It’s no secret that healthcare costs in the United States are skyrocketing, as the latest estimates put our annual healthcare spending at 18% of the U.S. GDP. Furthermore, the health of Americans ranks among the worst compared to health outcomes in similar developed countries. This complex reality is aggravated by a number of problems. Much of the care that we receive is known as “fee-for-service”—we pay for each medical service or test we receive. What this means for patients is that the more they see their doctor, the more they pay. This is problematic for many Americans, as nearly 40% have a high deductible health plan where individuals are responsible for on average $5,248 of out of pocket medical expenses each year. A survey from the Kaiser Family Health Foundation found that 1/3 of adults have trouble paying their medical bills, and 73% have cut back on spending on food, clothing or basic household items to pay their medical bills. With the cost of healthcare in the U.S. being such a recognized problem, one of the many concerns that contributes to this issue is what is known as “low value care,” or in other terms, wasteful healthcare services. 

Choosing Wisely® is an international initiative that promotes facilitating conversations between patients and their doctors about the clinical need for low value care. The goal is to reduce wasteful medical tests and unnecessary health services.  As part of this initiative, over 80 partners have published an extensive list of clinically-vetted recommendations that represent medical best practices. A 2014 study of the Virginia All Payer Claims Database applied a list of these clinical recommendations and found that low cost, high volume health services contribute the most to unnecessary health spending; wasteful spending in this study was estimated at $538 million.

What does spending on wasteful healthcare services look like at an employer level? One of our clients, a large, self-insured employer, was interested in understanding if wasteful health spending was an area of concern for their members. To answer this question, we looked through 3 years of their medical and pharmacy claims to pull out services that were deemed “clinically wasteful.” From this data, we narrowed our focus to 11 specific measures of wasteful services which are based on areas of waste that are clinically validated under both the Choosing Wisely® initiative and HEDIS. These 11 areas are as follows:

1. Don’t do imaging for an uncomplicated headache.
2. Don’t perform PAP smears on women younger than 21.
3. Don’t perform PAP smears on women who had hysterectomy for non-cancer disease.
4. Don’t perform routine annual PAP tests in women 30–65 years of age.
5. Don’t diagnose or manage asthma without spirometry.
6. Members with a primary diagnosis of low back pain should not have an imaging study (plain x-ray, MRI, CT scan) within 28 days (4 weeks) of diagnosis.
7. Don’t indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
8. Don’t order sinus computed tomography (CT) for uncomplicated acute rhinosinusitis.
9. In the evaluation of simple syncope and normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
10. Don’t do CT for evaluation of suspected appendicitis in children until after ultrasound has been considered.
11. Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

Out of the entire member population consisting of employees, spouses and children who were covered under the company’s health benefits, there were 2515 members who received care in the 11 categories of care that we studied. Our study found that half (1274) of these people received medical services that are considered clinically wasteful.

15.5% of spending in these 11 categories was considered to be wasteful. Out of $1.47 million spent on care within these 11 categories, $229k was spent on these clinically wasteful services. 

There are a few limitations to keep in mind while evaluating these measures of waste. First, we examined 11 out of over 500 clinical best practices. This is because we wanted to focus on data points that were more accurately represented by claims data, as EMR notes were not available as part of this study. What we measured were specific types of waste and we did not calculate the total amount of “healthcare waste” in this employer’s spending. Furthermore, our study examined direct claims-based costs and made no assumptions of additional downstream medical costs for those who received low value care services. 

What do these findings mean for this company and others who are paying for healthcare? Healthcare waste (low value care) is a reality in our healthcare system today. Patients, providers, and those paying for care are all affected. Even in this study that examined health spending in one company, out of the 11 areas of clinical waste we studied we found that half of the people receiving care in these categories received low value services. Initiatives such as Choosing Wisely® are effective in raising awareness of low value care and opening conversations between patients and their doctors to avoid unnecessary medical tests and treatments. You can find more information on this educational initiative at www.choosingwisely.org. 

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BetaXAnalytics is a healthcare data consulting firm that helps payers and providers to maximize their CMS reimbursements and helps employers to reduce their healthcare spending through proven strategies to contain costs. For more insights on using data to drive healthcare, pharmacy and wellbeing decisions, follow BetaXAnalytics on Twitter @betaxanalytics, Facebook @bxanalytics and LinkedIn at BetaXAnalytics.