Blog

From the team at DocSpot: Happy Thanksgiving!

As different organizations consider how to be more efficient with healthcare dollars, people have been trying to identify and eliminate "low-value care" -- care that costs money or time, but do not actually improve health outcomes. In a previous era where doctors were paid more to do more (and perhaps when budget constraints were less of a concern), it is understandable how low-value care was incorporated into clinical protocols ("just in case" or "why not?"). KFF Family News reports that "Of the $3 trillion spent each year on health care in the U.S., 10% to 30% consists of this low-value care" and that eliminating low-value care is challenging.

Part of the issue is organizational momentum -- when guidelines and protocols that included such low-value care were developed and integrated into the organization's workflow, it can be difficult to change people's patterns. Part of the problem is satisfying concerned patients (or parents) who might feel that without certain tests or imaging, a diagnosis might not be thorough enough. The article quoted one physician as saying "One of the hardest things to do in this work is to align financial incentives."

Yet, the article reports that when low-value tests or imaging appear to reveal a potential problem, follow-up tests cost money, but do not actually improve results -- that is, they were "false positives" that yielded warnings when there was actually no need for concern. To be clear, these tests and imaging procedures can be helpful in other contexts, but may be low-value in specific contexts (e.g. for certain conditions) that provider organizations may need to spend time to identify.

ProPublica published a lawyer's challenge in getting a health insurance company to cover the costs of a specific cancer treatment. While the insurer offered to cover a different treatment, that treatment is less precise and could cause significant damage to the patient's health. Part of the article details the multiple medical reviews by different medical doctors that the appeal went through, leading readers to think that the denial was reasonable. However, it becomes clear that all of the doctors relied on guidelines that were published by a separate company. For the lawsuit that the patient field, one of the patient's doctors compiled evidence that the preferred treatment could lead to meaningfully better health outcomes. After losing the case, the insurer filed an appeal, which ended in the patient's favor.

The article explains that in this case, the insurer was governed by a statute known as the Employee Retirement Income Security Act (ERISA), which apparently gives insurers broad discretion in deciding what to cover. This arrangement seems like an inherent conflict of interest. Theoretically, the insurer adopting guidelines published by an independent company addresses the conflict of interest. However, if most of the company's revenue is derived from insurers, it is not difficult to imagine the company guidelines being biased in a certain direction. Additionally, it is not clear how strong of an incentive the company has to evaluate and recommend newer technologies, especially since they tend to be more expensive.

The federal government (or state governments) could offer an appeals panel to adjudicate disputes on what constitutes "medically necessary" on a case-by-case basis. Alternatively, the government could publish guidelines. A less direct way would be to hold the insurer responsible for unnecessary pain and suffering -- beyond the cost of the operation. If legal liabilities were significant enough over a long enough period of time, insurers might be more collaborative. This option is likely the least pleasant for patients, and perhaps for insurers as well -- assuming the legal liabilities are high enough.

As mental health issues become more prevalent, it seems that Medicare has adjusted: KFF Health News reports that for the first time, Medicare will be paying marriage and family therapists and mental health counselors for their services. The article notes: "For decades, Medicare has covered only services provided by psychiatrists, psychologists, licensed clinical social workers, and psychiatric nurses. But with rising demand and many people willing to pay privately for care, 45% of psychiatrists and 54% of psychologists don't participate in the program. Citing low payments and bureaucratic hassles, more than 124,000 behavioral health practitioners have opted out of Medicare — the most of any medical specialty."

Given that the wider population (not just 65 and over) frequently sees therapists and mental health counselors for mental health treatment, it makes sense that Medicare would also pay for their services for the elderly population. As the article notes, it is unclear whether meaningful numbers of these types of providers will sign up. Nevertheless, this seems like a step in the right direction.

KFF Health News reported on small businesses that offer a free (or inexpensive) clinic to their employees. In this context, "small business" appears to mean companies that employ between 200 and 999 workers. The article reports on companies who help set up such clinics, and that these small businesses might share the clinics with other employers -- both of which seem like creative and practical industry approaches.

The small business featured in the article thinks that the effort has been successful at diverting costly emergency room and urgent care visits, while others who have considered doing something similar are skeptical of the value of the employee benefit. The article points out that it can take years before the benefits are apparent. Interestingly, the featured small business offered a monetary incentive to employees to undergo a physical, with the CEO explaining that the region is known for poor health. This idea of rewarding patients for engaging with their health has been around for a while, but does not seem mainstream. It seems likely that there is no single approach that is cost-effective for all employers, but it is encouraging that a benefit that one might think of as exclusively in the domain of large companies is now a possibility for much smaller ones.