Provider Payment Mechanisms May Influence Low-Value Care Use

Fee-for-service providers in the Military Health System were more likely to order 11 of 19 low-value care services compared to salaried providers, a new study shows.

A new study in Health Affairs found evidence that patients in the Military Health System received potentially low-value care, but the amount of low-value care varied by how the providers were paid.

Researchers defined low-value care as overused or inappropriate care. Such care included procedures and treatments that were clinically inappropriate or inappropriate for a certain population (i.e., prescribing antibiotics for viral infections or cardiac stress imaging in low-risk or asymptomatic patients).

Low-value care in the analysis also constituted excessively intensive or sophisticated care (i.e., cross-sectional imaging both with and without contrast) and services that involved the delivery of services with excessive frequency (i.e., unnecessary follow-up visits).

These low-value services drive up healthcare costs without adding to patient outcomes or quality of care. In fact, low- or no-value care accounts for about $200 billion annually, researchers reported citing a 2012 JAMA study.

Low-value care is especially an issue for providers implementing value-based care. Ensuring patients only receive necessary, high-quality care is key to achieving value-based care goals, which include lowering costs and improving population health.

With the Military Health System moving to value-based care under the National Defense Authorization Act for Fiscal Year 2017, researchers set out to uncover the use of low-value care within the healthcare system and which providers delivered the most low-value care: military-operated and -funded military treatment facilities (direct care) or private, civilian-sector facilities (purchased care).

The analysis of TRICARE claims data for more than 2.9 million beneficiaries showed that seven percent received one or more of the 19 low-value services studied in 2014.

The most common overused services among the beneficiaries were the application of traction for patients with a diagnosis of low back pain (104,540 occurrences among eligible beneficiaries) and the use of sinus computed tomography or antibiotics for uncomplicated acute rhinosinusitis (33,226 occurrences among eligible episodes), researchers reported.

Both the overused services were prescribed more often by providers in purchased care, who are paid via fee-for-service rather than salary.

In fact, purchased care providers were more likely to prescribe 11 of the 19 low-value procedures analyzed by researchers, while just six procedures were significantly more likely to be prescribed in direct care, researchers found.

Overall, direct care providers were significantly less likely to use six low-value services: nasal endoscopy for sinusitis, MRI for mild traumatic brain injury, diagnostic tests in the evaluation of allergy, MRI of the lumbar spine for low back pain, and thorax or abdomen CTs with contrast material.

Although, researchers found that direct care providers did overuse three procedures compared to their peers in purchased care. The procedures were fiberoptic laryngoscopy for sinusitis diagnosis, preoperative chest radiography in the absence of clinical suspicion for intrathoracic pathology, and sinus CT or antibiotics for uncomplicated acute rhinosinusitis.

“Differences in payment mechanisms in the direct and purchased care environments may influence health care delivery,” researchers gleaned from the findings.

The data supports claims that fee-for-service incents providers to overprescribe and overtreat patients, while salaried providers are financially motivated to limit care to services that are necessary and high-value.

The value-based care movement aims to curb the use of low-value care by redesigning provider payment mechanisms through pay-for-performance payments, capitation, and other incentives based on cost and quality of care.

As the Military Health System transitions to a value-based system, researchers advised leaders to increase awareness and monitoring of low-value care use. Leaders may want particularly pay attention to the use of MRIs for low back pain, which direct care providers ordered more often then providers in purchased care and Medicare.

Low back pain is also an especially sensitive condition in the Military Health System. The condition can result in military discharge in some cases and is associated with medical evacuation from deployment settings, researchers pointed out.

“This difference highlights the fact that the MHS and other systems may differ in their prioritization of addressing low-value care services,” they explained.