Does Value Mean Doing Less?

Over the past decade, the concept of improving value by avoiding excessive care has taken center stage in discussions about the U.S. health care system. As the costs of health care services has increased, so has the acknowledgment that overtesting and overtreating patients can lead to both physical and financial harms.

“We all want – and our patients all deserve – the best possible care. That includes appropriate care,” said Lisa Hicks, MD, a hematologist at St. Michael’s Hospital in Toronto and chair of the American Society of Hematology’s (ASH’s) Committee on Quality. “Care that is unnecessary or that involves some overtreatment or overtesting always carries some harm, beyond additional costs and time it takes to deliver.”

Several national organizations have also taken up the cause of increasing the value of U.S. health care. For instance, the ABIM Foundation launched its Choosing Wisely® campaign in 2012, an educational campaign to encourage U.S. medical societies to identify tests, treatments, and procedures that were overused in their specialty and did not provide meaningful benefit to patients.

Improving quality and value of health care was a central tenet of 2010’s Patient Protection and Affordable Care Act, which incentivized health care providers and hospitals to deliver care more efficiently through the creation of accountable care organizations (ACOs) and initiatives like Medicare’s Hospital Readmissions Reduction Program and the Hospital Value-Based Purchasing Program.

Not everyone sees the value in these value-based initiatives, however. Critics note that measuring value primarily through the lens of controlling costs could lead to unintended consequences, such as undertreatment, and question whether the initiatives have accomplished their goals of improving patient outcomes.

ASH Clinical News spoke with Dr. Hicks and other experts about the shift from volume to value, whether quality-improvement initiatives have been successful and the potential downsides of this transition.

Defining Value-Based Care

In a basic sense, value refers to getting the most for the least. As an official definition, the Centers for Medicare & Medicaid Services (CMS) describes value-based programs as those that “reward health care providers with incentive payments for the quality of care they give to people with Medicare.” The goals of government-run, value-based programs are to improve care for individuals, improve health for populations, and reduce costs.

Christopher Moriates, MD, assistant dean for health care value and associate professor of internal medicine at Dell Medical School at The University of Texas at Austin, said that his institution relies on the definition supplied by Michael Porter and Elizabeth Teisberg in Redefining Health Care: Creating Value-Based Competition on Results, which describes maximizing patients’ health outcomes per dollar spent.

According to Dr. Moriates, the shift to value-based care began about a decade ago, when the health care industry started to realize that more care does not always translate to better care. This represented a departure from traditional fee-for-service models, in which providers are paid based on the volume of health care services they deliver.

“Only recently have people said, ‘Wait a second – people are harmed when they get too little care and when they get too much,’” he said. Overuse is incredibly prevalent in health care, he added. A 2016 review published in JAMA Internal Medicine estimated that use of advanced imaging nearly doubled between 1999 and 2010 (from 6.7% to 13.9%), as did the rate of specialty referrals (6.9% to 13.2%).1

The CMS recently predicted that, by 2027, national health spending will grow to nearly $6.0 trillion in the U.S.2 However, health outcomes aren’t keeping pace, according to Andrew Ryan, PhD, professor in the department of health management and policy at the University of Michigan School of Public Health. Patient outcomes in similar high-income countries are consistently better than outcomes in the US, despite the U.S.’s astronomical spending. An analysis of health care spending and outcomes in the U.S. and 11 other high-income countries revealed that the U.S. spent 17.8% of its gross domestic product on health care, substantially higher than spending in countries like Australia (9.6%) or Switzerland (12.4%).3 Yet average U.S. life expectancy was lower compared with the average across all other high-income countries: 78.8 years versus 81.7 years.

“Cutting out waste and care that doesn’t make anyone healthier is one of the most straightforward, noncontroversial ways to close that gap,” Dr. Moriates said.

The proliferation of high-deductible health plans in the early 2010s increased pressure to cut costs, but value truly came under the microscope with advances in measured development and large-scale computing, said Dr. Ryan.4 These tools made it possible to assess health care providers’ quality performance and spending performance, paving the way for a series of initiatives on the federal and local levels that target overtreatment and overuse.

Putting Value Into Practice

With its Choosing Wisely campaign, the ABIM Foundation launched a comprehensive effort to reduce possible waste across medical specialties. More than 70 societies, including ASH, have joined the campaign and released their own recommendations. As part of its Choosing Wisely involvement, ASH identified “Ten Things Physicians and Patients Should Question,” as well as another five recommendations relevant to hematology that were developed by other medical societies and a pediatric-focused list of 5 more items in conjunction with the American Society of Pediatric Hematology/Oncology (see SIDEBAR).5

“What I love about Choosing Wisely is that it is solidly anchored in preventing harm and optimizing care,” Dr. Hicks said. “That resonates with patients and clinicians.”

The ASH recommendations range from re-evaluating routine use of inferior vena cava (IVC) filters in patients with acute venous thromboembolism to skipping baseline or routine surveillance computed tomography scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia.

Dr. Hicks also highlighted the Society’s Choosing Wisely Champions program as a sign of ASH’s commitment to reducing medical overuse. Each year since 2016, the program honors three practitioners working to eliminate costly and potentially harmful overuse of tests and procedures through projects they have developed and implemented in their practice, institution, or hospital system.

The 2019 winners, announced at the 2019 ASH Annual Meeting, included Stephen L. Wang MD, from Kaiser Permanente Santa Clara Medical Center, who began an educational campaign on IVC filter efficacy, guidelines, and complications at 14 medical centers. In the year following the efforts, IVC filter use decreased and IVC filter retrieval increased, successfully changing long-held practice patterns and improving follow-up of these potentially risky devices.

Another winner, Jordan Schaefer MD, from the University of Michigan, focused on reducing the inappropriate use of aspirin, in response to guidelines that advocate for warfarin monotherapy in place of combination therapy with warfarin and aspirin. A tailored screening process identified cases of unclear or potentially inappropriate use of aspirin, prompting the primary care provider to discuss aspirin use with the patient. Using data from these efforts, Dr. Schaefer and researchers developed an “Anticoagulation Toolkit” used in practices participating in the Michigan Anticoagulation Quality Improvement Initiative.

By acknowledging efforts to find practical ways to reduce overuse, ASH is creating “a growing repertoire of successful projects that can be translated into other practices and institutions,” Dr. Hicks said.

Across the country, other small-scale projects are tackling waste, Colleen Morton, MBBCh, MS, an associate professor of medicine and section chief for classical hematology at the Vanderbilt-Ingram Cancer Center, told ASH Clinical News. She described “anticoagulation stewardship” programs that are designed to evaluate and standardize care for patients on blood thinners such as warfarin and newer direct oral anticoagulants.

The goal of these programs is to ensure patients are receiving the best care possible – performing all necessary labs and appropriately managing peri-operative anticoagulation.
“Having a properly managed anticoagulation clinic helps to avoid complications and problems down the line,” said Dr. Morton, who also serves as the medical director for Anticoagulation Stewardship at Vanderbilt.

Other quality improvement efforts at her institution include growing opportunities for telemedicine and managing peri-operative anemia. “If a patient is anemic prior to surgery, the outcomes after surgery are worse in terms of healing, mortality, and complications,” Dr. Morton said. At the peri-operative anemia clinics developed at her institution, patients receive iron supplementation before heading to surgery, to help with postprocedure recovery.

There is plenty of anecdotal evidence to support the use of these and other quality-improvement initiatives, but some experts say that quality metrics for hematology are not yet well-defined – particularly in classical hematology – making it difficult to judge which interventions work.

“Quality metrics in hematology is a fairly nascent field,” Dr. Hicks said, adding that, historically, efforts to improve care in this field have focused more on underuse than overuse.

“At a patient level, it can be very challenging to identify clear examples of overuse. It’s easier to look for things that weren’t done, rather than things that were done and shouldn’t have been,” she explained.

Value-Based Care on the National Stage

On the national scale, CMS has taken several approaches to promoting value-based care, including establishing ACOs, or networks of doctors and hospitals that share financial and medical responsibility for providing coordinated care to patients, giving providers an opportunity to share in the savings if efficiency goals are met.

Another initiative, the Hospital Readmission Reduction Program (HRRP), was created in 2010 to incentivize hospitals to lower their 30-day readmission rates “by improving their process, both on the inpatient and outpatient side,” Dr. Ryan said. Initially, the program penalized hospitals with high readmission rates for such common medical conditions as heart attack, heart failure, and pneumonia but has now expanded to include other indications such as chronic obstructive pulmonary disease, coronary artery bypass graft surgery, and elective hip and knee arthroplasty.

In October 2019, CMS handed out penalties to 2,583 hospitals – 83% of the 3,129 hospitals evaluated in the program. The penalties will be deducted from payments for Medicare patient stays, which CMS estimates will cost hospitals $563 million over the next fiscal year.6

Whether the program has been successful in reducing readmissions and thereby improving patient outcomes is still is up for debate. Critics have noted that the HRRP may have the opposite effect of its intended goal, since hospitals may avoid readmitting patients with a legitimate need for additional inpatient care out of fear of the financial repercussions. And, as Dr. Ryan and colleagues found in a recent analysis of HRRP data, the actual number of readmissions may not reflect meaningful change.

“As physicians, we’ve been trained to test, test, test. We are, I think, appropriately concerned about missing things, but that culture can lead to harms from overtesting.”

—Lisa Hicks, MD

To avoid unfairly penalizing hospitals that care for patients with higher severity of illness, penalties are adjusted based on patients’ coded severity of illness. This creates a loophole for hospitals that want to avoid penalties: Hospitals can improve their calculated rates of readmission by increasing their coded level of severity. In reviewing data before and after HRRP went into effect, “we found there were large increases in comorbidity coding that occurred around the same time that program was implemented,” Dr. Ryan said.7 “While the pro-gram has led to a reduction in readmissions, the reported reductions perhaps weren’t quite as great as they were in reality,” he added.

In a similar vein, the Hospital Value-Based Purchasing Program (HVBP) was created to tackle waste by tying Medicare payments to efficiency. Using a complex formula, the program calculates hospitals’ Total Performance Score, based on their performance on four domains: clinical outcomes, person and community engagement, safety, and efficiency and cost reduction.

It is a noble goal, but again, Dr. Ryan pointed out that the success of the HVPB program has been questionable. When hospitals exposed to the HVBP program were compared with control hospitals, there were no significant reductions in mortality among patients who were admitted for acute myocardial infarction or heart failure, but HVPB program exposure was associated with a significant reduction in mortality among patients who were admitted for pneumonia.8

“Our research has found that the program hasn’t consistently driven quality improvement, and we speculate that [may be the result of] incentives being quite small,” he explained. “It also is a complicated design, so putting those two things together, the program has not motivated a whole lot of improvement efforts from hospitals.”

He believes that the HRRP and HVBP can make hospitals more efficient and lower overall spending, but “there is less evidence that they have improved quality in a way that’s meaningful to patients.”

To be successful, Dr. Ryan said value-based efforts should contain large incentives and relatively simple structures, so that hospitals can easily identify what they need to improve. The programs also require an appropriate lever for continuous improvement.

“When the HRRP was implemented, it was pretty clear that there were some substantial gains to be had and low-hanging fruit that hospitals could ‘pick’ to improve care and manage discharges more appropriately,” he said. “Over time, the rates of readmissions haven’t changed much, and there’s a notion that we have squeezed out whatever could be gleaned.”

Challenging the Status Quo

As the industry continues to move toward value-based efforts, it will continue to face significant obstacles. One of the most challenging, according to Dr. Hicks, is that tackling overuse is a tremen-dous cultural change for physicians and patients.

“As physicians, we’ve been trained to test, test, test,” she said. “We are, I think, appropriately concerned about missing things, but that culture can lead to harms from overtesting.”

Physicians and patients often tend to equate thoroughness with more, but thoroughness, she said, is being thoughtful, appropriate, and inclusive in the care one does provide. “It doesn’t mean overtesting, actually,” she said. “One can be incredibly thorough and still do appropriate testing.”

Dr. Moriates also acknowledged that shifting the health care industry’s mind-set away from overuse will be an uphill climb. “It’s a major cultural change, and I don’t think that we’ve seen enough progress yet in getting people to redesign the ways they deliver care,” he said. “We have seen specific projects that have been successful, where hospitals were able to decrease use appropriately and improve outcomes in a certain area, but achieving that on a large scale is still very much a work in progress.”

Implementing value-based programs also takes time and resources, Dr. Morton added, and will require the support of an institution to be successful.

Value Versus Volume

One of the potential criticisms – or concerns – about value-based care is that it can lead to undertreatment or provide patients with less care than they need. While experts say that is something that hematologists need to be cognizant of, in many instances, researchers have found that implementing efficiency or waste-reduction efforts does not lead to a reduction in necessary care.

“High-value care can certainly be about giving more care or more tests. It’s just about whether or not it’s worth it,” Dr. Moriates said. “By and large, the concern that we are going to start cutting out useful testing [has not] been borne out.”

The key to ensuring that patients are still receiving the necessary care they need, he said, is continuing to place the focus on patient outcomes. “If we are trying to improve outcomes across the board, then there’s no real motivation for underuse,” he added.

If a patient does request a “low-value” service, experts who spoke with ASH Clinical News said it can open an opportunity for a dialogue with the patient about why certain care decisions are being made.

“We can explore the question with the patient and spend time helping the patient understand why a service or treatment may not be helpful or is even potentially harmful,” Dr. Hicks said. “I find that, when patients understand that there is a downside to the overtesting, they are often receptive to not having a given test.”

There may be some instances, she noted, where physicians need to be sensitive to patient preferences. Even though a person might not fit traditional criteria for a certain test or treatment, it may still make sense for that particular patient.

“I may have a patient who wants a follow-up CT scan after a lymphoma diagnosis and after being in remission for some time. He may not actually fit the usual criteria of someone who would benefit from that test, but he is terribly anxious, and the anxiety is undermining his quality of life,” she said. “When we talk about Choosing Wisely or value-based care or overuse, our anchor must always be what is best for the patient.” —By Jill Sederstrom

ASH's Choosing Wisely List

10 Things Physicians and Patients Should Question

  1. Don’t transfuse more than the minimum number of red blood cell (RBC) units necessary to relieve symptoms of anemia or to return a patient to a safe hemoglobin range (7 to 8 g/dL in stable, noncardiac in-patients).
  2. Don’t test for thrombophilia in adult patients with venous thromboembolism (VTE) occurring in the setting of major transient risk factors (surgery, trauma, or prolonged immobility).
  3. Don’t use inferior vena cava (IVC) filters routinely in patients with acute venous thromboembolism (VTE).
  4. Don’t administer plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists (i.e., outside of the setting of major bleeding, intracranial hemorrhage, or anticipated emergent surgery).
  5. Limit surveillance computed tomography (CT) scans in asymptomatic patients following curative-intent treatment for aggressive lymphoma.
  6. Don’t treat with an anticoagulant for more than three months in a patient with a first venous thromboembolism occurring in the setting of a major transient risk factor.
  7. Don’t routinely transfuse patients with sickle cell disease (SCD) for chronic anemia or uncomplicated pain crisis without an appropriate clinical indication.
  8. Don’t perform baseline or routine surveillance CT scans in patients with asymptomatic, early-stage chronic lymphocytic leukemia.
  9. Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pretest probability of HIT.
  10. Don’t treat patients with immune thrombocytopenic purpura (ITP) in the absence of bleeding or a very low platelet count.

Non-ASH Choosing Wisely Recommendations of Relevance to Hematology

  1. Don’t image for suspected pulmonary embolism (PE) without moderate or high pretest probability of PE.
  2. Don’t routinely order thrombophilia testing on patients undergoing a routine infertility evaluation.
  3. Don’t perform repetitive complete blood count (CBC) and chemistry testing in the face of clinical and lab stability.
  4. Don’t transfuse red blood cells for iron deficiency without hemodynamic instability.
  5. Avoid using positron emission tomography (PET) or PET-CT scanning as part of routine follow-up care to monitor for a cancer recurrence in asymptomatic patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome.

ASH-ASPHO Choosing Wisely Pediatric Focused List

  1. Don’t perform routine pre-operative hemostatic testing (PT, aPTT) in an otherwise healthy child with no prior personal or family history of bleeding.
  2. Don’t transfuse platelets in an asymptomatic (i.e., non-bleeding) pediatric patient (e.g. aplastic anemia, leukemia, etc.), with a platelet count > 10,000/mcL unless other signs and/or symptoms for bleeding are present, or if the patient is to undergo an invasive procedure.
  3. Don’t order thrombophilia testing on children with venous access (i.e., peripheral or central) associated thrombosis in the absence of a positive family history.
  4. Don’t transfuse packed red blood cells for iron deficiency anemia in asymptomatic pediatric patients when there is no evidence of hemodynamic instability or active bleeding.
  5. Don’t routinely administer granulocyte colony stimulating factor for empiric treatment of pediatric patients with asymptomatic autoimmune neutropenia in the absence of recurrent or severe bacterial and/or fungal infections.

References

  1. Morgan DJ, Dhruva SS, Wright SM, Korenstein D. Update on medical overuse. JAMA Intern Med. 2016;176:1687-92.
  2. Centers for Medicare & Medicaid Services. National Health Expenditure Projections 2018-2027. Accessed November 4, 2019, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf.
  3. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319:1024-39.
  4. The Commonwealth Fund. State Trends in the Cost of Employer Health Insurance Coverage, 2003–2013. Accessed November 6, 2019, from https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2015_jan_1798_schoen_state_trends_2003_2013.pdf.
  5. American Society of Hematology. Choosing Wisely. Accessed November 6, 2019, from https://hematology.org/Clinicians/Guidelines-Quality/502.aspx.
  6. Kaiser Health News. New Round of Medicare Readmission penalties hits 2,583 hospitals. Accessed November 5, 2019, from https://khn.org/news/hospital-readmission-penalties-medicare-2583-hospitals/.
  7. Ibrahim AM, Dimick JB, Sinha SS, et al. Association of coded severity with readmission reduction after the Hospital Readmissions Reduction Program. JAMA Intern Med. 2018;178:290-2.
  8. Ryan AM, Krinsky S, Maurer KA, et al. Changes in hospital quality associated with Hospital Value-Based Purchasing. N Engl J Med. 2017;376:2358-66.