Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations

Abstract

Objective: To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care.

Data sources: 2009-2011 national Medicare and commercial insurance administrative data.

Design: We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics.

Methods: We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these.

Principal findings: Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians.

Conclusions: Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.

Keywords: Low-value care; overuse; regional variation; waste.

Figure 1

Geographic Variation—Commercial

Figure 2

Geographic Variation—Medicare

1. Notes. Hospital Referral Region (HRR)‐level analysis provides statistically stable denominator populations for our estimates of service use prevalence. However, aggregating at this level likely obscures differences among health care providers within an HRR. The above maps reflect the different available years of data between the two datasets. Only years 2009–2011 were used in analysis, but the full spread of available data is used here to reduce the presence of unpopulated HRRs.

Figure 3

Mean Annual Prevalence of Choosing Wisely Service Use, 2009–2011

1. Notes. “Back Pain Imaging” is the average annual percent of beneficiaries with uncomplicated, incident low‐back pain who received nonindicated low‐back‐pain imaging in the 6 weeks following diagnosis, 2010–2011. “Vitamin D Screening” is the average annual percent of low‐risk beneficiaries who received at least one nonindicated vitamin D screening test, 2009–2011. “Cervical Cancer Screening” is the average annual percent of female beneficiaries who received at least one nonindicated screening test for cervical cancer, 2009–2011. “Opioids in Migraine Patients” is the average annual percent of beneficiaries with a diagnosed migraine who received a nonindicated opioid prescription in the 21 days after an office visit with migraine diagnosis, 2009–2011. “Cardiac Screening” is the average annual percent of low‐risk beneficiaries who received one or more nonindicated cardiac tests, 2009–2011. “DXA Testing (short interval)” is the average annual percent of nonindicated dual‐energy X‐ray absorptiometry (DXA) tests performed within 23 months of a previous DXA test, 2011. “Preoperative Cardiac Testing (low‐risk noncardiac surgery)” is the average annual percent of beneficiaries undergoing low‐risk, noncardiac surgery who received one or more nonindicated cardiac tests in the 30 days before surgery, 2009–2011.