Association of Low-Value Care Exposure With Health Care Experience Ratings Among Patient Panels

Abstract

Importance: Patient reviews of health care experiences are increasingly used for public reporting and alternative payment models. Critics have argued that this incentivizes physicians to provide more care, including low-value care, undermining efforts to reduce wasteful practices.

Objective: To assess associations between rates of low-value service provision to a primary care professional (PCP) patient panel and patients' ratings of their health care experiences.

Design, setting, and participants: This quality improvement study used Medicare fee-for-service claims from January 1, 2007, to December 31, 2014, for a random 20% sample of beneficiaries to identify beneficiaries for whom each of 8 low-value services could be ordered but would be considered unnecessary. The study also used health care experience reports from independently sampled beneficiaries who responded to the 2010-2015 Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare fee-for-service survey. Statistical analysis was performed from January 1, 2019, to December 9, 2020.

Main outcomes and measures: The main outcomes were health care experience ratings from Medicare beneficiaries who responded to the CAHPS survey from 2 domains, namely "Your Health Care in the Last 6 Months" (overall health care, office wait time, timely access to nonurgent care, and timely access to urgent care) and "Your Personal Doctor" (overall personal physician and a composite score for interactions with personal physician). Beneficiaries in both samples were attributed to the PCP with whom they had the most spending. For each PCP, a composite score of low-value service exposure was constructed using the 20% sample; this score represented the adjusted relative propensity of the PCP patient panel to receive low-value care. The association between low-value service exposure and health care experience ratings reported by the CAHPS respondents in the PCP patient panel was estimated using regression analysis.

Results: The final sample had 100 743 PCPs, with a mean of approximately 258 patients per PCP. Only 1 notable association was found; more low-value care exposure was associated with more frequent reports of having to wait more than 15 minutes after the scheduled time of an appointment (a mean of 0.448 points lower CAHPS score on a 10-point scale for PCP patient panels who received the most low-value care vs the least low-value care). Although some other associations were statistically significant, their magnitudes were substantially smaller than those typically considered meaningful in other CAHPS literature and were inconsistent in direction across levels of low-value service exposure.

Conclusions and relevance: This quality improvement study found that more low-value care exposure for a PCP patient panel was not associated with more favorable patient ratings of their health care experiences.

Figure 1.. Mean Percentage of Beneficiaries Receiving Specific Low-Value Services by Quintile of Low-Value Service Exposure

Mean percentage of low-value service receipt is calculated by first computing, for each primary care professional (PCP) patient panel, the percentage of beneficiaries who received the service among those in the denominator population for that service, and then averaging those percentages across PCP patient panels. The first quintile represents the PCP patient panels with the least low-value care exposure and the fifth quintile represents the PCP patient panels with the most low-value care exposure. PSA indicates prostate-specific antigen; PTH, parathyroid hormone; and T3, triiodothyronine.

Figure 2.. Differences Between Consumer Assessment of Healthcare Providers and Systems (CAHPS) Scores at Levels of Low-Value Service Exposure and Overall Mean CAHPS Score

Each CAHPS outcome was separately modeled with a linear regression that adjusted for age, Medicaid-Medicare dual status, highest level of education completed, overall physical health rating, and overall mental or emotional health rating and included physician-clustered SEs. Trend lines are horizontally offset by small amounts (0.8 deciles) for readability. Vertical bars indicate 95% CIs.