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Medically unnecessary requests, such as asking for antibiotics for a viral infection or an MRI for lower back pain, are often driven by the consumer and will be examined by the Smarter Care Virginia program. (Joe Raedle/Getty Images)

When Less Is More: How One State Is Using Data to Reduce Unnecessary Medical Care

In 2014, U.S. health care spending reached $3 trillion — 17.5% of the nation’s gross domestic product. Overutilization of medical services, especially unnecessary or minimally beneficial tests or procedures, has been cited as a large contributor to the high costs of health care in this country.

Dr. Oz once called Vitamin D the No. 1 thing you need more of.” But not long after that, experts from the U.S. Preventive Services Task Force (USPSTF) announced they found no evidence to back his claim. They gave the supplement a D” rating — meaning it’s not recommended for most people — and concluded that checking for Vitamin D levels did not provide any clinical benefit to patients.

It turns out, Vitamin D supplements are not recommended for most people, according to the U.S. Preventive Services Task Force. (Mark Lennihan/​Associated Press)

Research has shown that Vitamin D screenings and several hundred other medical tests — or low-value care — are unnecessary or minimally beneficial. Low-value denotes medical care that offers no clinical benefit or could result in harm to patients, and it’s a big problem in the U.S. In 2009, unnecessary services, along with other wasteful spending like excessive administrative costs, were responsible for $750 billion, or roughly 30 percent of the United States’ total health care budget, according to the Institute of Medicine.

In 2017, the state of Virginia alone spent $747 million on approximately 2 million medical services that did not improve the health of Virginians, according to a report by the Virginia Center for Health Innovation (VCHI) and Virginia Health Information (VHI). The report — which analyzed claims data for approximately 5 million Virginians — sent shock waves through the state’s health reform community and quickly led to the creation of Smarter Care Virginia, an initiative aimed at reducing low-value care. 

The initiative is led by VCHI, an organization focused on moving Virginians toward a value-based model of care where payment is tied to quality. The first phase of the program targets 7,000 clinicians at six Virginia health systems and focuses on seven provider-driven questionable measures” identified in earlier state work on low-value care. 

We will be able to run reports for every single clinician, by their NPI number, of how much of the seven measures deemed unnecessary they’re ordering every year,” said Beth Bortz, President and CEO of VCHI. The data will produce variance reports of how they’re doing, how their practice is doing, and how their whole system is doing. We’ll be using that to help improve health system performance.”

Sometimes, a patient’s lack of education about what health care services are necessary may contribute to this problem. And when pressured, doctors may cave into patient demands. According to a 2014 Choosing Wisely survey, 53 percent of surveyed doctors said they would order a medical test if a patient insists — even if they know that test is medically unnecessary. Such requests, like asking for antibiotics for a viral infection or an MRI for lower back pain, are driven by the consumer and will be examined by Smarter Care Virginia in the second phase of the program.

Waste in Health Care

  • Though 57 percent of employers believe that up to one-quarter of health care dollars are wasted, nearly two-thirds of businesses surveyed don’t collect or analyze data to track waste.
  • Employers also report little success managing health care waste, such as low-value care. Those efforts were in the areas of medical imaging and physician referrals.

For that reason, Virginia is going beyond working with clinicians to tackle this problem. They’re hoping to reach patients through their employers. A big part of Smarter Care Virginia is to help employees become advocates for their own health by seeking appropriate care. 

We want them (employers) involved because they are a trusted source of information,” said Bortz. 

As purchasers of health services, employers can leverage policies and contracts to ensure benefits are designed to reduce low-value care and support high-value care. For example, employers can change the benefit design, meaning they can stop covering certain services, require prior authorization for some services, or increase the copay. There are all kinds of strategies that could be involved.”

Knowledge is Power: Mobilizing Employers 

Virginia Health and Human Resources Secretary Daniel Carey announced recently the composition of Smarter Care Virginia’s employee task force, which brings together leaders from more than a dozen public and private employers to discuss ways to discourage unnecessary and costly services for their employee populations. Among them are the Virginia State Health Plan, The Port of Virginia, and Carmax.

Members of the employee task force will be required to either submit their own health claims data to the Virginia all-payer claims database (APCD) or commit to producing such data. Specifically, they will be asked to get company-specific performance data as it relates to the provider and consumer-driven low-value care measures being considered by the employer task force.

We will work with them so they can look at their own employee data and see how much of the targeted unnecessary care is happening in their employee population,” said Bortz. They can help us identify the levers they may have — like improving communications, changing benefit design, requiring different data be provided to them by their health plan — so they can make informed decisions.”

The data will produce variance reports of how they’re doing, how their practice is doing, and how their whole system is doing. We’ll be using that to help improve health system performance.
Beth Bortz President and CEO, Virginia Center for Health Innovation

Part of the reason it’s important to get employers involved is because their data might be missing from the statewide APCD. Virginia’s APCD — the main data source for the program — has data at any given time for about 5 million people (or 63 percent of the population). 

We have a rich source of data that includes all the Medicare and Medicaid claims data, and it has about 50 percent of the commercial claims, but the biggest missing bucket is large, commercially-insured employers who have the ability to opt out of submitting their data,” said Bortz.

With the help of employers, the state could have access to more data, which in turn can help paint a more accurate and representative picture of how low-value care is being used. Over the next three years, data from the APCD and employer-specific data will be analyzed through the Milliman MedInsight Waste Calculator, an analytical tool that identifies potentially unnecessary care. 

Over the initial three years of the program, Virginia aims to achieve a 25 percent relative reduction in seven provider measures (those ordered by doctors and clinicians) while also prioritizing up to six consumer-driven measures (those demanded by patients). There are a few remaining slots on the task force, which will be confirmed in the coming weeks. For more information, visit the Smarter Care Virginia Employer Task Force.