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. 2021 Feb 1;4(2):e2037328.
doi: 10.1001/jamanetworkopen.2020.37328.

Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018

John N Mafi  1   2 , Rachel O Reid  3   4   5 , Lesley H Baseman  3 , Scot Hickey  2 , Mark Totten  2 , Denis Agniel  2 , A Mark Fendrick  6   7 , Catherine Sarkisian  8   9 , Cheryl L Damberg  2
Affiliations

Trends in Low-Value Health Service Use and Spending in the US Medicare Fee-for-Service Program, 2014-2018

John N Mafi et al. JAMA Netw Open. .

Abstract

Importance: Low-value care, defined as care offering no net benefit in specific clinical scenarios, is associated with harmful outcomes in patients and wasteful spending. Despite a national education campaign and increasing attention on reducing health care waste, recent trends in low-value care delivery remain unknown.

Objective: To assess national trends in low-value care use and spending.

Design, setting, and participants: In this cross-sectional study, analyses of low-value care use and spending from 2014 to 2018 were conducted using 100% Medicare fee-for-service enrollment and claims data. Included individuals were aged 65 years or older and continuously enrolled in Medicare parts A, B, and D during each measurement year and the previous year. Data were analyzed from September 2019 through December 2020.

Exposure: Being enrolled in fee-for-service Medicare for a period of time, in years.

Main outcomes and measures: The Milliman MedInsight Health Waste Calculator was used to assess 32 claims-based measures of low-value care associated with Choosing Wisely recommendations and other professional guidelines. The calculator designates services as wasteful, likely wasteful, or not wasteful based on an absence of indication of appropriate use in the claims history; calculator-designated wasteful services were defined as low-value care. Spending was calculated as claim-line level (ie, spending on the low-value service) and claim level (ie, spending on the low-value service plus associated services), adjusting for inflation.

Results: Among 21 045 759 individuals with fee-for-service Medicare (mean [SD] age, 77.4 [7.9] years; 12 515 915 [59.5%] women), the percentage receiving any of 32 low-value services decreased from 36.3% (95% CI, 36.3%-36.4%) to 33.6% (95% CI, 33.6%-33.6%) from 2014 to 2018. Uses of low-value services per 1000 individuals decreased from 677.8 (95% CI, 676.2-679.5) to 632.7 (95% CI, 632.6-632.8) from 2014 to 2018. Three services comprised approximately two-thirds of uses among 32 low-value services per 1000 individuals: preoperative laboratory testing decreased from 213.8 (95% CI, 213.4-214.2) to 166.2 (95% CI, 166.2-166.2), while opioids for back pain increased from 154.4 (95% CI, 153.6-155.2) to 182.1 (95% CI, 182.1-182.1) and antibiotics for upper respiratory infections increased from 75.0 (95% CI, 75.0-75.1) to 82 (95% CI, 82.0-82.0). Spending per 1000 individuals on low-value care also decreased, from $52 765.5 (95% CI, $51 952.3-$53 578.6) to $46 921.7 (95% CI, $46 593.7-$47 249.7) at the claim-line level and from $160 070.4 (95% CI, $158 999.8-$161 141.0) to $144 741.1 (95% CI, $144 287.5-$145 194.7) at the claim level.

Conclusions and relevance: This cross-sectional study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign in collaboration with clinician specialty societies and increased attention on low-value care. While most use of low-value care came from 3 services, 1 of these was opioid prescriptions, which increased over time despite the harms associated with their use. These findings may represent several opportunities to prevent patient harm and lower spending.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Fendrick reported receiving royalties from the sale of the Milliman MedInsight Health Waste Calculator; receiving consulting fees from AbbVie, Amgen, Bayer, Centivo, the Community Oncology Alliance, Covered California, EmblemHealth, Exact Sciences, Freedman HealthCare, Grail, Harvard University, HealthCorum, MedZed, Merck, Montana Health Cooperative, Penguin Pay, Phathom Pharmaceuticals, the state of Minnesota, the Department of Defense, Virginia Center for Health Innovation, and Yale New Haven Health System; owning equity interest in Health and Wellness Innovations, Health at Scale Technologies, Sempre Health, Wellth, and Zansors; conducting research for the Agency for Healthcare Research and Quality (AHRQ), Arnold Ventures, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, Pharmaceutical Research and Manufacturers of America, Robert Wood Johnson (RWJ) Foundation, and state of Michigan and Centers for Medicare & Medicaid Services (CMS); and serving in outside positions as coeditor for the American Journal of Managed Care, member of the Medicare Evidence Development and Coverage Advisory Committee, and partner of Valued-Based Insurance Design Health. Dr Mafi reported receiving grants from the National Institutes of Health (NIH) National Center for Advancing Translational Sciences, NIH National Institute on Aging (NIA), RWJ Foundation, and Arnold Ventures outside the submitted work. Dr Reid reported receiving grants from the AHRQ during the conduct of the study and research contracts from the CMS, Milbank Memorial Fund, and American Academy of Physician Assistants and grants from the NIA outside the submitted work. Drs Agniel and Damberg reported receiving grants from AHRQ during the conduct of the study. No other disclosures were reported.

Figures

Figure.
Figure.. Services Used Among Individuals With Fee-for Service Medicare
See this image and copyright information in PMC

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