Getting an “A”: Report Cards for Reducing Health Care Waste

Abstract

The health care system in our country is facing a number of challenges. We spend close to $3 trillion, or 18% of our gross domestic product, on health care annually, with projections to reach an unsustainable 20% of our gross domestic product by 2020.1 A good first step to reducing costs is eliminating waste because up to one third of medical expenditures constitute waste and rework.1 Berwick and Hackbarth 1 prioritize cutting waste over the more traditional routes of cuts in care or coverage, "Here is a better idea: cut waste. That is a basic strategy for survival in most industries today, ie to keep processes, products, and services that actually help customers and systematically remove the elements of work that do not." Physicians have envisaged this lean strategy as a decrease in "low-value care," defined as health care services with little potential benefit or for which less expensive alternatives are available.2 In addition to increasing costs, low-value care has the potential to harm patients, decreasing the quality of care. Therefore, eliminating low-value care has benefits on both sides of the value equation, defined as quality divided by costs.Efforts to improve the health care delivery system and decrease waste are generally mediated through quality metrics. Although outcome measures exist, currently most quality measures are process measures. These process measures can target underuse, in which too little care has been provided (eg, failure to obtain an appropriate screening test); overuse, in which too much care has been provided (eg, prescribing antibiotics for a viral upper respiratory tract infection); or misuse, in which care has been provided incorrectly or a preventable complication occurs (eg, a delay in antibiotic therapy for bacterial pneumonia or a central line-associated bloodstream infection).2,3 Key federal efforts to improve the health care delivery system include the creation of the National Quality Forum (NQF), and the Medicare Access and Children' s Health Insurance Program Reauthorization Act. The NQF reviews and endorses quality measures with over 625 endorsed measures. The Medicare Access and Children' s Health Insurance Program Reauthorization Act represents the federal government' s attempt to incentivize quality through its quality program, including the Merit-based Incentive Payment System (MIPS), which ties payment to quality. The quality metrics contained in the MIPS are primarily process measures. Of the 271 quality measures for MIPS in 2017, ∼15 (5.5%) can be classified as overuse measures, and only 3 of those apply directly to children: avoiding systemic antibiotics in otitis externa and in upper respiratory infections, and avoiding computerized tomography scans for mild head trauma (refer to https://qpp.cms.gov/mips/quality-measures). The majority of NQF measures are also process measures. Although NQF does not specifically track overuse measures, a brief review found ∼20 (3%) NQF-endorsed measures address some aspect of overuse (Shantanu Agrawal, MD, MPhil, personal c...