and others. They then scoured the database to see how frequently these services were provided, and calculated the aggregate costs associated with them.

Two findings stand out:
1. The services were prevalent: patients in Virginia received a total of 1.7 million low value services in 2014, for a total cost of $586 million.
2. Because low cost services were so much more frequently performed than high cost services (think useless blood test instead of useless MRI), almost two-thirds of the total cost was driven by the low cost ones.

The conclusion that more money is wasted on “a lot of little things” instead of “a smaller number of big things” ought to change how we approach efforts to lowering the cost of care. It suggests that tight utilization management of “big ticket” items may not have the impact of changing more “every day” patterns of care. That seems harder to me, but it also seems like work that has to be done, and it will require strong physician leadership to accomplish.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.