Medicare FFS Claims Suggest Targeted Low-Value Care Interventions

Hospitals that are for-profit, non-teaching, and/or located in the South administer the highest rates of low-value care among traditional Medicare beneficiaries, according to a new study published in JAMA Network Open.

The study analyzed fee-for-service claims data for Medicare beneficiaries over 65 years old from 2015 through 2017. The data included claims from 2,415 hospitals with the capacity to deliver 7 out of 12 low-value services.

Head imaging for syncope was the most common low-value service administered (29.9 percent), followed by coronary artery stenting for stable coronary disease (15.8 percent).

Southern hospitals were most likely to administer low-value services, with a 0.06 higher mean overuse score than midwestern hospitals, and a 0.08 higher overuse score than both northeast hospitals and western hospitals.

For-profit hospitals were more likely to provide low-value services compared to non-profit hospitals, with a 0.03 difference in mean overuse scores.

Non-teaching hospitals were more likely to administer low-value services than their academic counterparts, with an average overuse score 0.10 greater than major teaching hospitals. Smaller teaching hospitals had an average score that was 0.07 greater than major teaching hospitals.

“To our knowledge, the method of scoring of low-value services reported here represents the first metric that can be applied at a hospital level, allowing for comparisons across hospitals and examination of hospital characteristics associated with low-value care,” the study authors wrote.  

“Our findings that larger hospitals, major teaching hospitals, and non-profit hospitals are more likely to avoid overuse may provide guidance for targeted improvement efforts,” they continued. “For example, payers such as CMS might consider structuring financial incentives for reducing overuse around specific hospital factors in our data.”

The researchers found that 73.5 percent of major teaching hospitals had low scores of overuse in all services except for spinal fusion.

“Why this service might be an outlier among these hospitals is unclear,” the authors wrote. “It may be driven by patient demand for spinal fusion, but more likely factors for its entrenchment include the sparsity of high-quality evidence and such hospital-level factors as investment in devices, local market competition, and the procedure’s relatively high profit margin.”

The researchers also discovered that diagnostic testing rates were lower in major teaching hospitals compared to other hospitals. These analyses could direct targeted interventions for eliminating healthcare waste among Medicare fee-for-service beneficiaries.

“Although clinicians are responsible for ordering tests and treatments, their practice patterns may be influenced by hospital policies and culture,” the authors wrote. “Hospital-level interventions to reduce overuse exist, but to measure and compare their success, a hospital-level measure is required.”

“This novel measurement of hospital-associated overuse is a useful method for combining results across multiple indicators of overuse and comparing overall overuse within US hospitals,” they continued.

Overall, the problem of low-value care is getting batter, some data has shown.

A recent RAND Corporation study that analyzed data from over 21 million patients enrolled in fee-for-service Medicare found that low-value care spending dropped 3 percent from 2014 to 2018 (36.3 percent and 33.6 percent of all services rendered, respectively).

However, antibiotic and opioid prescriptions—two of the three services that make up the majority of low-value healthcare spending—increased despite a national campaign to promote value-based care.

The RAND study found that two-thirds of low-value care spending went towards opioids prescribed for back pain, antibiotics prescribed for upper respiratory infections, and preoperative laboratory testing.

“Our study highlights several promising opportunities for targeted interventions that may reduce wasteful health care spending while improving the quality of care,” John N. Mafi, the study's lead author and an adjunct physician policy researcher at RAND, said in a statement.

“Given mushrooming deficits and the fact that the Medicare trust fund is running out of cash, there will be enormous pressure to find ways to trim spending in the Medicare program and making significant progress in reducing low value care needs to be a top priority,” said Mafi, who also is an assistant professor of medicine at the David Geffen School of Medicine at UCLA.