A Policy Approach to Reducing Low‐Value Device‐Based Procedure Use

Abstract

Low‐value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low‐value care stems from the use of medical device‐based procedures. We describe here a novel academic‐policymaker collaboration in which evidence‐based clinical coverage for device‐based procedures is implemented through prior authorization‐based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low‐value medical device‐based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low‐value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low‐value device‐based care.

A Critical Examination of Independent Medical Review Decision-making for Cardiovascular Procedures Shows Low Rate of Evidence Citation in Reviews

“…This finding is consistent with numerous studies showing that cardiovascular procedures are often used inappropriately before guideline-directed, noninvasive therapies, mostly in nonacute indications 23–25 . This indicates an opportunity to improve high-value care through choosing less invasive therapies before moving to riskier treatments 2 …”

“…[23][24][25] This indicates an opportunity to improve high-value care through choosing less invasive therapies before moving to riskier treatments. 2 To improve patient and provider understanding and confidence in IMR decision-making, reviewers should provide specific references to current evidence. This is especially important because possible biases in IMR decision-making were found in this study and previous work.…”

“…Decision-making, evidence review processes and coverage criteria vary for different payors. 1,2 In 2001, the Independent Medical Review (IMR) program was created by California legislature to address public concern that insurance coverage decisions were based on cost rather than medical necessity or appropriateness. [3][4][5] Currently, 46 states and 1 US territory have state-based external review processes; California's external review program, IMR, was used as a case example for this paper due to the state's large population size and high annual volume of cases.…”

“…Insurers develop coverage policies based on available scientific evidence and professional society guidelines. Decision-making, evidence review processes and coverage criteria vary for different payors 1,2 . In 2001, the Independent Medical Review (IMR) program was created by California legislature to address public concern that insurance coverage decisions were based on cost rather than medical necessity or appropriateness 3–5 .…”

Randomized Experiments to Reduce Overuse of Health Care

“…These include efforts to promote highvalue care through payer coverage policy or alternative payment models, including bundled payment programs or implementation of accountable care organizations. 51 The review of these interventions was outside the scope of this project.…”