Claims Reimbursement Changes Notably Reduce Low-Value Care

A greater reduction in low-value vitamin D screening was associated with a claims reimbursement change related to recommendations, according to a recent study.

Published in JAMA Network Open on February 10th, the cross-sectional study of adult patients in Ontario, Canada who had primary care visits between January 1, 2010, and June 30, 2015, found that while recommendations can work to reduce low-value care, they have a greater impact when they are reinforced by changes to policy and payment. 

“Our study found small reductions in the use of unnecessary vitamin D screenings in response to recommendations from the Choosing Wisely campaign, but much greater reductions in Ontario when recommendations were complemented by policy change,” Eve Kerr, MD, MPH, senior author of the new paper and a professor in the U-M Department of Internal Medicine, stated in a press release. “The biggest lesson is that while recommendations alone can work to reduce low value care, recommendations have greater impact when they are reinforced by changes to policy and practice.”

In 2010, population-based vitamin D screening failed to improve outcomes, leading the province’s health plan to declare it would no longer pay for low-value vitamin D tests. Soon after, there was a 92.7 percent reduction in low-value vitamin D screenings, researchers found.. 

In contrast, recommendations from Choosing Wisely – an education campaign that aims to reduce the levels of low-value care – were associated with a small 4.5 percent reduction in unnecessary vitamin D testing in Ontario, as well as a 13.8 percent decrease for the US Veterans Health Administration and a 14 percent reduction for US employer-sponsored insurance, the study stated. 

Choosing Wisely recommendations were connected with very little reduction in the use of low-value vitamin D screenings and were not linked with reduced use of low-value T3 testing. But for vitamin D screenings, the recommendations were associated with a slowing of trends toward increased overuse.

Researchers used claims data to examine the use of low-value vitamin D screening and T3 level testing across CA-Ontario, and US Veterans, and US Commercial.  

In 2011, vitamin D screening rates increased modestly in Ontario but remained substantially lower than rates in the US jurisdiction. For example, US- Veterans and US- Commercial screening rates were 6.05 times and 3.22 times higher, respectively, than in Ontario.

No payment change took place in the US between 2011 and 2015 so there was an average of 213,000 unnecessary screenings that could have been avoided each year among Veterans and 4.4 million in the US-Commercial market. 

Researchers emphasized that to boost the uptake of Choosing Wisely recommendations without seeing underuse, the “promotion of implementation of effective and diverse interventions tailored to both clinical and health system context are needed.”

Furthermore, interventions with regional or national policies or incentives that can be broadly but safety applied by healthcare clinicians in a given region are needed to ensure the acceleration of uptake. 

This rate of overuse is partly because the Veterans Health Administration (VHA) is a capitated system in which the VHA facilities or clinicians receive additional payments for performing laboratory tests. Because of this, the focus on saving resources, policies that restrict test ordering, and evidence-based clinical decision support may “better yield desired decreases in low-value services,” researchers highlighted.  

Overall, two low-value laboratory tests saw a marginal reduction associated with the launch of Choosing Wisely recommendations, but the larger reduction in low-value vitamin D screening was linked to a payment policy change implemented in Ontario, Canada.

“These findings suggest that recommendations alone may be insufficient to significantly reduce use of low-value services and that pairing recommendations with policy change may be more effective,” researchers concluded.