low-value care

How to Lower Health Care Costs: Why Not Provide Greater Access to Mid-Level Providers?

By M2|2017-10-08T11:38:37+00:00June 28th, 2017|Uncategorized|

How to Lower Health Care Costs: Why Not Provide Greater Access to Mid-Level Providers?

We see news reports every day of rising health care costs; overall, U.S. health spending is much higher for all categories of care, especially for ambulatory care, compared to other developed countries. And a recent survey shows that nearly 30% of adults in the U.S. reported that someone in their household has had problems paying medical bills in the past year.

I am often asked for ideas about how to reduce health care costs, but honestly, most of what I recommend, while based on evidence, is not very popular. In the latest example, a recent study in the American Journal of Managed Care shows that NPs and PAs make different prescribing decisions as compared to primary care providers, and those decisions result in lower costs.

The study evaluated the prescribing and ordering habits of primary care providers compared with those of NPs and PAs, specifically for patients with neck or back pain or acute respiratory infection (ARI). These two medical conditions are frequently associated with orders for ancillary services that are “overused and add cost without value,” such as CT scans/MRIs and narcotic analgesics for management of neck/back pain, and antibiotics to manage ARI.

The study found that overall, NPs and PAs were less likely to order these kinds of ancillary services and prescriptions, than were physicians.

For neck/back pain, primary care providers (PCPs) “were more likely to order CTs/MRIs and narcotic analgesics and NPs/PAs were more likely to order nonnarcotic analgesics and muscle relaxants,” the study finds.

“Similarly, differences were noted in management of ARI: PCPs were more likely to order CTs/MRIs – although the rate of these orders was low – as well as x-rays, broad spectrum antibiotics, and rapid strep tests; NPs/PAs were more likely to order any antibiotic,” the authors say.

“On balance, PCPs tended to be more likely than NPs/PAs to order diagnostic or therapeutic services related to N/B pain and ARI visits and to order more costly services among alternatives (e.g., CTs/MRIs vs x-rays for adults with N/B pain, broad spectrum antibiotics vs first-line general antibiotics for adults with ARIs).”

“The pattern of ancillary services use suggests that NPs/PAs might have been more judicious in use of ‘low-value’ ancillary services than PCPs,” the study finds. “

This is particularly important for treatment of back pain, where there is concern about overuse of CTs/MRIs and narcotic analgesics. For management of ARI, “overuse of antibiotics—particularly broad-spectrum antibiotics—is a long-standing concern.” In addition, overuse of rapid strep tests is another concern in management related to treating ARIs.

The study sheds further light on the issue of “low-value care,” defined as expensive procedures and tests with questionable therapeutic value; as I noted in a recent blog, a study found that one-third of Americans “have difficulty envisioning benefits from avoiding low-value care.”

Turning to hospitals, this sector is increasingly looking to non-MDs, such as NPs/PAs, to help alleviate the physician shortage, as described in a recent Practice Management News article.

The Association of American Medical Colleges (AAMC) has projected the provider shortfall will grow to 104,900 physicians by 2030. Given that NPs and PAs are typically paid less than MDs – e.g., PAs earned about $111,500 on average in 2016 versus $294,000 for average physician compensation in 2017 – hospitals may save on costs by increasing their ratio of PAs/NPs to physicians.

This study suggests that using mid-level (non-MD) providers may be one way to reduce health care expenditures. It’s not a popular solution with certain stakeholders (you can guess which ones), but when it comes to consumers, this study clearly shows a way to lower health care costs.

Despite Americans’ Support for Avoiding Low-Value Health Care, One-Third Have Difficulty Understanding Benefits of Conservative Approaches; Few Favor Doctors Who Avoid Unnecessary Care

By M2|2017-10-09T01:52:43+00:00May 10th, 2017|Evidence-Based Medicine, Uncategorized|

Despite Americans’ Support for Avoiding Low-Value Health Care, One-Third Have Difficulty Understanding Benefits of Conservative Approaches; Few Favor Doctors Who Avoid Unnecessary Care

“Low-value care” is defined as expensive procedures and tests with questionable therapeutic value; examples include unnecessary screenings and antibiotics.

As much as 30% of U.S. health care spending may be unnecessary. However, one-third of Americans “have difficulty envisioning benefits from avoiding low-value care,” according to a study published in The Milbank Quarterly. This figure increases to one-half for minorities and those who are less educated.

“The public’s awareness of low-value care is incomplete, with substantial disparities related to race, ethnicity, and socioeconomic status,” the study finds. “Media messaging can help fill these gaps but, in the short run, would be enhanced by fine-tuning how low-value care is characterized. In the longer run, building robust public support for reducing low-value care may require refocusing attention away from specific tests and treatments and toward the relational benefits for patients if clinicians spent less time on testing and more time on personalized care.”

The research, conducted by Mark Schlesinger, Yale School of Public Health, and Rachel Grob, University of Wisconsin-Madison, involved a range of methods, including focus groups, intensive interviews with patients and a national survey.

Less time on low-value care means more time on personal care, right? Not so fast…

Specifically, the respondents anticipated two distinct changes: they “expected that spending less time ordering and reading tests would allow clinicians more time to talk with their patients” and that “taking a more mindful, less routinized approach to testing would encourage discussion of the benefits and limitations of each approach and greater acknowledgment of clinical uncertainty,” the authors note.

“Most Americans who anticipate benefits hope that less testing and treatment will be replaced by more interactive and personalized care. Even without media priming, many Americans would avoid common forms of low-value care like unnecessary antibiotics or excess imaging for lower back pain,” the authors say. However, “few favor clinicians who avoid these practices.”

For example, “many patients now seek specific tests or procedures or insist on quick interventions because they feel the pressure of work and home responsibilities. Clinicians find such requests difficult to refuse, even when they recognize that acquiescing will have little clinical benefit.”

These findings demonstrate that even though we are wasting nearly one-third of our health care dollars, people still are not sure they want to actively not choose “low-value care.”

Interestingly, we have seen this dynamic before (see our recent blog on “Breast Cancer: Less is More, Says Surgical Chief”); it is difficult to convince physicians and patients both that less is more.

What can we do to address this disconnect? Educating the public is a good place to start, as the authors recommend.

“To debunk the opinion that ‘more is better’ when it comes to health care, the study suggests that public education is vital to reducing spending, with an emphasis on the great risks and limited rewards of low-value procedures,” as the Association of Schools & Programs of Public Health (ASPPH) says.

But how we message this matters, the study authors emphasize: In order to maximize public education efforts on low-value care, the messages, and resulting media coverage, “must be adapted to resonate as strongly as possible with the public’s values, perceptions, and preferences about medical care,” they say.

We need to start explaining what low-value care even means. “What is needed is a message campaign that has the capacity to reach, and mobilize, the majority of Americans who currently see no advantage in reducing low-value care, particularly the third of the population that has little current understanding of what that concept even means or why it matters.”