Analysis of Physician Variation in Provision of Low-Value Services

Abstract

Importance: Facing new financial incentives to reduce unnecessary spending, provider organizations may attempt to reduce wasteful care by influencing physician practices or selecting more cost-effective physicians. However, physicians’ role in determining the use of low-value services has not been well described. Objective: To quantify variation in provision of low-value health care services among primary care physicians and to estimate the proportion of variation attributable to physician characteristics that may be used to predict performance. Design, Setting and Participants: Retrospective analysis of national Medicare fee-for-service claims of 3,159,834 beneficiaries served by 41,773 generalist physicians from 2008‒2013. Multilevel modeling was employed to estimate the extent of variation in service use across physicians within region and within provider organization, adjusted for patient clinical and sociodemographic characteristics and sampling variation. The proportion of variation attributable to physician characteristics that may be used to predict performance (age, sex, MD credential, professorship, publication record, trial investigation, grant receipt, pharmaceutical/device manufacturer payment, and panel size) was estimated via additional regression analysis. Measures: Annual count per beneficiary of 17 primary care related services that provide minimal clinical benefit. Results: The average annual rate of low-value services was 33.1 services per 100 beneficiaries. There was considerable variation across physicians within the same region (SD, 8.8; 95% CI, 8.7‒8.9; 10th percentile, 21.8; 90th/10th percentile ratio, 2.03; 95% CI, 2.01‒2.06) and across physicians within the same organization (SD, 6.1; 95% CI, 6.0‒6.2; 10th percentile, 25.3; 90th/10th percentile ratio, 1.61; 95% CI, 1.60‒1.63). Observable physician characteristics accounted for only 4.4% of physician variation within region and 1.4% of physician variation within organization. Conclusion and Relevance: Physician practices may substantially contribute to low-value service use, which is prevalent even among the least wasteful physicians. Because little variation is predicted by measured physician characteristics, direct measures of low-value care provision may aid organizational efforts to encourage high-value practices.

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration

“…This strategy differs from prior approaches broadly assessing low-value care among Medicare beneficiaries, which depict low-value care as counts among 100 beneficiaries, making direct comparisons between VA and Medicare beneficiaries challenging. 5 , 7 , 8 Nevertheless, these data, in concert with the growing body of literature on this topic, suggest that low-value care is common and occurs across multiple disease states in the VHA, as it does among Medicare and private insurance beneficiaries.…”

Trends in Use of Low-Value Care in Traditional Fee-for-Service Medicare and Medicare Advantage

“…Use of low-value care is especially prevalent among older adults in the US. 2 , 4 , 5 , 6 , 7 , 8 , 9 , 10 A 2014 study 2 found that among 26 low-value services in 6 categories (ie, cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing and procedures, and other surgical procedures), 24% to 41% of individuals enrolled in traditional fee-for-service Medicare (TM) received at least 1 low-value service in 2009. The rate of use of low-value care varied across services, ranging from 0.1% for electroencephalography for headache to 12.4% for imaging for low-risk low back pain.…”

Per Capita Medicare Inflation in the Last Decade: Unit Cost Increases Offset by Reduced Utilization

“…While accountability may have driven care to lower cost settings and reduced waste, we found relatively high unit cost growth in most care services. Although limited by its reliance on administrative data, and an inability to adjust for changing patient needs, these initial findings invite further research examining the effectiveness of efforts to reduce components of per capita Medicare inflation by reducing low-value care provision (reducing service use), 5 reducing estimated unit costs for longitudinal services (reducing episode costs), or enhancing provider productivity (improving care efficiency). 6 Figure 1 For Medicare fee-for-service enrollees younger than age 65 (top) and 65 years old and older (bottom), compound annual inflation rates for the period 2007-2017 overall for each service (in the black circle) and for each inflation rate component (the proportion of the service population that used the service, the number of events per service, the estimated cost per event (for single-use services), and the number of days per episode and the estimated cost of each episode day (for longitudinal services).…”