Eliminating Low-Value Health Care: Where Pathways Approaches Have Succeeded

Low-value health care continues to put stress on the US economy, as 20% to 40% of all health spending is designated as wasteful. To date, there have been few broad and sustained efforts to reign in wasteful spending. One reason may be that health care is late in developing industrial process control mechanisms when compared with other industries. Pathways represent a method to attack low-value health care waste. The Institute for Healthcare Improvement and others have shown that a mechanistic problem-solving approach, codified in pathway-like modules, can be successful. Recently, the precepts of the Choosing Wisely campaign have been utilized by the Low Value Waste Task Force to focus employers on health care waste interventions. Tools that can be used as pathways are part of this initiative, framing the problem as an industrial process control issue. Pathways, along with effective employer payer mobilization, can be a major step to reducing wasteful health care spending, leaving funds for productive innovation and technology.  

Low-value health care, defined as treatment and testing that exposes patients to costs, harms, and risks that outweigh any benefits conferred based on the clinical situation, costs the United States between $158 and $226 billion (2011 dollars) annually.¹ Wasteful clinical care drives much of the inefficiency in the US health care system. Estimates of wasteful spending range from approximately 20% to 40% of all US health spending.² Much of this waste harms patients; all of it harms purchasers’ bottom lines; and no American benefits when money is wasted that could be put to more valuable ends, including medical care and medical innovation.³

Frameworks exist to manage low-value health care, yet it continues to defy systematic resolution. Every segment of the US health care system has assessed the problem from its own business perspective—payers, providers and delivery systems, pharmaceutical and medical device manufacturers, pharmacy benefit managers and group purchasing organizations. These organizations agree on 2 things: that there is a lack of aligned incentives and regulatory harmony in the US health care ecosystem, and that the problem is someone else’s fault. The ways in which other industries identify and manage waste in the context of specific alignments and governance could inform a path forward for health care. For example, health care can learn from the way manufacturing has, over time, improved processes, raised productivity, and eliminated waste. The American worker in manufacturing today continues to improve in productivity year over year (the effects of the Great Recession notwithstanding). Today, the Bureau of Labor Statistics Index of Labor Productivity for manufacturing is two and a half times higher than it was in 1987.⁴ The increase reflects several factors: greater investment in new machinery; an increase in worker training and skills; and process streamlining and improvement. 

We should seek to not only understand how other industries identify and eliminate useless and low-value spending but also look within health care to see where early adopters of innovative strategies are succeeding.  

What We Can Learn From Current Efforts to Reduce Waste

Current efforts at waste reduction in the US health care system have been making important first steps, yielding best practices in some cases and important lessons for the future. Some have led to meaningful changes in hospital processes. 

Institute for Healthcare Improvement (IHI) Codifies “Do no Harm”

IHI codified changes to hospital processes affecting infections, adverse drug events, and other complications that hospital patients endure. Launched December 2006, the IHI “5 Million Lives Campaign” built upon the success of the “100,000 Lives Campaign” in which 3100 participating hospitals reduced inpatient deaths by an estimated 122,000 in 18 months through overall improvement in inpatient care.⁵

The hallmark of the IHI campaign was a set of protocols that incorporated pathways. These pathway-style protocols are discrete ways of working to manage inpatients at high risk for highly morbid or fatal events, often across short time horizons. It requires identification and avoidance of preventable errors using standardization of best practices and processes that require precision and clinical skill. Such capabilities include: deployment of rapid response teams for patients at the first sign of cardiac or respiratory decline; protocols for evidence-based, step-wise, team-based care of myocardial infarction; central line placement (to prevent infection); surgical wound care (to prevent infection); mechanically ventilated patients (to prevent infection), and prevention of adverse drug event through medication reconciliation at care transitions. In addition, pre-built root cause analyses allow small teams to optimally manage critically ill patients in an acute care environment filled with complexity, communication and documentation challenges, and resource and time constraints.

Notably, the pathway-style protocols utilized by hospitals succeed by using industrial management science process control: problem identification, alternative generation, and, finally, choice of the best evidence-based alternative. Broadening these learnings has led to the adoption of best practices throughout the hospital industry. Today, these best practices are hardwired into daily operations. They are tangible and measurable, and they are aligned to diagnostic related grouping payment mechanisms and Centers for Medicare & Medicaid Services (CMS) quality measurement. 

National Quality Forum (NQF) Targets Unnecessary Care

Encompassing more than hospital care, the NQF in 2010 convened a National Priorities Partnership (NPP) to improve health care across all settings, including attention to low-value health care in the form of overuse of care. This came in response to a request for proposal from the Department of Health and Human Services, seeking a better way to manage care and more affordable care, resulting in healthier people/healthier communities.  

The 6 areas of focus were: Patient and Family Engagement, Safety, Care Coordination, Palliative and End-of-Life Care, Elimination of Overuse, and Population Health.⁶ NPP targeted the following specific areas: inappropriate medication use, unnecessary lab tests, unwarranted maternity care interventions, unwarranted diagnostic procedures, unwarranted procedures, unnecessary consultations, preventable emergency department visits and hospitalizations, inappropriate nonpalliative services at end of life, and potentially harmful preventive services with no benefit. All these areas are amenable to some form of evidence-based guidelines, pathways, or “playbooks.” Since 2010, each of these areas of focus have received additional attention and scrutiny, but none have created system-wide changes to reliably eliminate the low-value care within their scope of work. Maternity care in the form of unnecessary C-sections has made significant progress in the form of hospital-level benchmarking, and CMS has implemented programs scrutinizing readmission rates, but these are not complete fixes to the problems.

The Need for Broad Alignment Remains

Quantification of low-value health care as a discipline is new but emerging and growing. Frameworks exist, but what is needed is the broad acceptance of tangible tools across disparate health care businesses that could be used to align key stakeholders to drive change. Industrial manufacturing plants have a set of tools they use to drive efficiency and eliminate waste, but the same is not true in health care. The contained environment of a hospital, as shown by the IHI initiative, is mostly designed to provide efficient and error-free care in specific areas. Once outside of those 4 walls, however, one health care setting’s waste is another’s profit margin—a misalignment that is the major impediment to eliminating low-value care. This is where tools for use and alignment for driving change must be re-engineered and the creation of programs reimagined. Below are examples of where attempts at progress in this area have been made.

The Mayo Clinic Focuses on Rapid Iteration and Rapid Diffusion

Leaders at the Mayo Clinic have adopted the mantra of “think big, start small, act fast” as a blueprint for transforming clinical practice.⁷ They recognize multiple types of innovation, and, by using human-centered design practices—like scanning and framing, experimenting, prototyping, and implementing—can quickly test concepts. Beyond rapid framing and testing of often latent customer needs, this model emphasizes communication augmented by asking “why are we doing this?” In addition, the Mayo Clinic recognized that innovation without widespread adoption has limited utility, so they have created an “Innovation Accelerator platform” to speed up diffusion and broad use. Mayo’s approach would seem to be an ideal model for moving solutions in low-value health care forward. In larger scale uptake initiatives, this should include a pathways tools and structure approach. Only with a structured industrial process mechanism, ie, pathways, can large scale change happen efficiently and effectively. In terms of timing, this appears to be happening.⁷

VBID Health Works to Align Incentives

A task force on low-value care was formed by VBID Health in 2016 to address processes and alignment of incentives in health care waste reduction. Working from materials born out of the “Choosing Wisely” initiative,⁸ the task force seeks to draw attention to research on low-value medical care; disseminate effective, practical tactics for enabling payers and purchasers to reduce low-value care; and identify and prioritize strategies for impacting the state and federal policymaking dialogue on low-value care.⁹ 

Central to this effort is the creation of a discrete set of standardized tools for the management of specific low-value activities. Ideally, these tools should be able to be implemented quickly and practically by health care services purchasers, acting as pathway-like process control mechanisms that represent “solutions in a box.” Standardized tools, validated and adopted by purchasers, have the potential to succeed in reducing low-value health care where previous efforts could not obtain broad uptake. Additionally, there are communication efforts by VBID Health and others to align purchasers, particularly employers, around the ability to effect change rapidly by working together. Taken as a whole, these efforts have the ingredients to address much of what is missing in the effort to eliminate low-value care.

The VBID Task Force also targets 5 health care services where there is universal agreement that they offer no clinical benefit, creating for each a “workflows in a box” type tool. The 5 services are vitamin D screening tests, prostate-specific antigen testing in men over 75 years, unneeded testing and laboratory work prior to low-risk surgery, imaging for uncomplicated low back pain within first 6 weeks, and use of more expensive branded medications when generics are available.¹⁰ No employer payer would want to pay for these services, and no provider or delivery system can clinically justify offering them. By beginning the attack on low-value care with the clinical activities that are easiest to identify and remediate, this approach “eats the elephant one bite at a time.”

Employer Appeal

The incremental approach has tremendous appeal for employer health care purchasers who want to ease the clinical and financial burden of low-value care. Data science plays a big part in this approach. Algorithms with existing population health data can be applied to standard code sets (eg, ICD, CPT, NDC, HCPCS, LOINC, BETOS, GPI) to calculate the size and scale of the saving opportunity. The data evaluation also allows for a mapping of workflows to identify the points of leverage and decision, which is key for success in change management. When this data is mapped against the employer’s request-for-proposal (RFP) language, the result for the employer is a customized pathway for savings in a benefits design and care payment system. The RFP is essentially the wish list based on which the algorithm delivers a bespoke pathway. That RFP language includes use of coverage policies to drive low-value care avoidance, use of nonfinancial, provider-facing best practices for performance improvement, patient-facing initiatives and outreach, and provider-facing financial incentives, performance measures, and network design.¹¹

Data science is key, but so is old-fashioned fact-driven storytelling. Stories are powerful in managing the human change element, or culture change, needed to drive wide adoption of a pathway approach. These become necessities when change involves not just costs but also alterations of strongly held beliefs—all tied to industry business relationships. Take this anecdote, for example. The American Health Policy Institute (AHPI) recently published an analysis of cost savings in elimination of wasteful services, “Waste in the Health Care World: An AHPI/VBID Collaboration.” The study involved 35 companies, which spend about $10 billion collectively in providing health care to about 1 million individuals (representative of a cross-section of large US employers). The analysis applied a Health Waste Calculator tool, developed by Milliman under guidance from VBID Health.¹² It found approximately $2 billion in wasteful and unnecessary health spend—about 20% of total spending.¹³

This is a powerful story about a huge savings opportunity for employers. The overall message to employers and their benefits designers and purchasers is “you can do this!” The Health Waste Calculator uses the same taxonomy as the Harvard Business Review study titled “How the US Can Reduce Wasteful Spending in Healthcare By $1 Trillion,”¹² published in October 2015 and based on the original research and analysis conducted by Donald M Berwick, MD, MPP, and Andrew D Hackbarth.¹ The study broke the wasteful spending into 4 main categories: pharmacy (4%); inpatient (6%); outpatient (9%); and administrative (2%). While an analysis of each area and where waste emanates from is beyond the scope of this discussion, we should note that specific tactics and approaches can be developed to manage each area in ways that work for individual business. VBID Health, for example, has a number of publications outlining the levers available to employers and carriers and the importance of using these levers synergistically.⁹

Reasons for Optimism

As waste reduction programs grow, we should be optimistic about the future of health care here in the United States. Pathways represent a foundational part of this effort. From this, we can expect a higher quality of care delivered more reliably to a greater proportion of people over time, ultimately reducing the amount of low- and no-value care.  

While still in the early stages of an industry transformation that has already occurred in other sectors of the American economy, change is happening. This change is a wholesale adoption of management science principles to knit together a fractious and unaligned set of business partners.  Goal number 1 is elimination of low-value care, an area where there is universal agreement.  While the science to achieve these goals has been available for some time, the story and the message of what and how to do this were previously muted.  

Conclusion

The push to eliminate low-value care through use of pathways is a signal of an inflection-point in the health care ecosystem. There is too much economic and political pressure for employers not to reassess their employee health benefits design and too much scientific evidence to not utilize pathway and step approaches to eliminate low-value care. Only a few examples of models and initiatives have been illustrated above. It is not inclusive of the tremendous work being done by many in the health care quality, policy, and outcomes measurement world to bring about this needed evolution. Health care stakeholders must work together, so that we can collectively move toward smarter, better, and less expensive health care. 

References

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307
(14):1513-1516.

2. Health Policy Brief: Reducing waste in healthcare [policy brief]. Health Affairs. December 13, 2012. https://www.healthaffairs.org/do/10.1377/hpb20121213.959735/full/. Accessed January 29, 2019.

3. Budros M, Fendrick AM. Levers to reduce use of unnecessary services: creating needed headroom to enhance spending on evidence-based care. Am J Manag Care. 2018:24(8):353-355.

4. DeSilver D. Most Americans unaware that as U.S. manufacturing jobs have disappeared, output has grown. FactTank. Pew Research Center. July 25, 2017. https://www.pewresearch.org/fact-tank/2017/07/25/most-americans-unaware-that-as-u-s-manufacturing-jobs-have-disappeared-output-has-grown/. Accessed January 29, 2019.

5. Institute for Healthcare Improvement. 5 Million Lives Campaign. An initiative of the Institute for Healthcare Improvement. https://www.ihi.org/about/documents/5millionlivescampaigncasestatement.pdf. Published 2006. Accessed January 29, 2019.

6. National Priorities Partnership. Guidance for responding to request for public feedback on HHS Secretary’s proposed national quality strategy and plan. https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=41594. Published 2010. Accessed January 29, 2019.

7. LaRusso N, Spurrier B, Farrugia G.  Think Big, Start Small, Move Fast: A Blueprint for Transformation from the Mayo Clinic Center for Innovation. New York, NY; McGraw-Hill Education; 2015.

8. Heekin AM, Kontor J, Sax HC, Keller MS, Wellington A, Weingarten S. Choosing wisely clinical decision support adherence and impatient outcomes. Am J Manag Care. 2018;24(8):361-366. 

9. VBID Health. Mission, Task force on low-value care. vibdhealth.com website. https://vbidhealth.com/low-value-care-task-force-mission.php. Accessed January 29, 2019.

10. Buxbaum JD, Mafi JM, Fedrick AM. Tackling low-value care: A new “top five” for purchaser action [blog]. Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20171117.664355/full/. Published November 21, 2017. Accessed January 29, 2019. doi:10.1377/hblog20171117.664355

11. VBID Health. Task force on low-value care. https://vbidhealth.com/docs/LVC-RFP-Language-080918.pdf. Published January 16, 2018. Accessed January 29, 2019.

12. Sahni NR, Chicurupati A. Kocher B, Cutler DM. How the US can reduce waste in health care spending by $1 trillion. Harvard Bus Rev. October 13, 2015. https://hbr.org/2015/10/how-the-u-s-can-reduce-waste-in-health-care-spending-by-1-trillion. Accessed January 29, 2019.

13. Edman D, Manz P. Using data-driven disruption to reduce wasteful healthcare spending. https://www.americanhealthpolicy.org/Content/documents/resources/Wasteful_Spending_AHPI_2016.pdf. American Health Policy Institute and VBID Health. Published 2016. Accessed January 29, 2019.