Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit.

Importance: For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. Objective: To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. Design, Setting, and Participants: Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. Exposure: Receipt of a given test within 1 week before or after the AWV. Main Outcomes and Measures: Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. Results: Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. Conclusions and Relevance: In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.

Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries.

OBJECTIVE: To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes. DATA SOURCES: Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data. STUDY DESIGN: Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse. DATA COLLECTION/EXTRACTION METHODS: 1 604 580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414 209 beneficiaries were considered clinically complex (frailty or 2 + chronic conditions). PRINCIPAL FINDINGS: Financial integration and clinical integration were weakly correlated (correlation coefficient = 0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]). CONCLUSIONS: Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

Association between specialist compensation and Accountable Care Organization performance.

OBJECTIVE: To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance. DATA SOURCES: National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016). STUDY DESIGN: We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates. PRINCIPAL FINDINGS: Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7]). CONCLUSION: Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.

Cascades of Care After Incidental Findings in a US National Survey of Physicians.

Importance: Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and experiences of these cascades nationally. Objective: To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians. Design, Setting, and Participants: Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019. Main Outcomes and Measures: Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades. Results: This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. Conclusions and Relevance: The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.

Association Between Care Management and Outcomes Among Patients With Complex Needs in Medicare Accountable Care Organizations.

Importance: People with complex needs account for a disproportionate amount of Medicare spending, partially because of fragmented care delivered across multiple practitioners and settings. Accountable care organization (ACO) contracts give practitioners incentives to improve care coordination to the extent that coordination initiatives reduce total spending or improve quality. Objective: To assess the association between ACO-reported care management and coordination activities and quality, utilization, spending, and health care system interactions in older adults with complex needs. Design, Setting, and Participants: In this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) conducted from July 20, 2017, to February 15, 2018, was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or 2 or more chronic conditions associated with high costs and clinical need were included. Exposures: Beneficiary attribution to ACO reporting comprehensive (top tertile) care management and coordination activities. Main Outcomes and Measures: All-cause prevention quality indicator admissions, 30-day all-cause readmissions, acute care and critical access hospital admissions, evaluation and management visits in ambulatory settings, inpatient days, emergency department visits, total spending, post-acute care spending, health care contact days, and continuity of care (from Medicare claims). Results: Among 1 402 582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1% were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary [interquartile range (IQR), 8.0-21.0] in both tertiles), longer median inpatient days (11.0 [IQR, 4.0-33.0] vs 10.0 [IQR, 4.0-32.0]), higher median annual spending ($14 350 [IQR, $4876-$36 119] vs $14 229 [IQR, $4805-$36 268]), lower median health care contact days (28.0 [IQR, 17.0-44.0] vs 29.0 [IQR, 18.0-45.0]), and lower continuity-of-care index (0.12 [IQR, 0.08-0.20] vs 0.13 [IQR, 0.08-0.21]). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities. Conclusions and Relevance: The ACO self-reports of care management and coordination capacity were not associated with differences in spending or measured outcomes for patients with complex needs. Future efforts to care for patients with complex needs should assess whether strategies found to be effective in other settings are being used, and if so, why they fail to meet expectations.

ACO Contracts With Downside Financial Risk Growing, But Still In The Minority.

Success of the accountable care organization (ACO) model may require stronger financial incentives, such as including downside risk in contracts. Using the National Survey of ACOs, we explored ACO structure and contracts in 2012-18. Though the number of ACO contracts and the proportion of ACOs with multiple contracts have grown, the proportion bearing downside risk has increased only modestly.

Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries.

IMPORTANCE: Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care. OBJECTIVE: To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between April 1, 2013, and September 30, 2015, and underwent cataract surgery between July 1, 2014 and June 30, 2015. Data were analyzed from March 12, 2018, to April 9, 2019. EXPOSURES: Receipt of a preoperative EKG. The comparison group included patients who underwent cataract surgery but did not receive a preoperative EKG. MAIN OUTCOMES AND MEASURES: Cascade event rates and associated spending in the 90 days after preoperative EKG, or in a matched timeframe for the comparison group. Secondary outcomes were patient, physician, and area-level characteristics associated with experiencing a potential cascade. RESULTS: Among 110 183 cataract surgery recipients, 12 408 (11.3%) received a preoperative EKG (65.6% of them were female); of those, 1978 (15.9%) had at least 1 potential cascade event. The comparison group included 97 775 participants (63.1% female). Those who received a preoperative EKG experienced between 5.11 (95% CI, 3.96-6.25) and 10.92 (95% CI, 9.76-12.08) additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 (95% CI, 1.34-3.02) and 7.98 (95% CI, 7.12-8.84) tests, 0.33 (95% CI, 0.19-0.46) treatments, 1.40 (95% CI, 1.18-1.62) new patient cardiology visits, and 1.21 (95% CI, 0.62-1.79) new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary (95% CI, $342-$775), or an estimated $35 025 923 annually across all Medicare beneficiaries in addition to the $3 275 712 paid for the preoperative EKGs. Among preoperative EKG recipients, those who were older (adjusted odds ratio [aOR] for patients aged 75 to 84 years vs 66 to 74 years old, 1.42; 95% CI, 1.28-1.57), had more chronic conditions (aOR for each additional Elixhauser condition, 1.18; 95% CI, 1.14-1.22), lived in more cardiologist-dense areas (aOR, 1.05; 95% CI, 1.02-1.09), or had their preoperative EKG performed by a cardiac specialist rather than a primary care physician (aOR, 1.26; 95% CI, 1.10-1.43) were more likely to experience a potential cascade. CONCLUSIONS AND RELEVANCE: Care cascades after preoperative EKG for cataract surgery are infrequent but costly. Policy and practice interventions to reduce low-value services and the cascades that follow could yield substantial savings.

ICD-10 Coding Will Challenge Researchers: Caution and Collaboration may Reduce Measurement Error and Improve Comparability Over Time.

BACKGROUND: The October 1, 2015 US health care diagnosis and procedure codes update, from the 9th to 10th version of the International Classification of Diseases (ICD), abruptly changed the structure, number, and diversity of codes in health care administrative data. Translation from ICD-9 to ICD-10 risks introducing artificial changes in claims-based measures of health and health services. OBJECTIVE: Using published ICD-9 and ICD-10 definitions and translation software, we explored discontinuity in common diagnoses to quantify measurement changes introduced by the upgrade. DESIGN: Using 100% Medicare inpatient data, 2012-2015, we calculated the quarterly frequency of condition-specific diagnoses on hospital discharge records. Years 2012-2014 provided baseline frequencies and historic, annual fourth-quarter changes. We compared these to fourth quarter of 2015, the first months after ICD-10 adoption, using Centers for Medicare and Medicaid Services Chronic Conditions Data Warehouse (CCW) ICD-9 and ICD-10 definitions and other commonly used definitions sets. RESULTS: Discontinuities of recorded CCW-defined conditions in fourth quarter of 2015 varied widely. For example, compared with diagnosis appearance in 2014 fourth quarter, in 2015 we saw a sudden 3.2% increase in chronic lung disease and a 1.8% decrease in depression; frequency of acute myocardial infarction was stable. Using published software to translate Charlson-Deyo and Elixhauser conditions yielded discontinuities ranging from -8.9% to +10.9%. CONCLUSIONS: ICD-9 to ICD-10 translations do not always align, producing discontinuity over time. This may compromise ICD-based measurements and risk-adjustment. To address the challenge, we propose a public resource for researchers to share discovered discontinuities introduced by ICD-10 adoption and the solutions they develop.

ACOs with risk-bearing experience are likely taking steps to reduce low-value medical services.

OBJECTIVES: Accountable care organizations (ACOs) are groups of healthcare providers responsible for quality of care and spending for a defined patient population. The elimination of low-value medical services will improve quality and reduce costs and, therefore, ACOs should actively work to reduce the use of low-value services. We set out to identify ACO characteristics associated with implementation of strategies to reduce overuse. STUDY DESIGN: Survey analysis. METHODS: We used the National Survey of ACOs to determine the percentage of responding ACOs aware of the Choosing Wisely campaign and to what degree ACOs have taken steps to reduce the use of low-value services. We identified characteristics of ACOs associated with implementing low-value care-reducing strategies using 3 statistical models (stepwise and LASSO logistic regression and random forest). RESULTS: Responding executives of 155 of 267 ACOs (58%) were aware of Choosing Wisely. Eighty-four of those 155 ACO leaders said that their ACOs also actively implemented strategies to reduce the use of low-value services, largely through educating physicians and stimulating shared decision making. All 3 models identified the presence of at least 1 commercial payer contract and prior joint experience pursuing risk-based payment contracts as the most important predictors of an ACO actively implementing strategies to reduce low-value care. CONCLUSIONS: In the first year of implementation, just one-third of ACOs had taken steps to reduce the use of low-value medical services. Safety-net ACOs and those with little experience as a risk-bearing organization need more time and support from healthcare payers and the Choosing Wisely campaign to prioritize the reduction of overuse.

Overuse and insurance plan type in a privately insured population.

OBJECTIVES: A substantial portion of healthcare spending is wasted on services that do not directly improve patient health and that cause harm in some cases. Features of health insurance coverage, including enrollment in high-deductible health plans (HDHPs) or health maintenance organizations (HMOs), may provide financial and nonfinancial mechanisms to potentially reduce overuse of low-value healthcare services. STUDY DESIGN: Using 2009 to 2013 administrative data from 3 large commercial insurers, we examined patient characteristics and health insurance plan types associated with overuse of 6 healthcare services identified by the Choosing Wisely campaign. METHODS: We explored associations between overuse and patient characteristics using multivariate logistic regression models, including patient age, gender, enrollment in an HMO, enrollment in an HDHP, an indicator of primary care fragmentation, and number of outpatient visits as explanatory variables. RESULTS: Measurement of services highlighted as potential overuse by the Choosing Wisely recommendations revealed low to moderate prevalence, depending on the service. HMO coverage and enrollment in HDHPs were significantly associated with differences in prevalence of all 6 services, albeit differently in terms of the direction of the effects. Primary care fragmentation was significantly associated with higher rates of overuse. CONCLUSIONS: Neither HDHPs nor HMO plans, with their closed networks and referral requirements, consistently reduced overuse, although HMO plans were never associated with higher rates of overuse. As policy makers seek levers for reducing low-value healthcare utilization, health insurance plan features may prove a valuable target, although the effect may be complicated by other factors.

Measuring overuse with electronic health records data.

OBJECTIVES: To measure overuse of low-value care using electronic health record (EHR) data and manual chart review and to evaluate whether certain low-value services are better captured using EHR data. STUDY DESIGN: We implemented algorithms to extract performance on 13 Choosing Wisely-identified healthcare services using EHR data at a large physician practice group between 2011 and 2013. METHODS: We calculated rates of overuse using automated EHR extracts. We manually reviewed the charts for 200 cases of overuse for each measure to determine if they had clinical risk factors that could explain use of the low-value service and then calculated adjusted rates of overuse. We explored trends in overuse for each low-value service in the 3-year duration using logistic regression. RESULTS: Unadjusted rates of overuse ranged from 0.2% to 92%. Automated EHR extracts and manual chart review identified explanatory risk factors for most measures, although the magnitude varied: for some measures (eg, bone densitometry exam for women younger than 65 years), manual chart review did not identify many additional risks (3.0%). In contrast, in patients who had sinus computed tomography or an antibiotic prescription for uncomplicated acute rhinosinusitis, manual chart review identified more explanatory risk factors (22.5%) than the automated EHR extract (9.5%). Adjusted rates of overuse ranged from 0.2% to 61.9%. Eight services demonstrated a statistically significant decrease in overuse over 3 years, while 1 increased significantly. CONCLUSIONS: The use of EHR data, both extracted and manually abstracted, provides an opportunity to more accurately and reliably identify overuse of low-value healthcare services.

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

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.

Choosing Wisely Campaign: Valuable For Providers Who Knew About It, But Awareness Remained Constant, 2014-17.

Together with physician specialty societies, the Choosing Wisely® campaign has codified recommendations of which health care services' use should be questioned and discussed with patients. The ABIM Foundation administered surveys in 2014 and 2017 to examine physicians' attitudes toward and awareness of the use of low-value care. The surveys included questions on the factors driving that use, physicians' comfort in having conversations with patients about that use, and physicians' exposure to the Choosing Wisely campaign. Despite continued publicity and physician outreach efforts, there were no significant changes between 2014 and 2017 in awareness of the campaign among physicians (awareness increased from 21 percent to 25 percent) or physician-reported difficulty in talking to patients about avoiding a low-value service (42 percent reported that such conversations had gotten harder in 2014, and 46 percent did so in 2017). Barriers to the adoption of recommendations included malpractice concerns, patient demand and satisfaction, and physicians' desire for more information to reduce uncertainty. Multifaceted interventions that reinforce guidelines through personalized education, follow-up, and feedback, as well as aligned financial incentives, should be pursued to reduce the use of low-value services.

Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review.

The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.