The Roadmap for Addressing Low-Value Care, a step-by-step guide to assist health care stakeholders in determining opportunities to curb spending and improve patient outcomes, made its debut last week at a webinar hosted by AMGA (American Medical Group Association) and the Going Below The Surface (GBTS) Forum. The event brought together experts from AMGA, the National Pharmaceutical Council (NPC), HealthPartners and Intermountain Medical Group for a discussion on how to use the Roadmap to identify and reduce low-value care – treatments and services that are inefficient, increase costs and have little or no benefit for patients. AMGA members also shared how they are reducing low-value care and spending throughout their organizations, an especially meaningful step to take during the economic downturn caused by the COVID-19 pandemic. The Roadmap was developed in partnership with GBTS, a research initiative launched by NPC, examining health care spending and outcomes.

The Spending Puzzle

NPC’s Chief Science Officer and Executive Vice President, Robert Dubois, said the initial idea for a roadmap for reducing low-value care came about when the 19 organizations comprising the GBTS Forum met two years ago with the goal of starting a national discussion about health care spending. The group decided to focus on two central questions: how much money should be spent on health care, and how should those dollars be used?

“We said, maybe there’s a piece of this puzzle that’s missing and the GBTS partnership could fill that gap,” said Dubois. “And then we realized that the only way we’re going to make a change is if an organization makes a change. For an organization to make a change, there’s a lot of pieces to that puzzle.”

The Roadmap is an eight-step guide to finding those missing pieces. It provides organizations with an outline of the key goals, questions and tactics stakeholders can take to reduce low-value care treatments and services. The Roadmap helps to locate opportunities for change and uses motivating questions to put together a rationale for that change. There are no right or wrong motivating questions, but it’s really helpful to know what the inspiration is, noted Dubois.

“You can’t just say what things you want me to do or not to do, you’ve got to motivate me with rationale or nothing’s going to happen. That will ultimately lead you to the rationale to explain to folks why we are doing this,” he said.

The Do Everything Plan

Beth Averbeck, Senior Medical Director of Primary Care at HealthPartners in Minneapolis, Minn., said one of the key steps in the Roadmap is collaboration. Her organization works with many local partners in the community – a health system, a community group, a mental health facility, a physical therapy group, paramedics, firefighters – to align goals and provide better care at a lower cost. She said she calls this approach “the do everything plan.”

“If it was just one thing, we would have figured it out. All of the AMGA member groups would have figured it out. But it’s not just one thing.”

Averback recalled how an “unexplained variation” in spine surgeries set in motion one such collaboration. Her group found out that Minnesota had a higher rate of spine surgeries than its neighboring state Wisconsin, and they didn’t know why. Her motivating goal was to find a “better back pain pathway for patients to get the appropriate care quicker and potentially avoid unnecessary surgery.”

Her organization developed a partnership with a local physical therapy group that agreed to provide “active physical therapy” with a lower number of weekly visits than what the other therapy groups required. She said this collaboration helped to reduce the number of spine surgeries in her state and has saved her organization $1.5 million year after year.

“We were able to have a pathway where a patient gets physical therapy earlier than they had before, focusing on activity and decreasing opioid use,” she said. “If they’re not better, then we have a medical spine specialist help guide patients on whether or not it’s best to have any type of spine procedure, or if a comprehensive rehab program would be best for them.”

Do No Harm

For panelist Mark Briesacher, Senior Vice President and Chief Physician Executive at Intermountain Healthcare and President of the Intermountain Medical Group in Salt Lake City, Utah, the greatest opportunity for eliminating low-value care is in the space of patient harm. This includes clinical harm, harm from racism and inequities, and financial harm. His aspirational goal is to get to zero harm – the day when avoidable harm is completely eliminated.

“I think there’s no more important area of focus when it comes to reducing the waste in health care than starting with patient safety and patient harm. It provides you with a determined platform to engage every clinical area across your organization, and it’s highly aligned intrinsically with all the reasons that each of us had gotten into health care.”

Briesacher believes that another important key to reducing low-value care is to empower all the leaders at every clinic and hospital to take on and own the work of advancing safety. He said this takes the right combination of psychological safety and accountability.

Briesacher noted that the steps in the Roadmap reflect the key approaches that his organization used in helping its urgent care department to reduce the prescription of antibiotics. His group set-up a virtual telehealth antimicrobial stewardship function and developed a report to share with others in the organization. He said the key event that triggers a safety concern is an adverse health outcome.

“We saw the variation in prescribing in our urgent care which was extraordinary wide and we began showing that information to doctors. And through that process we have greatly reduced the amount of antibiotics for respiratory conditions,” he said. “This has a huge impact from the cost perspective to patients as well as the downstream effect on the biogram each of our hospitals look at for resistance perspective over time.”

Briesacher said that learning from patients is very important to reducing low-value care. When health providers talk to patients, they realize that patients want things to be easier for them – easier to find care, to pay for care, to navigate their care. “When you have optimized those experiences, if someone feels it’s easy to find and get good care, then they’ll be less pressured to get all the care they can get all at once in a given visit,” he said. “We should own what we’re not good at, and we’re not great at helping people navigate health systems.”

Download the Roadmap on the GBTS website, and watch the webinar on demand via AMGA’s website.