Welcome to 2020! We’ve been busy scouring the interweb for all health spending happenings. So…sit back, relax and don’t forget to drop us a line or tweet using #GoingBelowTheSurface.

Digging Deeper

This month, it’s all about low-value care, alternative care interventions and shared decision-making. We recap a webinar focused on navigating low-value care, a crucial issue affecting our health system, and examine two cases in which care interventions intended to reduce costs and improve outcomes missed the mark. We explore some of the unexpected pitfalls of alternative care models in the context of hospital readmission rates, and we challenge assumptions about shared decision-making between clinicians and patients. Sometimes cost-cutting efforts are not so obvious, but a good starting point in eliminating low-value care.

Navigating Low-Value Care

Earlier this month, the Going Below The Surface Forum, in conjunction with partners AcademyHealth and the National Pharmaceutical Council, hosted a webinar to discuss low-value care.

While identifying and eliminating low-value care from our health care system is critical, it can be difficult to identify low-value care, and once identified, it is even more daunting to determine how to collaborate or organize to eliminate these services. In order to be successful, stakeholders need new guidance and tools to prioritize which areas of low-value care to tackle. Additionally, stakeholders must continue to ask the tough questions about how we define, spotlight and root out low-value care.

Why It Matters: As much as $340 billion is being spent on low-value or unnecessary health care in the United States. This figure alone speaks volumes. The Going Below the Surface Forum is working on a roadmap that helps to navigate these issues and better arm stakeholders to address low-value care at a macro level, which will be rolled out at in the early spring. In the meantime, read more in our recap.

Complexities of Coordinated Care

The Camden Coalition of Healthcare Providers has worked for nearly two decades to reduce hospital utilization rates with a unique and attractive theory: it emphasized the coordination of outpatient follow-up care for the patients who used the most health care services and therefore were responsible for a disproportionate share of the costs.

Researchers publishing in the New England Journal of Medicine (NEJM) put the approach – known as “hotspotting” – through a randomized control trial, looking at patients assigned to the Coalition’s care program compared with those who received traditional care. The good news: readmission decreased by approximately 38% in the Camden group. But more significant was the bad news: a similar readmission rate was seen in the control group, suggesting the intervention failed to have significant impact over traditional care.

Why It Matters: The NEJM study emphasized the benefit of challenging our assumptions about implementing new health care strategies. The Camden approach was widely lauded as a common-sense solution; it’s only because researchers were willing to test the theory that we now have data-driven, if disappointing, answers to the impact of “hotspotting.” It’s also important to recognize that funding aimed at these endeavors or “shiny new objects” could have been spent wisely elsewhere.

Shared Decision-Making Drawbacks

A recent Health Affairs study explored the use of shared decision-making, where patients and clinicians discuss the trade-offs of different treatment options to ensure care aligns with patient values. The goal was to see if such an approach would reduce invasive procedures and lower costs.

Researchers examined two groups of patients who were seeking consultation for hip or knee surgeries. One group used shared decision-making tools while the other group experienced a standard consultation. Individuals exposed to the shared decision-making process were two-and-a-half-times more likely to undergo hip replacement surgery and nearly twice as likely to undergo knee replacement surgery within six months of their consultations. Overall, the researchers said the use of shared decision-making did not demonstrate reduced utilization as expected.

Why It Matters: Like “hotspotting,” the idea that open dialogue between clinicians and patients may reduce health care utilization has been seen as a promising way to align patient preferences and cost savings. The new Health Affairs study, however, suggests that shared decision-making alone will not lead to reduced utilization. Health systems looking to shared decision-making and other patient-centered tools should consider that while incorporating patient preferences may increase the perceived value of care, the impact on cost may be counter-intuitive.

What We’re Reading

Here, we’re featuring two articles that consider health spending in different ways, but a common thread is the importance of primary care. The first article considers how to lower spending, with making primary care a priority among its suggestions. The second article questions why we aren’t spending more on primary care in commercially insured populations. Both give us food for thought as we consider where we need to place our health care dollars.

  • Pyenson B, Schulman M. There’s Nothing Wrong With U.S. Health Care That Less Money Couldn’t Fix. December 6, 2019, Health Affairs Blog
    This article acknowledges that the growth in health care spending is problematic, points to some of its root causes, and offers a series of recommendations to lower spending. Their ideas? Prioritize primary care, minimize the middleman, move away from fee-for-service and deflate all health care prices, to name a few.
  • Reiff J, et al. Primary Care Spending in the Commercially Insured Population. December 10, 2019, JAMA
    Primary care has been touted as a way to maintain health and decrease spending by reducing the need to see a specialist or stay in the hospital and avoiding more serious health complications down the road. Despite the benefits of primary care, this JAMA study found that spending on primary care interventions in the commercially insured population has decreased in recent years. The study also acknowledges the need to dig deeper on the factors affecting primary care spending — patient and primary care clinician demographics and insurance plan benefit design were not studied.

Dialogues on Health Care Spending

Hosting a conference about health care spending or related topics? Drop us a line and let us know about it!

  • National Health Policy Conference: AcademyHealth is hosting its annual National Health Policy Conference on Feb. 10-11 in Washington, D.C. The featured speakers and panel discussions will cover a wide range of topics, including health care spending and improving patient care. Check out the agenda and register online.
  • Price of Good Health: The Going Below The Surface Forum’s efforts to address health care spending were spotlighted during a session at the Council for Affordable Health Coverage’s 3rd Annual Price of Good Health Summit on Jan. 16. CAHC is a Forum partner.
  • Tradeoffs Podcast: If you’re a podcast fan, be sure to check out Tradeoffs, aimed at “exploring our confusing, costly, and often counterintuitive health care system.” New episodes are posted regularly.