key: cord-0049014-0x0d56fb
authors: Sorenson, Corinna; Japinga, Mark; Crook, Hannah; McClellan, Mark
title: Building A Better Health Care System Post-Covid-19: Steps for Reducing Low-Value and Wasteful Care
date: 2020-08-21
journal: NEJM Catal Innov Care Deliv
DOI: 10.1056/cat.20.0368
sha: 3929794d46d883b5fa4a2cf1f83508e8d928e6b0
doc_id: 49014
cord_uid: 0x0d56fb

The upheaval in the provision of routine health care caused by the Covid-19 pandemic offers an unprecedented opportunity to reduce low-value care significantly with concurrent efforts from providers and health systems, payers, policymakers, employers, and patients.

to the system we had before, and this is an ideal time to build something better. But the window is already closing. In-person care has rebounded -outpatient care visits in June were about 11% lower than the baseline level, compared to 58% lower in March.2 Without continued momentum, organizations risk reverting to "business as usual," especially with so many health care providers under intense financial strain from lost fee-for-service revenues.

One key focus area for reopening should be identifying and reducing low-value care: medical services that provide little to no clinical benefit or may cause harm to patients, such as antibiotic use for a likely uncomplicated viral infection or imaging for non-specific low-back pain. Use of low-value care is pervasive, accounting for 10% to 20% of annual health spending.3 , 4 We should be spending this money instead on providing high-value care that benefits patients; building stronger prevention, public health, and pandemic preparedness capabilities; and, addressing health disparities and the systemic inequalities that underly them.

To date, low-value care has been stubbornly difficult to reduce, due to a complex range of barriers.5 However, the system-wide disruption and resource scarcity brought forth by Covid-19 has provided maybe the strongest impetus yet for rethinking how best to prioritize what and how much care to provide, to and by whom, and in which settings. Recent reopening guidance from the CDC and CMS highlights the importance of prioritizing services that most benefit patient health and reduce exposure to both Covid-19 and broader care complications.6 , 7

The coming months offer a unique and critical window for providers and health systems, and the stakeholders who support and interact with them, to take short-and long-term steps to reduce waste and build a better system that prioritizes high-quality, high-value care. We discuss these steps in more detail below.

As a first step, providers and health systems should prioritize the safety of patients and health care workers alike by triaging treatment for high-need patients, helping them avoid the emergency department (ED) whenever possible. More broadly, providers should work with all patients to develop immediate care plans, or "care blueprints." Such plans should weigh the benefits and harms of different therapeutic pathways while incorporating Covid-19 risk. Emerging guidance from professional associations and clinical experts can serve as important resources for development.8 -10 These care protocols offer an immediate opportunity to spur provider and patient discussion on the harms of unnecessary care.

As a first step, providers and health systems should prioritize the safety of patients and health care workers alike by triaging treatment for high-need patients, helping them avoid the emergency department whenever possible." " On a macro-level, guidance and broader reopening plans could also include "Do Not Restart" lists. For example, a group of expert oncologists recently called for eliminating treatments with marginal benefit in their recommendations for modifying oncology care due to Covid-19.11 Suggestions include discontinuing the use of certain drugs and having shared decision-making discussions for continuing intensive treatment for incurable cancers. Other experts have identified overuse practices in hospital medicine that can lead to harm of both patients and health care workers.12

A range of resources are available to help providers and health systems develop these lists, including Choosing Wisely and the U.S. Preventive Services Task Force recommendations and the Task Force on Low-Value Care's "top five" services to.13 -15 Existing tools such as the Milliman MedInsight Health Waste Calculator and the Research Consortium for Health Care Value Assessment's Low Value Care Visualizer can also be employed to measure and track known lowvalue care services.16 , 17 There are also publicly available algorithms that can be used to analyze select low-value services in administrative data.18 , 19 Once care returns closer to a steady-state, these tools can help monitor use, track progress, and identify new low-value care targets. (Table 1) To support "Do Not Restart" lists, providers and health systems can encourage guidelines for concordant care and make it easier for physicians and other health care professionals to avoid lowvalue services and identify higher value alternatives. Organizations could integrate appropriate care guidelines into point-of-care decision supports, such as alerts embedded into electronic health records, which would give front-line providers rapid access to evidence-based protocols. They could also offer regular provider reports, ideally with peer comparisons,20 on use of low-value care with recommendations on how to improve. • Developed by professional societies, lists over 600 commonly used tests or procedures by clinical area whose necessity should be questioned and discussed • Offers education materials to facilitate conversations between providers and patients on unnecessary care U.S. Preventive Services Taskforce T2 • Panel of medical experts that reviews the evidence for and effectiveness of clinical services

• Issues evidence-based recommendations on the use of preventive services, using a letter grade system based on the balance of benefits and harms • Lists almost 20 Grade D "discourage use of service" recommendations Task Force on Low-Value Care's "Top-Five" Services T3

• Based on harms, costs, prevalence, and opportunity for change • The five services include: diagnostic testing and imaging prior to low-risk surgery; vitamin D screening; prostate specific antigen (PSA) screening in men ages 75 and older; imaging in the first six weeks of low back pain; and use of branded drugs when generics are available Milliman MedInsight Health Waste Calculator T4

• Proprietary tool available to health care organizations to identify and quantify unnecessary services using their own claims, billing, or electronic medical record data Low Value Care Visualizer T5 • Free, open-source, web-based tool that helps organizations identify low-value care via their processed claims data and creates user-friendly visualizations of data Publicly-Available Algorithms T6, T7

• Code sets or specifications to measure a range of low-value care services in Medicare, Medicaid, and commercial claims data Leveraging alternative care pathways and care sites, such as telehealth, home-based care, and community-based care, can also help keep patients out of the ED and provide alternatives to lowvalue and wasteful care. ED visits and hospitalizations are frequently preventable and, once there, patients often receive unnecessary imaging and lab tests. Instead of unnecessary imaging or surgery for back or joint pain, patients could receive home-based or telehealth physical therapy, which can be as effective as in-person therapy in certain cases.21 The Covid-19 era also offers opportunities to advance other alternative care pathways, such as palliative care and onco-primary care survivorship clinics.22 , 23 Instead of cancer survivors seeing their oncologist in the hospital for a routine check-up, they could receive needed care by a PCP in a survivorship clinic. Not only can these delivery alternatives result in safer and more efficient and effective care, they are likely to align more closely with patient preferences.24 , 25

Leveraging alternative care pathways and care sites, such as telehealth, home-based care, and community-based care, can also help keep patients out of the ED and provide alternatives to lowvalue and wasteful care."

As providers and health care systems reintroduce care and implement new protocols, they should concurrently track and evaluate the impact on health outcomes, quality of care, patient experience, known or new disparities, and costs. The drastic changes in health care delivery due to Covid-19, combined with incremental resumption of elective procedures and services, provides a natural experiment to generate much needed evidence for eliminating or reducing many types of low-value care. Such evidence could pinpoint situations where care is unnecessary or inappropriate in certain populations, settings, or circumstances, which would provide valuable insights on opportunities for broader care redesign. (Table 2 )

Action from stakeholders across the health care system can help providers and health systems to reduce low-value care.

Payers play a critical role in adjusting incentives for providers so that providing high-value care and eliminating wasteful services are the right financial decision. Payers could decrease or cease payment for low-value services that create excess risk in the pandemic and align coverage policies to support "Do Not Restart" recommendations from professional organizations and practices. They could also support the development of alternative strategies via short-term payments to offset the costs of practice redesign and any necessary retraining, and ensure accessibility of actionable data and supportive tools for determining whether or not a procedure is necessary and tracking outcomes. If these efforts succeed, payers should promise to share savings with provider groups. Some payers such as Blue Cross Blue Shield of Massachusetts have already succeeded in reducing commonly overused services using these approaches.26

Long-term, payers should accelerate development of value-based payment models. Providers practicing within these models have been more successful in responding to the pandemic and weathering the ongoing economic uncertainties,27 as a result of more predictable financial structures and associated investments in infrastructure, staff, programs, and data systems to improve population health and care delivery.28 These are many of the same capabilities required to eliminate low-value services.

Payers should also engage consumers through this process, adopting value-based insurance design principles that deter use of low-value care and reduce barriers to necessary care. For example, if seeing a physical therapist via telehealth over an orthopedist in an office offers a safer, higher-value pathway, then benefit design should reflect this higher value through lower co-payments. Many payers have provided expanded telehealth services with low or no copays during the pandemic.29 Payers should also prioritize lower copays for high-value pandemic services like Covid-19 testing and non-Covid-19 essential care such as preventive and mental health services, while increasing cost-sharing for low-value, high-risk services like spinal fusion, knee arthroscopy, and other outpatient lab and surgical services. Recent evidence indicates that utilization of low-value services can be reduced through modifying cost-sharing for patients.30

Policymakers should create opportunities for providers, health systems, and payers to pilot innovative models that reduce low-value care and reflect the new Covid-19 reality, integrating telehealth and a wider range of health care professionals. CMS could direct additional Covid-19 relief funding to hospitals and providers who agree to pilot new models for health care reopening that actively seek to aid in the pandemic response, and who participate in alternative payment models to build a stronger health care system.31 More broadly, CMS should work with health care providers and payers to assess how and where relaxed telehealth regulations have worked particularly well to align care with patient need, using it as the basis for deciding how to continue to encourage effective telehealth. Finally, CMS should continue encouraging states to address social drivers of health and advance clinical and social care integration through 1115 waivers, such as North Carolina's Healthy Opportunities Pilots,32 as well as other policies that support home and community-based services.

Even though high unemployment due to Covid-19 has underscored the weaknesses of employersponsored health care, the majority of Americans are still insured in this manner-and the higher reimbursements health systems get from these plans means employers must also play a key role in building this new normal. They can accelerate the adoption of tools already used successfully by many large, self-insured employers to limit wasteful care. "Centers of Excellence" (COE) programs, in which employees pay reduced (or no) out-of-pocket costs in return for using a highquality institution, have reduced inappropriate joint and spine surgery for Walmart enrollees by 20-50% and reduced readmission rates by 70-95%.33 , 34 COEs could also provide remote second opinions on treatment. High-value provider networks linked to employer benefit design are also encouraging enrollees to see providers that perform well on quality metrics, while encouraging lower performers to improve. These approaches should be applied systematically to a range of therapeutic areas, starting with those that have opportunities for reducing known unnecessary care, such as orthopedics, oncology, cardiology, and obstetrics.

Finally, patients seeking care as health systems reopen will have a critical impact on the development of the new normal. Telehealth can make patient-provider interactions significantly easier and safer-a Better Medicare Alliance poll found that 91% of seniors in Medicare Advantage using telehealth services had a "very or somewhat favorable experience."35 However, patients need help and support in distinguishing needed services worth the risk from those that are unnecessary, and providers must account for how health disparities and access issues can impact a patient's experience. Shared decision-making strategies can help facilitate these discussions around the risks and benefits of in-person care and have been found to result in patients choosing less-invasive treatments.36 , 37 Patient engagement will be critical to building and maintaining trust in new care approaches and for monitoring health outcomes.

While Covid-19 has exposed critical gaps in the U.S. health care system, it has also created significant new opportunities, offering reason to hope for a better future. Many of the capabilities required to respond effectively to Covid-19 -proactive care management within the community, collaborative care coordination, nimble clinical practice and policy approaches, value-based payment and care delivery models, timely data collection and sharing, and a sense of shared responsibility to protect and improve population health -are similar to those needed to tackle lowvalue care and more broadly create a better system for delivering care.

The range of actions we outline herein are certainly not exhaustive, but represent critical steps that a range of stakeholders can take in the coming months. Now more than ever, we need to allocate our limited health care resources towards services that produce better outcomes, at lower costs, and that align with patient values and preferences. This "new normal" can help build a more flexible, innovative system for achieving these goals. 

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