Changes in Low-Value Services in Year 1 of the Medicare Pioneer Accountable Care Organization Program

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

BACKGROUND

Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important.

OBJECTIVES

The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups.

METHODS

In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections.

RESULTS

We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included.

CONCLUSIONS

Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration

IMPORTANCE

Low-value care is associated with harm among patients and with wasteful health care spending but has not been well characterized in the Veterans Health Administration.

OBJECTIVES

To characterize the frequency of and variation in low-value diagnostic testing for 4 common conditions at Veterans Affairs medical centers (VAMCs) and to examine the correlation between receipt of low-value testing for each condition.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used Veterans Health Administration data from 127 VAMCs from fiscal years 2014 to 2015. Data were analyzed from April 2018 to March 2020.

EXPOSURES

Continuous enrollment in Veterans Health Administration during fiscal year 2015.

MAIN OUTCOMES AND MEASURES

Receipt of low-value testing for low back pain, headache, syncope, and sinusitis. For each condition, sensitive and specific criteria were used to evaluate the overall frequency and range of low-value testing, adjusting for sociodemographic and VAMC characteristics. VAMC-level variation was calculated using median adjusted odds ratios. The Pearson correlation coefficient was used to evaluate the degree of correlation between low-value testing for each condition at the VAMC level.

RESULTS

Among 1 022 987 veterans, the mean (SD) age was 60 (16) years, 1 008 336 (92.4%) were male, and 761 485 (69.8%) were non-Hispanic White. A total of 343 024 veterans (31.4%) were diagnosed with low back pain, 79 176 (7.3%) with headache, 23 776 (2.2%) with syncope, and 52 889 (4.8%) with sinusitis. With the sensitive criteria, overall and VAMC-level low-value testing frequency varied substantially across conditions: 4.6% (range, 2.7%-10.1%) for sinusitis, 12.8% (range, 8.6%-22.6%) for headache, 18.2% (range, 10.9%-24.6%) for low back pain, and 20.1% (range, 16.3%-27.7%) for syncope. With the specific criteria, the overall frequency of low-value testing across VAMCs was 2.4% (range, 1.3%-5.1%) for sinusitis, 8.6% (range, 6.2%-14.6%) for headache, 5.6% (range, 3.6%-7.7%) for low back pain, and 13.3% (range, 11.3%-16.8%) for syncope. The median adjusted odds ratio ranged from 1.21 for low back pain to 1.40 for sinusitis. At the VAMC level, low-value testing was most strongly correlated for syncope and headache (ρ = 0.56; P < .001) and low back pain and headache (ρ = 0.48; P < .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, low-value diagnostic testing was common, varied substantially across VAMCs, and was correlated between veterans' receipt of different low-value tests at the VAMC level. The findings suggest a need to address low-value diagnostic testing, even in integrated health systems, with robust utilization management practices.

Medicare Accountable Care Organizations Reduce Spending on Surgery

BACKGROUND

Surgical care among older adults is costly. While Medicare accountable care organizations (ACOs) are designed around primary care, there are reasons to believe that participation may also affect spending on surgery. This study examines the impact that Medicare ACO alignment has on spending for inpatient and outpatient surgical care.

STUDY DESIGN

We conducted a retrospective cohort study using national Medicare claims (2008 through 2015). Among a 20% random sample of beneficiaries, we identified adults 65 years of age and older enrolled in fee-for-service Medicare, distinguishing between those aligned and unaligned with a Medicare ACO. We then measured payments for surgical services made on their behalf. Finally, we fit multivariable regression models to evaluate the association between ACO alignment and spending for inpatient and outpatient surgical care.

RESULTS

We identified 37,249,845 beneficiary-year observations, of which 2,950,188 (7.9%) were aligned with a Medicare ACO. After adjustment for patient factors, ACO alignment was associated with $181 [95% confidence interval (CI), -$243 to -$118; P <0.001] lower spending per beneficiary-year. ACO alignment was associated with 2.9% fewer inpatient surgical episodes per year [incidence rate ratio (IRR), 0.97; 95% CI, 0.96 to 0.98; P <0.001] but 2.3% more outpatient episodes per year (IRR, 1.02; 95% CI, 1.02 to 1.03; P <0.001). Among inpatient surgical episodes, average payments were $956 lower for ACO aligned beneficiaries (95%CI -$1218 to -$694, P <0.001).

CONCLUSIONS AND RELEVANCE

ACO alignment was associated with savings on surgical care. These savings resulted from increased outpatient surgery and reduced use of inpatient surgery as well as reduced spending per inpatient surgical episode. Greater focus on surgical care may improve the ability of ACOs to control healthcare spending.

Understanding Geographic Variation in Systemic Overuse Among the Privately Insured

BACKGROUND

Medical care overuse is a significant source of patient harm and wasteful spending. Understanding the drivers of overuse is essential to the design of effective interventions.

OBJECTIVE

We tested the association between structural factors of the health care delivery system and regional differences systemic overuse.

RESEARCH DESIGN

We conducted a retrospective analysis of deidentified claims for 18- to 64-year-old adults from the IBM MarketScan Commercial Claims and Encounters Database. We calculated a semiannual Johns Hopkins Overuse Index for each of the 375 Metropolitan Statistical Areas in the United States, from January 2011 to June 2015. We fit an ordinary least squares regression to model the Johns Hopkins Overuse Index as a function of regional characteristics of the health care system, adjusted for confounders and time.

RESULTS

The supply of regional health care resources was associated with systemic overuse in commercially insured beneficiaries. Regional characteristics associated with systemic overuse included number of physicians per 1000 residents (P=0.001) and higher Medicare malpractice geographic price cost index (P<0.001). Regions with a higher density of primary care physicians (P=0.008) and a higher proportion of hospital-based providers (P=0.016) had less systemic overuse. Differences in hospital and insurer market power were inversely associated with systemic overuse.

CONCLUSIONS

Systemic overuse is associated with observable, structural characteristics of the regional health care system. These findings suggest that interventions that aim to improve care efficiency via reductions in overuse should focus on the structural drivers of this phenomenon, rather than on the eradication of individual overused procedures.

Differences in the Receipt of Low-Value Services Between Publicly and Privately Insured Children

BACKGROUND

Children frequently receive low-value services that do not improve health, but it is unknown whether the receipt of these services differs between publicly and privately insured children.

METHODS

We analyzed 2013-2014 Medicaid Analytic eXtract and IBM MarketScan Commercial Claims and Encounters databases. Using 20 measures of low-value care (6 diagnostic testing measures, 5 imaging measures, and 9 prescription drug measures), we compared the proportion of publicly and privately insured children in 12 states who received low-value services at least once or twice in 2014; the proportion of publicly and privately insured children who received low-value diagnostic tests, imaging tests, and prescription drugs at least once; and the proportion of publicly and privately insured children eligible for each measure who received the service at least once.

RESULTS

Among 6 951 556 publicly insured children and 1 647 946 privately insured children, respectively, 11.0% and 8.9% received low-value services at least once, 3.9% and 2.8% received low-value services at least twice, 3.2% and 3.8% received low-value diagnostic tests at least once, 0.4% and 0.4% received low-value imaging tests at least once, and 8.4% and 5.5% received low-value prescription drug services at least once. Differences in the proportion of eligible children receiving each service were typically small (median difference among 20 measures, public minus private: +0.3 percentage points).

CONCLUSIONS

In 2014, 1 in 9 publicly insured and 1 in 11 privately insured children received low-value services. Differences between populations were modest overall, suggesting that wasteful care is not highly associated with payer type. Efforts to reduce this care should target all populations regardless of payer mix.

Addition of Efficiency Measures to Current Accuracy Measures in the Vascular Laboratory Can Be Used for Future Accreditation and Payment Models

BACKGROUND

The Medicare Access and CHIP Reauthorization Act (MACRA) brings with it increased regulatory requirements not traditionally addressed by standard vascular laboratory accreditation, which is based on accuracy. The new quality improvement project of the Intersocietal Accreditation Commission (IAC) may satisfy an improvement activity (IA) of the MACRA. We hypothesize that other IAs in the MACRA such as timeliness of test results or patient care quality performance requirements can be met by analyzing data already being collected by the vascular laboratory. After a process improvement strategy, we chose to review progress in our vascular laboratory related to time to interpretation (TI), patient check-in to study completion (study time), wait time for first available outpatient venous duplex scan (wait time), technologist productivity, and critical results reporting.

METHODS

Data from our hospital-based vascular laboratory were collected from 2010 to 2016. TI was collected through our reporting software VascuPro (Consensus Medical), and study time and wait time were obtained from electronic medical records (EMR) (Epic). Technologist productivity was calculated by commercially available productivity tools, and compliance with critical results reporting was calculated quarterly as per our quality assurance program. Appropriateness of carotid duplex scan testing was performed by expert review of International Classification of Disease codes used to request the test.

RESULTS

TI analysis comprised 91,352 studies with a mean of 3.3 hr between test completion and final interpretation. The TI improved from 5.0 to 2.1 hr on weekdays and was longer on weekends (4.9 hr; P < 0.001). The study time improved from 29.8 to 27.2 min and was 14.9 min shorter on the weekends (P < 0.001). The wait time ranged from a mean of 1-2.08 days. Technologist productivity improved from 90.7% to 93.6%. Critical results reporting quarterly audits showed a 100% compliance rate. On expert review, the International Classification of Disease code on carotid duplex scan requests in the EMR was deemed inaccurate in 17.4% of cases.

CONCLUSIONS

TI and study time improved; wait time and critical results reporting remained steady. Most of the data are readily available in a vascular laboratory standard EMR. The plan-do-study-act (PDSA or Shewhart Cycle) principle is critical to process improvement and needed as we transition from traditional accreditation mostly based on test accuracy to one demanding efficiency, timeliness, patient satisfaction, productivity, accountability, and appropriateness of testing. Process improvement studies will improve patient care and satisfaction, increase efficiency and throughput, while satisfying changing IAC standards and preparing for upcoming regulatory requirements of the MACRA.

Low-Value Care and Clinician Engagement in a Large Medicare Shared Savings Program ACO: a Survey of Frontline Clinicians

BACKGROUND

Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care.

OBJECTIVE

To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care.

DESIGN

Cross-sectional survey of ACO clinicians in 2018.

PARTICIPANTS

1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%.

MAIN MEASURES

Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care.

RESULTS

Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation.

CONCLUSIONS

Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.

The Medicare Shared Savings Program and Outcomes for Ischemic Stroke Patients: a Retrospective Cohort Study

BACKGROUND

Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care.

OBJECTIVE

To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke.

DESIGN

Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605).

MAIN MEASURES

Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated.

KEY RESULTS

For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed.

CONCLUSIONS

Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted.

REGISTRATION

None.

Waste in the US Health Care System: Estimated Costs and Potential for Savings

IMPORTANCE

The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains.

OBJECTIVES

To estimate current levels of waste in the US health care system in 6 previously developed domains and to report estimates of potential savings for each domain.

EVIDENCE

A search of peer-reviewed and "gray" literature from January 2012 to May 2019 focused on the 6 waste domains previously identified by the Institute of Medicine and Berwick and Hackbarth: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. For each domain, available estimates of waste-related costs and data from interventions shown to reduce waste-related costs were recorded, converted to annual estimates in 2019 dollars for national populations when necessary, and combined into ranges or summed as appropriate.

FINDINGS

The review yielded 71 estimates from 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature. Computations yielded the following estimated ranges of total annual cost of waste: failure of care delivery, $102.4 billion to $165.7 billion; failure of care coordination, $27.2 billion to $78.2 billion; overtreatment or low-value care, $75.7 billion to $101.2 billion; pricing failure, $230.7 billion to $240.5 billion; fraud and abuse, $58.5 billion to $83.9 billion; and administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: failure of care delivery, $44.4 billion to $97.3 billion; failure of care coordination, $29.6 billion to $38.2 billion; overtreatment or low-value care, $12.8 billion to $28.6 billion; pricing failure, $81.4 billion to $91.2 billion; and fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion.

CONCLUSIONS AND RELEVANCE

In this review based on 6 previously identified domains of health care waste, the estimated cost of waste in the US health care system ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste, excluding savings from administrative complexity, ranged from $191 billion to $286 billion, representing a potential 25% reduction in the total cost of waste. Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in US health care expenditures.

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries

IMPORTANCE

Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.

OBJECTIVE

To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019.

EXPOSURES

Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG.

MAIN OUTCOMES AND MEASURES

Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade.

RESULTS

Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade.

CONCLUSIONS AND RELEVANCE

Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.

Medicare Accountable Care Organizations Are Not Associated With Reductions in the Use of Low-Value Coronary Revascularization

BACKGROUND

Because specialty care accounts for half of Medicare expenditures, improving its value is critical to the success of Medicare accountable care organizations (ACOs) in curbing spending growth. However, whether ACOs have reduced low-value specialty care without compromising use of high-value services remains unknown.

METHODS AND RESULTS

Using national Medicare data, we identified 2 cohorts: beneficiaries for whom the value of coronary revascularization is lower (those with ischemic heart disease without angina, congestive heart failure, or recent admission for acute myocardial infarction) and beneficiaries for whom its value is higher (those with recent acute myocardial infarction admission). We then determined the provider groups who cared for the cohorts, distinguishing between those participating (n=298) and those not participating in a Medicare ACO (1329). After measuring the provider groups' use of coronary artery bypass grafting and percutaneous coronary intervention among the 2 cohorts, we fit multivariable models to test the statistical significance of rates of change in low- and high-value revascularization after ACO participation. During the pre-ACO period, participating and nonparticipating provider groups had similar rates of low- and high-value revascularization. Our multivariable model results show that rates of change for low- and high-value coronary revascularization were not altered by a provider group's participation in a Medicare ACO (lower value: difference, -0.04 per year; 95% confidence interval, -0.11 to 0.03; higher value: difference, 0.96 per year; 95% confidence interval, -0.46 to 2.4).

CONCLUSIONS

We found no association between provider group participation in a Medicare ACO and use of low- or high-value coronary revascularization.

To do or not to do-balancing governance and professional autonomy to abandon low-value practices: a study protocol

BACKGROUND

Many interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations.

METHODS

Theories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance.

DISCUSSION

This study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.

Health Information Technology and Accountable Care Organizations: A Systematic Review and Future Directions

Background:

Since the inception of Accountable Care Organizations (ACOs), many have acknowledged the potential synergy between ACOs and health information technology (IT) in meeting quality and cost goals.

Objective:

We conducted a systematic review of the literature in order to describe what research has been conducted at the intersection of health IT and ACOs and identify directions for future research.

Methods:

We identified empirical studies discussing the use of health IT via PubMed search with subsequent snowball reference review. The type of health IT, how health IT was included in the study, use of theory, population, and findings were extracted from each study.

Results:

Our search resulted in 32 studies describing the intersection of health IT and ACOs, mainly in the form of electronic health records and health information exchange. Studies were divided into three streams by purpose; those that considered health IT as a factor for ACO participation, health IT use by current ACOs, and ACO performance as a function of health IT capabilities. Although most studies found a positive association between health IT and ACO participation, studies that address the performance of ACOs in terms of their health IT capabilities show more mixed results.

Conclusions:

In order to better understand this emerging relationship between health IT and ACO performance, we propose future research should consider more quasi-experimental studies, the use of theory, and merging health, quality, cost, and health IT use data across ACO member organizations.

Low-Value Prostate Cancer Screening Among Older Men Within the Veterans Health Administration

BACKGROUND/OBJECTIVES

Prostate-specific antigen (PSA) screening can be of low value in older adults. Our objective was to quantify the prevalence and variation of low-value PSA screening across the Veterans Health Administration (VA), which has instituted programs to reduce low-value care.

DESIGN

Retrospective cohort.

SETTING

VA administrative data, 2014 to 2015.

PARTICIPANTS

National random sample (N = 214 480) of male veterans, aged 75 years or older.

MEASUREMENTS

We defined PSA screening in men aged 75 years or older without a history of prostate cancer as low value, per established definitions in Medicare. We calculated screening rates overall and by VA Medical Center (VAMC), adjusting for patient and VAMC-level factors. We characterized variation across VAMCs using the adjusted median odds ratio (OR) and compared the adjusted OR of screening between VAMCs in different deciles of low-value screening rates. In separate sensitivity analyses, we assessed screening in veterans at greatest risk of 1-year mortality and among veterans after excluding those who underwent prostatectomy, had a prior PSA elevation, or had a clinical indication for testing.

RESULTS

Overall, 37 867 (17.7%) of veterans underwent low-value PSA screening (VAMC range = 3.3%-38.2%). The adjusted median OR was 1.88, meaning the median odds of screening would increase by 88% were a veteran to transfer his care to a VAMC with higher screening rates. Veterans at VAMCs in the top decile had an adjusted OR of 12.9 (95% confidence interval = 11.0-15.2) compared to those veterans in the lowest decile. Among veterans with the greatest mortality risk (n = 23 377), 3496 (15.0%) underwent screening (VAMC range = 1.7%-46.3%). After excluding veterans with a prior prostatectomy, PSA elevation, or a potential clinical indication, 31 556 (14.7%) underwent screening (VAMC range = 2.0%-49.9%).

CONCLUSIONS

In a national cohort of older veterans, more than one in six received low-value PSA screening, with greater than 10-fold variation across VAMCs and high rates of screening among those with the greatest mortality risk. J Am Geriatr Soc 67:1922-1927, 2019.

Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study

BACKGROUND

Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood.

OBJECTIVES

To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored.

METHODS

A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software.

RESULTS

Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care.

CONCLUSIONS

A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.

Systemic overuse of health care in a commercially insured US population, 2010-2015

BACKGROUND

Overuse is a leading contributor to the high cost of health care in the United States. Overuse harms patients and is a definitive waste of resources. The Johns Hopkins Overuse Index (JHOI) is a normalized measure of systemic health care services overuse, generated from claims data, that has been used to describe overuse in Medicare beneficiaries and to understand drivers of overuse. We aimed to adapt the JHOI for application to a commercially insured US population, to examine geographic variation in systemic overuse in this population, and to analyze trends over time to inform whether systemic overuse is an enduring problem.

METHODS

We analyzed commercial insurance claims from 18 to 64 year old beneficiaries. We calculated a semiannual JHOI for each of the 375 Metropolitan Statistical Areas and 47 rural regions of the US. We generated maps to examine geographic variation and then analyzed each region's change in their JHOI quintile from January 2011 to June 2015.

RESULTS

The JHOI varied markedly across the US. Across the country, rural regions tended to have less systemic overuse than their MSA counterparts (p < 0.01). Regional systemic overuse is positively correlated from one time period to the next (p < 0.001). Between 2011 and 2015, 53.7% (N = 226) of regions remained in the same quintile of the JHOI. Eighty of these regions had a persistently high or persistently low JHOI throughout study duration.

CONCLUSIONS

The systemic overuse of health care resources is an enduring, regional problem. Areas identified as having a persistently high rate of systemic overuse merit further investigation to understand drivers and potential points of intervention.

Recommended Cancer Screening in Accountable Care Organizations: Trends in Colonoscopy and Mammography in the Medicare Shared Savings Program

PURPOSE

Accountable care organizations (ACOs) are a delivery and payment model designed to encourage integrated, high-value care. We designed a study to test the association between ACOs and two recommended cancer screening tests, colonoscopy for colorectal cancer and mammography for breast cancer.

METHODS

Using the random 20% sample of Medicare claims, beneficiaries were attributed to ACO or non-ACO cohorts on the basis of providers' enrollment in the Medicare Shared Savings Program. An inverse probability of treatment weighting was used to balance patient characteristics between ACO and non-ACO cohorts. A propensity score-weighted, difference-in-differences analysis was then performed using the same provider groups in 2010-pre-ACO-as a baseline. A secondary analysis for older-nonrecommended-age ranges was performed.

RESULTS

Prevalence of colonoscopy in recommended age ranges in ACOs from 2010 to 2014 increased from 15.3% (95% CI, 14.9% to 15.6%) to 17.9% (95% CI, 17.3% to 18.5%). This differed significantly from the change in non-ACOs (difference in differences, 1.2%; P < .001). Among women in ACOs, mammography prevalence rose from 53.7% (95% CI, 53.0% to 54.4%) to 54.9% (95% CI, 54.2% to 55.7%). In contrast to colonoscopy, the difference in mammography prevalence was not significantly different in ACO versus non-ACOs (difference in differences, 0.49%; P < .13). A similar pattern was also observed in older-nonrecommended-age ranges with significant difference in differences (ACO v non-ACO) in colonoscopy, but not mammography.

CONCLUSION

The impact of ACOs on cancer screening varies between screening tests. Our results are consistent with a greater effect of ACOs on high-cost, high-complexity screening services, which may be more sensitive to integrated care delivery models.

The impact of provider payment reforms and associated care delivery models on cost and quality in cancer care: A systematic literature review

OBJECTIVES

To investigate the impact of provider payment reforms and associated care delivery models on cost and quality in cancer care.

METHODS

Data sources/study setting: Review of English-language literature published in PubMed, Embase and Cochrane library (2007-2019). Study design: We performed a systematic literature review (SLR) to identify the impact of cancer care reforms. Primary endpoints were resource use, cost, quality of care, and clinical outcomes. Data collection/extraction methods: For each study, we extracted and categorized comparative data on the impact of policy reforms. Given the heterogeneity in patients, interventions and outcome measures, we did a qualitative synthesis rather than a meta-analysis.

RESULTS

Of the 26 included studies, seven evaluations were in fact qualified as quasi experimental designs in retrospect. Alternative payment models were significantly associated with reduction in resource use and cost in cancer care. Across the seventeen studies reporting data on the implicit payment reforms through care coordination, the adoption of clinical pathways was found effective in reduction of unnecessary use of low value services and associated costs. The estimates of all measures in ACO models varied considerably across participating providers, and our review found a rather mixed impact on cancer care outcomes.

CONCLUSION

The findings suggest promising improvement in resource utilization and cost control after transition to prospective payment models, but, further primary research is needed to apply robust measures of performance and quality to better ensure that providers are delivering high-value care to their patients, while reducing the cost of care.

A method for analyzing inpatient care variability through physicians' orders

OBJECTIVE

Administrators assess care variability through chart review or cost variability to inform care standardization efforts. Chart review is costly and cost variability is imprecise. This study explores the potential of physician orders as an alternative measure of care variability.

MATERIALS & METHODS

The authors constructed an order variability metric from adult Vanderbilt University Hospital patients treated between 2013 and 2016. The study compared how well a cost variability model predicts variability in the length of stay compared to an order variability model. Both models adjusted for covariates such as severity of illness, comorbidities, and hospital transfers.

RESULTS

The order variability model significantly minimized the Akaike information criterion (superior outcome) compared to the cost variability model. This result also held when excluding patients who received intensive care.

CONCLUSION

Order variability can potentially typify care variability better than cost variability. Order variability is a scalable metric, calculable during the course of care.

Quality and Experience of Outpatient Care in the United States for Adults With or Without Primary Care

IMPORTANCE

The US health care system is typically organized around hospitals and specialty care. The value of primary care remains unclear and debated.

OBJECTIVE

To determine whether an association exists between receipt of primary care and high-value services, low-value services, and patient experience.

DESIGN, SETTING, AND PARTICIPANTS

This is a nationally representative analysis of noninstitutionalized US adults 18 years or older who participated in the Medical Expenditure Panel Survey. Propensity score-weighted quality and experience of care were compared between 49 286 US adults with and 21 133 adults without primary care from 2012 to 2014. Temporal trends were also analyzed from 2002 to 2014.

EXPOSURES

Patient-reported receipt of primary care, determined by the 4 "Cs" of primary care: first-contact care that is comprehensive, continuous, and coordinated.

MAIN OUTCOMES AND MEASURES

Thirty-nine clinical quality measures and 7 patient experience measures aggregated into 10 clinical quality composites (6 high-value and 4 low-value services), an overall patient experience rating, and 2 experience composites.

RESULTS

From 2002 to 2014, the mean annual survey response rate was 58% (range, 49%-65%). Between 2012 and 2014, compared with respondents without primary care (before adjustment), those with primary care were older (50 [95% CI, 50-51] vs 38 [95% CI, 38-39] years old), more often female (55% [95% CI, 54%-55%] vs 42% [95% CI, 41%-43%]), and predominately white individuals (50% [95% CI, 49%-52%] vs 43% [95% CI, 41%-45%]). After propensity score weighting, US adults with or without primary care had the same mean numbers of outpatient (6.7 vs 5.9; difference, 0.8 [95% CI, -0.2 to 1.8]; P = .11), emergency department (0.2 for both; difference, 0.0 [95% CI, -0.1 to 0.0]; P = .17), and inpatient (0.1 for both; difference, 0.0 [95% CI, 0.0-0.0]; P = .92) encounters annually, but those with primary care filled more prescriptions (mean, 14.1 vs 10.7; difference, 3.4 [95% CI, 2.0-4.7]; P < .001) and were more likely to have a routine preventive visit in the past year (mean, 72.2% vs 57.5%; difference, 14.7% [95% CI, 12.3%-17.1%]; P < .001). From 2012 to 2014, Americans with primary care received more high-value care in 4 of 5 composites. For example, 78% of those with primary care received high-value cancer screening compared with 67% without primary care (difference, 10.8% [95% CI, 8.5%-13.0%]; P < .001). Americans with or without primary care received low-value care with similar frequencies on 3 of 4 composites, although Americans with primary care received more low-value antibiotics (59% vs 48%; difference, 11.0% [95% CI, 2.8%-19.3%] P < .001). Respondents with primary care also reported significantly better health care access and experience. For example, physician communication was highly rated for a greater proportion of those with (64%) vs without (54%) primary care (difference, 10.2%; 95% CI, 7.2%-13.1%; P < .001). Differences in quality and experience between Americans with or without primary care were essentially stable between 2002 and 2014.

CONCLUSIONS AND RELEVANCE

Receipt of primary care was associated with significantly more high-value care, slightly more low-value care, and better health care experience. Policymakers and health system leaders seeking to improve value should consider increasing investments in primary care.

Analysis of Physician Variation in Provision of Low-Value Services

IMPORTANCE

Facing new financial incentives to reduce unnecessary spending, health care organizations may attempt to reduce wasteful care by influencing physician practices or selecting more cost-effective physicians. However, physicians' role in determining the use of low-value services has not been well described.

OBJECTIVES

To quantify variation in provision of low-value health care services among primary care physicians and to estimate the proportion of variation attributable to physician characteristics that may be used to predict performance.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective analysis included national Medicare fee-for-service claims of 3 159 834 beneficiaries served by 41 773 generalist physicians from January 1, 2008, through December 31, 2013 (data were analyzed in 2016 through 2018). Multilevel modeling was used to estimate the extent of variation in service use across physicians within their region and provider organization, adjusted for patient clinical and sociodemographic characteristics and sampling variation. The proportion of variation attributable to physician characteristics that may be used to predict performance (age, sex, academic degree, professorship, publication record, trial investigation, grant receipt, pharmaceutical or device manufacturer payment, and panel size) was estimated via additional regression analysis.

MAIN OUTCOMES AND MEASURES

Annual count per beneficiary of 17 primary care-associated services that provide minimal clinical benefit.

RESULTS

Among the 3 159 834 beneficiaries (58.3% women; mean [SD] age, 73.2 [11.0] years) served by 41 773 physicians (74.9% men; mean [SD] age, 48.0 [10.1] years), the mean annual rate of low-value services was 33.1 services per 100 beneficiaries. Considerable variation across physicians within the same region was found (SD, 8.8 [95% CI, 8.7-8.9]; 90th:10th percentile ratio, 2.03 [95% CI, 2.01-2.06]) and across physicians within the same organization (SD, 6.1 [95% CI, 6.0-6.2]; 90th:10th percentile ratio, 1.61 [95% CI, 1.60-1.63]). The corresponding rates at the 10th percentile of physicians within region and within organization respectively were 21.8 and 25.3 services per 100 beneficiaries. Observable physician characteristics accounted for only 4.4% of physician variation within region and 1.4% of physician variation within organization.

CONCLUSIONS AND RELEVANCE

Physician practices may substantially contribute to low-value service use, which is prevalent even among the least wasteful physicians. Because little variation is predicted by measured physician characteristics, direct measures of low-value care provision may aid organizational efforts to encourage high-value practices.

Regional Supply of Medical Resources and Systemic Overuse of Health Care Among Medicare Beneficiaries

BACKGROUND

Overuse of health care resources has been identified as the leading contributor to waste in the US health care system.

OBJECTIVE

To explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services.

DESIGN

Using Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas.

KEY RESULTS

Regions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P < 0.001). Regional characteristics associated with higher JHOI scores, indicating more systemic overuse, included number per 1000 residents of acute care hospital beds (P = 0.002) and of hospital-based anesthesiologists, pathologists, and radiologists (P = 0.02).

CONCLUSIONS

Regional variations in health care resources including the clinician workforce are associated with the intensity of systemic overuse of health care. The role of primary care doctors in reducing health care overuse deserves further attention.

Medicare Accountable Care Organizations and Use of Potentially Low-Value Procedures

OBJECTIVE

To evaluate the effect of Accountable Care Organizations (ACOs) on the use of vertebroplasty and arthroscopic partial meniscectomy, 2 procedures for which randomized controlled trials suggest similar outcomes to sham surgery and therefore may provide low value. Medicare Shared Savings Program ACOs aim to improve quality and decrease health care spending. Reducing the use of potentially low-value procedures can accomplish both of these goals.

METHODS

We performed a retrospective cohort study of patients who underwent potentially low-value orthopedic procedures (vertebroplasty and partial meniscectomy) and a control (hip fracture) from 2010 to 2015 using a 20% sample of national Medicare claims. We performed an interrupted time-series analysis using linear spline models to evaluate the count of each procedure per 1000 patients, stratified by ACO participation.

RESULTS

We identified 76 256 patients who underwent arthroscopic partial meniscectomy, 44 539 patients who underwent vertebroplasty, and 50 760 patients who underwent hip fracture admission. Arthroscopic partial meniscectomy rates decreased, vertebroplasty rates remained stable, and hip fracture rates increased for both groups during the study period, with similar trends among ACO and non-ACO patients. After January 1, 2013, ACO and non-ACO populations had similar trends for vertebroplasty (ACO incidence rate ratio [IRR] = 1.15 [1.08-1.23] vs non-ACO IRR = 1.11 [1.05-1.16]), meniscectomy (ACO IRR = 1.06 [1.01-1.12] vs non-ACO IRR = 1.03 [0.99-1.07]), and hip fracture (ACO IRR = 1.08 [1.01-1.14] vs non-ACO IRR = 1.08 [1.03-1.13]).

CONCLUSIONS

ACOs were not associated with a reduction in the frequency of vertebroplasty and arthroscopic partial meniscectomy.

The Accountable Care Organization for Surgical Care

Rising health care costs superimposed on uncertainty surrounding the relationship between health care spending and quality have resulted in an urgent need to develop strategies to better align health care payment with value. Such approaches, at least in theory, work to achieve the dual aims of reducing growth in health care spending and improving population health. To date, surgery has not been prioritized in accountable care organizations (ACOs). Nonetheless, it is critically important to begin to consider strategic and impactful mechanisms through which surgery can be seamlessly woven into innovative population health models.

ACOs with risk-bearing experience are likely taking steps to reduce low-value medical services

OBJECTIVES

Accountable care organizations (ACOs) are groups of healthcare providers responsible for quality of care and spending for a defined patient population. The elimination of low-value medical services will improve quality and reduce costs and, therefore, ACOs should actively work to reduce the use of low-value services. We set out to identify ACO characteristics associated with implementation of strategies to reduce overuse.

STUDY DESIGN

Survey analysis.

METHODS

We used the National Survey of ACOs to determine the percentage of responding ACOs aware of the Choosing Wisely campaign and to what degree ACOs have taken steps to reduce the use of low-value services. We identified characteristics of ACOs associated with implementing low-value care-reducing strategies using 3 statistical models (stepwise and LASSO logistic regression and random forest).

RESULTS

Responding executives of 155 of 267 ACOs (58%) were aware of Choosing Wisely. Eighty-four of those 155 ACO leaders said that their ACOs also actively implemented strategies to reduce the use of low-value services, largely through educating physicians and stimulating shared decision making. All 3 models identified the presence of at least 1 commercial payer contract and prior joint experience pursuing risk-based payment contracts as the most important predictors of an ACO actively implementing strategies to reduce low-value care.

CONCLUSIONS

In the first year of implementation, just one-third of ACOs had taken steps to reduce the use of low-value medical services. Safety-net ACOs and those with little experience as a risk-bearing organization need more time and support from healthcare payers and the Choosing Wisely campaign to prioritize the reduction of overuse.

Empirical and conceptual investigation of de-implementation of low-value care from professional and health care system perspectives: a study protocol

Background

A considerable proportion of interventions provided to patients lacks evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary, or even harmful care. Thus, in addition to implementing evidence-based practices, there is also a need to abandon interventions that are not based on best evidence, i.e., low-value care. However, research on de-implementation is limited, and there is a lack of knowledge about how effective de-implementation processes should be carried out. The aim of this project is to explore the phenomenon of the de-implementation of low-value health care practices from the perspective of professionals and the health care system.

Methods

Theories of habits and developmental learning in combination with theories of organizational alignment will be used. The project’s work will be conducted in five steps. Step 1 is a scoping review of the literature, and Step 2 has an explorative design involving interviews with health care stakeholders. Step 3 has a prospective design in which workplaces and professionals are shadowed during an ongoing de-implementation. In Step 4, a conceptual framework for de-implementation will be developed based on the previous steps. In Step 5, strategies for de-implementation are identified using a co-design approach.

Discussion

This project contributes new knowledge to implementation science consisting of empirical data, a conceptual framework, and strategy suggestions on de-implementation of low-value care. The professionals’ perspectives will be highlighted, including insights into how they make decisions, handle de-implementation in daily practice, and what consequences it has on their work. Furthermore, the health care system perspective will be considered and new knowledge on how de-implementation can be understood across health care system levels will be obtained. The theories of habits and developmental learning can also offer insights into how context triggers and reinforces certain behaviors and how factors at the individual and the organizational levels interact. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve de-implementation processes at all levels of the health care system. The framework and the strategies can thereafter be evaluated for their validity and impact in future studies.

Medicare Accountable Care Organization Enrollment and Appropriateness of Cancer Screening

IMPORTANCE

Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown.

OBJECTIVE

To determine whether Medicare Shared Savings Program (MSSP) ACO enrollment changes the appropriateness of screening for breast, colorectal, and prostate cancers.

DESIGN, SETTING, AND PARTICIPANTS

For this population-based analysis of Medicare beneficiaries, we used Medicare data from 2007 through 2014 and evaluated changes in screening associated with ACO enrollment using differences-in-differences (DD) analyses. We then performed difference-in-difference-in-differences (DDD) analyses to determine whether observed changes in cancer screening associated with ACO enrollment were different across strata of appropriateness, defined using age (65-74 years vs ≥75 years) and predicted survival (top vs bottom quartile).

MAIN OUTCOMES AND MEASURES

Rates of breast, colorectal, and prostate cancer screening measured yearly as a proportion of eligible Medicare beneficiaries undergoing relevant screening services.

RESULTS

Among Medicare beneficiaries, comprising 39 218 652 person-years before MSSP enrollment and 17 252 345 person-years after MSSP enrollment, breast cancer screening declined among both ACO (42.7% precontract, 38.1% postcontract) and non-ACO (37.3% precontract, 34.1% postcontract) populations. The adjusted rate of decline (DD) in the ACO population exceeded the non-ACO population by 0.79% (P < .001). This decline was most pronounced among elderly women (-2.1%), with minimal observed change among younger women (-0.26%). Baseline colorectal cancer screening rates were lower than those for breast cancer among both ACO (10.1% precontract, 10.3% postcontract) and non-ACO (9.2% precontract, 9.1% postcontract) populations. We observed an adjusted 0.24% (P = .03) increase in screening associated with ACO enrollment, most pronounced among younger Medicare beneficiaries (0.36%). For breast and colorectal cancer, we observed statistically significant differences in estimates of effect between age strata, suggesting that the ACO effect on cancer screening is mediated by age (DDD for both P < .001). Prostate cancer screening declined among ACO (35.1% precontract, 28.5% postcontract) and non-ACO (31.2% precontract, 25.7% postcontract) populations. The adjusted rate of decline in the ACO population exceeded that of the non-ACO population by 1.2%. We observed no difference in estimate of effect between age strata, suggesting that the ACO-mediated changes in prostate cancer screening are similar among younger and elderly men. Results characterizing appropriateness with predicted survival mirrored those when stratified by age.

CONCLUSIONS AND RELEVANCE

Medicare Shared Savings Program ACO enrollment is associated with more appropriate breast and colorectal screening, although the magnitude of the observed ACO effect is modest in the early ACO experience.

Oregon's Medicaid Reform And Transition To Global Budgets Were Associated With Reductions In Expenditures

In 2012 Oregon initiated an ambitious delivery system reform, moving the majority of its Medicaid enrollees into sixteen coordinated care organizations, a type of Medicaid accountable care organization. Using claims data, we assessed measures of access, appropriateness of care, utilization, and expenditures for five service areas (evaluation and management, imaging, procedures, tests, and inpatient facility care), comparing Oregon to the neighboring state of Washington. Overall, the transformation into coordinated care organizations was associated with a 7 percent relative reduction in expenditures across the sum of these services, attributable primarily to reductions in inpatient utilization. The change to coordinated care organizations also demonstrated reductions in avoidable emergency department visits and improvements in some measures of appropriateness of care, but also exhibited reductions in primary care visits, a potential area of concern. Oregon's coordinated care organizations could provide lessons for controlling health care spending for other state Medicaid programs.

ACOs Holding Commercial Contracts Are Larger And More Efficient Than Noncommercial ACOs

Accountable care organizations (ACOs) have diverse contracting arrangements and have displayed wide variation in their performance. Using data from national surveys of 399 ACOs, we examined differences between the 228 commercial ACOs (those with commercial payer contracts) and the 171 noncommercial ACOs (those with only public contracts, such as with Medicare or Medicaid). Commercial ACOs were significantly larger and more integrated with hospitals, and had lower benchmark expenditures and higher quality scores, compared to noncommercial ACOs. Among all of the ACOs, there was low uptake of quality and efficiency activities. However, commercial ACOs reported more use of disease monitoring tools, patient satisfaction data, and quality improvement methods than did noncommercial ACOs. Few ACOs reported having high-level performance monitoring capabilities. About two-thirds of the ACOs had established processes for distributing any savings accrued, and these ACOs allocated approximately the same amount of savings to the ACOs themselves, participating member organizations, and physicians. Our findings demonstrate that ACO delivery systems remain at a nascent stage. Structural differences between commercial and noncommercial ACOs are important factors to consider as public policy efforts continue to evolve.

Overuse and insurance plan type in a privately insured population

OBJECTIVES

A substantial portion of healthcare spending is wasted on services that do not directly improve patient health and that cause harm in some cases. Features of health insurance coverage, including enrollment in high-deductible health plans (HDHPs) or health maintenance organizations (HMOs), may provide financial and nonfinancial mechanisms to potentially reduce overuse of low-value healthcare services.

STUDY DESIGN

Using 2009 to 2013 administrative data from 3 large commercial insurers, we examined patient characteristics and health insurance plan types associated with overuse of 6 healthcare services identified by the Choosing Wisely campaign.

METHODS

We explored associations between overuse and patient characteristics using multivariate logistic regression models, including patient age, gender, enrollment in an HMO, enrollment in an HDHP, an indicator of primary care fragmentation, and number of outpatient visits as explanatory variables.

RESULTS

Measurement of services highlighted as potential overuse by the Choosing Wisely recommendations revealed low to moderate prevalence, depending on the service. HMO coverage and enrollment in HDHPs were significantly associated with differences in prevalence of all 6 services, albeit differently in terms of the direction of the effects. Primary care fragmentation was significantly associated with higher rates of overuse.

CONCLUSIONS

Neither HDHPs nor HMO plans, with their closed networks and referral requirements, consistently reduced overuse, although HMO plans were never associated with higher rates of overuse. As policy makers seek levers for reducing low-value healthcare utilization, health insurance plan features may prove a valuable target, although the effect may be complicated by other factors.

Low-Value Service Use in Provider Organizations

OBJECTIVE

To assess whether provider organizations exhibit distinct profiles of low-value service provision.

DATA SOURCES

2007-2011 Medicare fee-for-service claims and enrollment data.

STUDY DESIGN

Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variation across organizations, persistence within organizations over time, and correlations in use of different types of low-value services within organizations were estimated via multilevel modeling, with adjustment for beneficiary sociodemographic and clinical characteristics.

PRINCIPAL FINDINGS

Organizations provided 45.6 low-value services per 100 beneficiaries on average, with considerable variation across organizations (90th/10th percentile ratio, 1.78; 95 percent CI, 1.72-1.84), including substantial between-organization variation within hospital referral regions (90th/10th percentile ratio, 1.66; 95 percent CI, 1.60-1.71). Low-value service use within organizations was highly correlated over time (r, 0.98; 95 percent CI, 0.97-0.99) and positively correlated between 13 of 15 pairs of service categories (average r, 0.26; 95 percent CI, 0.24-0.28), with the greatest correlation between low-value imaging and low-value cardiovascular testing and procedures (r, 0.54).

CONCLUSIONS

Use of low-value services in provider organizations exhibited substantial variation, high persistence, and modest consistency across service types. These findings are consistent with organizations shaping the practice patterns of affiliated physicians.

Impact of Accountable Care Organizations on Utilization, Care, and Outcomes: A Systematic Review

Since 2010, more than 900 accountable care organizations (ACOs) have formed payment contracts with public and private insurers in the United States; however, there has not been a systematic evaluation of the evidence studying impacts of ACOs on care and outcomes across payer types. This review evaluates the quality of evidence regarding the association of public and private ACOs with health service use, processes, and outcomes of care. The 42 articles identified studied ACO contracts with Medicare ( N = 24 articles), Medicaid ( N = 5), commercial ( N = 11), and all payers ( N = 2). The most consistent associations between ACO implementation and outcomes across payer types were reduced inpatient use, reduced emergency department visits, and improved measures of preventive care and chronic disease management. The seven studies evaluating patient experience or clinical outcomes of care showed no evidence that ACOs worsen outcomes of care; however, the impact on patient care and outcomes should continue to be monitored.

Impact of consumer-directed health plans on low-value healthcare

OBJECTIVES

To assess the impact of consumer-directed health plan (CDHP) enrollment on low-value healthcare spending.

STUDY DESIGN

We performed a quasi-experimental analysis using insurance claims data from 376,091 patients aged 18 to 63 years continuously enrolled in a plan from a large national commercial insurer from 2011 to 2013. We measured spending on 26 low-value healthcare services that offer unclear or no clinical benefit.

METHODS

Employing a difference-in-differences approach, we compared the change in spending on low-value services for patients switching from a traditional health plan to a CDHP with the change in spending on low-value services for matched patients remaining in a traditional plan.

RESULTS

Switching to a CDHP was associated with a $231.60 reduction in annual outpatient spending (95% CI, -$341.65 to -$121.53); however, no significant reductions were observed in annual spending on the 26 low-value services (--$3.64; 95% CI, -$9.60 to $2.31) or on these low-value services relative to overall outpatient spending (-$7.86 per $10,000 in outpatient spending; 95% CI, -$18.43 to $2.72). Similarly, a small reduction was noted for low-value spending on imaging (-$1.76; 95% CI, -$3.39 to -$0.14), but not relative to overall imaging spending, and no significant reductions were noted in low-value laboratory spending.

CONCLUSIONS

CDHPs in their current form may represent too blunt an instrument to specifically curtail low-value healthcare spending.

Overuse of Repeat Upper Endoscopy in the Veterans Health Administration: A Retrospective Analysis

OBJECTIVES

Americans undergo ∼7 million esophagogastroduodenoscopies (EGDs) annually, and one-third of Medicare beneficiaries undergo a repeat EGD within 3 years. As many as 43% of these repeat EGDs are inappropriate. We aimed to determine the rate of repeat inappropriate EGD within the Veterans Health Administration (VHA), and identify factors associated with repeat EGD.

METHODS

We conducted retrospective analyses of Veterans undergoing an index EGD at 159 VHA facilities between 1 January 2003 and 30 June 2007. We excluded Veterans without regular use of VHA for health care or 5 years of follow-up. Appropriateness of repeat EGDs was classified based on diagnostic and procedure codes into three categories: Likely Appropriate, Possible Overuse, and Probable Overuse. The proportion of repeat EGDs in each category was tabulated. Multilevel logistic regression was performed to estimate the impact of patient-level and site-level factors on the odds of repeat EGD.

RESULTS

Of the 235,855 included Veterans, 85,690 (36.3%) underwent a repeat EGD within 5 years. Of the repeat EGDs, 42,412 (49.5%) were Likely Appropriate, 35,503 (41.4%) represented Possible Overuse, and 7,756 (9.1%) represented Probable Overuse. Patients with more frequent encounters with primary care providers and access to facilities performing EGD and with greater complexity of services were more likely to receive repeat EGD, regardless of whether the repeat EGD was appropriate or overuse. Women were slightly more likely to undergo repeat EGD in Probable Overuse situations.

CONCLUSIONS

Overuse of repeat EGD is common in VHA despite the absence of financial incentives that promote overuse. Efforts are needed to better understand the motivations for overuse and barriers to appropriate use, and to promote appropriate use of repeat EGD.

Clinician-Level Predictors for Ordering Low-Value Imaging

IMPORTANCE

Clinicians who order unnecessary radiographic imaging may cause financial harm to patients who have increasing levels of cost sharing. Clinician predictors of low-value imaging are largely unknown.

OBJECTIVE

To characterize clinician predictors of low-value imaging for acute uncomplicated back pain and headache, including clinicians who saw both conditions.

DESIGN, SETTING, AND PARTICIPANTS

Multivariate logistic regression modeling of imaging rates after acute uncomplicated back pain and headache visits as indicated by January 2010 to December 2014 commercial insurance claims and demographic data from a large US health insurer. Participants included 100 977 clinicians (primary care physicians, specialist physicians, and chiropractors).

MAIN OUTCOMES AND MEASURES

Imaging after acute uncomplicated back pain and headache visits was recorded. We identified whether the clinician's prior patient received imaging, whether the clinician was an owner of imaging equipment, and the varying impact by clinician specialty. We then used high rates of low-value back imaging as a predictor for low-value headache imaging.

RESULTS

Clinicians conducted 1 007 392 visits for 878 720 adults ages 18 to 64 years with acute uncomplicated back pain; 52 876 primary care physicians conducted visits for 492 805 adults ages 18 to 64 years with acute uncomplicated headache; 34 190 primary care clinicians conducted 405 721 visits for 344 991 adults ages 18 to 64 years with headache and had also conducted at least 4 visits from patients with back pain. If a primary care physician's prior patient received low-value back imaging, the patient had 1.81 higher odds of low-value imaging (95% CI, 1.77-1.85). This practice effect was larger for chiropractors (odds ratio [OR], 2.80; 95% CI, 2.74-2.86) and specialists (OR, 2.98; 95% CI, 2.88-3.07). For headache, a prior low-value head image predicted 2.00 higher odds of a subsequent head imaging order (95% CI, 1.95-2.06). Clinician ownership of imaging equipment was a consistent independent predictor of low-value imaging (OR, 1.65-7.76) across clinician type and imaging scenario. Primary care physicians with the highest rates of low-value back imaging also had 1.53 (95% CI, 1.45-1.61) higher odds of ordering low-value headache imaging.

CONCLUSIONS AND RELEVANCE

Clinician characteristics such as ordering low-value imaging on a prior patient, high rates of low-value imaging in another clinical scenario, and ownership of imaging equipment are strong predictors of low-value back and headache imaging. Findings should inform policies that target potentially unnecessary and financially burdensome care.

Care Transformation Strategies and Approaches of Accountable Care Organizations

Although accountable care organizations (ACOs) proliferate, little is known about the activities and strategies ACOs are pursuing to meet goals of reducing costs and improving quality. We use semistructured interviews with executives at 16 ACOs to understand ACO approaches. We identified two overarching ACO approaches to changing clinical care: a practice-based transformation approach, working to overhaul care processes and teams from the inside out; and an overlay approach, where ACO activities were centralized and delivered external to physician practices. We additionally identified four methods ACOs were using to achieve their aims: using patient support roles; targeted clinics, events, programs, and interventions; clinical process standardization; and tracking and identifying patients on which to focus resources. We expect that ACOs using either of the major approaches can succeed under current ACO programs, but that as value-based payment programs mature, ACOs will need to undertake practice-based approaches to be successful in the long term.

Precommitting to choose wisely about low-value services: a stepped wedge cluster randomised trial

Background

Little is known about how to discourage clinicians from ordering low-value services. Our objective was to test whether clinicians committing their future selves (ie, precommitting) to follow Choosing Wisely recommendations with decision supports could decrease potentially low-value orders.

Methods

We conducted a 12-month stepped wedge cluster randomised trial among 45 primary care physicians and advanced practice providers in six adult primary care clinics of a US community group practice.Clinicians were invited to precommit to Choosing Wisely recommendations against imaging for uncomplicated low back pain, imaging for uncomplicated headaches and unnecessary antibiotics for acute sinusitis. Clinicians who precommitted received 1–6 months of point-of-care precommitment reminders as well as patient education handouts and weekly emails with resources to support communication about low-value services.The primary outcome was the difference between control and intervention period percentages of visits with potentially low-value orders. Secondary outcomes were differences between control and intervention period percentages of visits with possible alternate orders, and differences between control and 3-month postintervention follow-up period percentages of visits with potentially low-value orders.

Results

The intervention was not associated with a change in the percentage of visits with potentially low-value orders overall, for headaches or for acute sinusitis, but was associated with a 1.7% overall increase in alternate orders (p=0.01). For low back pain, the intervention was associated with a 1.2% decrease in the percentage of visits with potentially low-value orders (p=0.001) and a 1.9% increase in the percentage of visits with alternate orders (p=0.007). No changes were sustained in follow-up.

Conclusion

Clinician precommitment to follow Choosing Wisely recommendations was associated with a small, unsustained decrease in potentially low-value orders for only one of three targeted conditions and may have increased alternate orders.

Trial registration number

NCT02247050; Pre-results.

Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care

BACKGROUND

Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low-value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care.

METHODS

Using a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer from 2010 through 2013. Rates of treatment, potential overtreatment (ie, treatment in men with a ≥75% chance of 10-year mortality from competing risks), and Medicare payments were measured using regression models. The impact of ACO participation was assessed using difference-in-differences analyses.

RESULTS

Before implementation of ACOs, the treatment rate was 71.8% (95% confidence interval [95% CI], 70.2%-73.3%) for ACO-aligned beneficiaries and 72.3% (95% CI, 71.7%-73.0% [P = .51]) for non-ACO-aligned beneficiaries. After implementation, this rate declined to 68.4% (95% CI, 66.1%-70.7% [P = .017]) for ACO-aligned beneficiaries and 69.3% (95% CI, 68.5%-70.1% [P<.001]) for non-ACO-aligned beneficiaries. There was no differential effect noted for ACO participation. The rate of potential overtreatment decreased from 48.2% (95% CI, 43.1%-53.3%) to 40.2% (95% CI, 32.4%-48.0% [P = .087]) for ACO-aligned beneficiaries and increased from 44.3% (95% CI, 42.1%-46.5%) to 47.0% (95% CI, 44.5%-49.5% [P = .11]) for non-ACO-aligned beneficiaries. These changes resulted in a significant relative decrease in overtreatment of 17% for ACO-aligned beneficiaries (difference-in-differences, 10.8%; P = .031). Payments were not found to be differentially affected by ACO alignment.

CONCLUSIONS

The treatment of prostate cancer and annual payments decreased significantly between 2010 and 2013, but ACO participation did not appear to impact these trends. Among men least likely to benefit, Medicare Shared Savings Program ACO alignment was associated with a significant decline in prostate cancer treatment. Cancer 2018;124:563-70. © 2017 American Cancer Society.

Frequency of low-value care in Alberta, Canada: a retrospective cohort study

OBJECTIVE

To determine how frequently 10 low-value services highlighted by Choosing Wisely are done and what factors influence their provision.

METHODS

This is a retrospective cohort study using routinely collected health data from five linked data sets from 2012 to 2015 in the Canadian province of Alberta to determine the frequency with which 10 low-value services were provided.

RESULTS

Between 2012 and 2015, 162 143 people (4% of all 3 814 536 adult Albertans and 5% of the 3  423 135 who saw a physician at least once in that time frame) received at least one of the 10 low-value services, including 29.8% of Albertans older than 75 years (57 811 of 194 068). The proportion of adults receiving low-value services ranged from carotid artery imaging in 0.1% of asymptomatic adults without cerebrovascular disease, to prostate-specific antigen (PSA) testing in 55.5% of men 75 years or older without a history of prostate cancer. Although age, Charlson scores and frequency of primary care visits were associated with low-value service provision, the directions of the association differed across services; however, higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians in the patient's region were associated with an increased risk of receiving all of the low-value services we examined. The low-value services which resulted in the greatest costs to the healthcare system were cervical cancer screening in women older than 65 without history of cervical dysplasia or genital cancer, PSA testing in men older than 75 without history of prostate cancer and preoperative stress testing/cardiac imaging before non-cardiac surgery.

CONCLUSIONS

Even within a universal coverage healthcare system, the proportion of patients receiving low-value services varied widely (from <0.1% to 56%). Increased use was associated with higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians.

Breast Cancer Screening for Patients of Rural Accountable Care Organization Clinics: A Multi-Level Analysis of Barriers and Facilitators

Not all women 50-74 years received biennial mammography and the situation is worse in rural areas. Accountable care organizations (ACO) emphasize coordinated care, use of electronic health system, and preventive quality measures and these practices may improve their patients' breast cancer screening rate. Using medical record data of 8,347 women patients aged 50-74 years from eight rural ACO clinics in Nebraska, this study examined patient-, provider-, and county-level barriers and facilitators for breast cancer screening. A generalized estimating equations model was used to account for the correlation among patients from the same provider and county. The multi-level logistic regression results suggest that uninsured non-Hispanic Black patients were less likely to meet the biennial mammography screening guideline. Patients whose preferred language being English, having a preventive visit in the past 12 months, having one or more chronic conditions were more likely to meet the biennial mammography screening guideline. Patients with a primary care provider (PCP) that was male, without a medical doctor degree were less likely to screen biennially. Patients with a PCP that reviewed performance report quarterly, or manually checked patients' mammography screening status during visits were more likely to screen biennially. Interestingly, patients whose PCP reported being reminded by a care coordination team were less likely to screen biennially. Patients living in counties with more PCPs were also more likely to screen biennially. The study findings suggest that efforts targeting individual and practice-level barriers could be most effective in improving mammography screening for these rural ACO patients.