- Rarely changes patient management
- X-rays and CT expose patients to unneeded radiation
- Detects clinically insignificant abnormalities
- Nationwide in 2014:
- About 1.6 million avoidable imaging services performed
- About $500 million in spending resulted
Develop Business Case
Template Business Case
A successful business case ultimately answers the question: "Is the juice worth the squeeze?" Addressing low-value care takes time and resources, and a business case argues that the benefits outweigh the costs and risks. For a business to tackle low-value care, and specifically the Task Force on Low-Value Care's Top Five services, a business needs to establish a concise financial- and health-oriented rationale. The key questions the business case should address:
- What is our current burden of Top Five low-value care services?
- What are the benefits (in terms of finances or health) associated with taking action?
- What are the costs associated with taking action?
- What are the risks (to the organization, employees, providers, or third party administrator)?
- What are the solutions and does the organization have the ability to deliver?
- If applicable, how will taking action impact business operations?
The template that follows provides background information and helpful tools to address low-value care, for a specific Top Five service. Click here to find templates for other Top Five services.
Click here to download the template (PDF).
Communicate with TPA
Communicate with your Third Party Administrator (TPA)
Once an organization identifies low-value care as a priority, the first step is to determine what your health plan already does to address low-value care.
When establishing a contract with a health plan, a purchaser can negotiate a number of policies relevant to avoiding low-value care. Some efforts will drive down aggregate low-value care among all employees, such as a plan incorporating low-value care performance measures in their network design (ie, the providers with whom they contract). While other efforts, such as asking about specific services, are more targeted.
Purchasers can incorporate the following model language in their health plan Request For Information (RFI) to address unnecessary imaging for lower-back pain. The language below is specific to imaging for lower-back pain within the first 6 weeks, but an expanded document of suggested RFI language can be found here.
General language for low-value care
- What services do you consider low value care (in which circumstances).
- How do you measure LVC
- Do you have programs to reduce LVC specifically. If so please describe.
- Do you have the ability to use benefit design to address low value care
- Do you have UM programs directed at low value care
- Do you have programs that financially reward providers that have lower rates of LVC.
- Do you profile providers based on their use of LVC
- Do you have programs that may indirectly reduce low value care. If so describe:
- Broad alternative payment models that discourage use of low value care (e.g. population base payment models
- Engagement with specific vendors that may reduce use of low value care
Lower-Back Pain - model RFI language and talking points:
Please describe general coverage policies and, where applicable, use of relevant edits and/or prior authorization requirements, for the following service:
- Radiography, computed tomography (CT), and magnetic resonance imaging (MRI) for acute low-back pain for the first six weeks after onset, unless clinical warning signs are present ("red flags" include
- Low back pain is a pervasive problem that affects three quarters of adults at some time in their lives (Chou et al., 2012). It ranks among the top ten reasons for patient visits to internists and is the most common and expensive reason for work disability in the U.S.
- Imaging for low back pain in the first 6 weeks does not provide any additional clinical information, unless specific clinical warning signs exist (eg, cancer diagnoses).
- Imaging can therefore expose Americans to unnecessary radiation and incidental findings that lead to unnecessary surgery and harm. Imaging also delays the use of evidence-based remedies (eg, heat, movement, over-the-counter analgesics, and lifestyle changes).
- Low back pain results in high indirect costs from disability, lost time from work, and decreased productivity while at work, and is the number one cause for activity limitations in younger adults (Chou, 2012).
- In 2014, Americans received 1.6 million avoidable imaging services for low-back pain, at an aggregate cost of about $500 million.
For more RFI language for all low-value care, see the VBID Health's RFI language resource.
For more information visit eCQI or VBIDHealth.
A sample of a coverage policy addressing Vitamin D testing, another Top Five low-value service, can be found here.
Explore Potential Levers
Explore Available Levers
A purchaser has a number of different levers at their disposal to target specific low-value care services, such as imaging for uncomplicated low back pain. Each option has different implications, both for benefit managers and for the employees.
There are, generally, four major areas in which a health plan can tackle low-value care:
- Use of coverage policies (eg, prior authorization);
- Use of non-financial, provider facing best practices and performance improvement (eg, profile reports or clinical decision supports);
- Use of patient-facing initiatives (eg, value-based insurance design); and,
- Use of provider-facing financial incentives, performance measurement, and network design.
For imaging low back pain, other purchasers have considered:
- Network design with relevant, low back pain APM performance measures (eg, HEDIS measure).
- Prior authorization to limit imaging services unless other clinical criteria present.
- Value-based insurance design, such as bundling physical therapy copayments to incentivize using physical therapy.
- Incentivizing providers to use Clinical Decision Supports, which would prompt a provider to select a reason to order such a service (eg, clinical red flags).
Considerations to improve levers
- Do you use a member service that could serve as a catalyst for LVC reduction? (eg Accolade)
- How can you incorporate multiple levers - single levers in isolation will not be as useful as multiple, synergistic levers in concert (patient and provider facing)
Example: Patient-facing, coverage policies
cover at all
Data specifications for claims-based analyses
Information plans will need to build medical policies that fit current evidence, analyze claims data, and use tools like prior authorization
Lower-back pain - codes and specifications (for claims-analyses):
Find the full list of ICD-10 codes here
Establish Communication Plan
Establish a communication plan
Communication to those affected by a new policy, namely employees, will be crucial to the ultimate success (or tolerance) of a given lever to reduce low-value care.
Once you have discussed with your TPA and chosen the right lever, consider how the new policy will affect the care of different employees. Some policies will require more patient-facing communication than others.
In general, communication of any low-value care avoidance policy should be expressed in terms of harm, rather than money. An internal business case is crucial for internal buy-in, but research clearly demonstrates that low-value care literacy is low and people respond more favorable when low-value care reduction focuses on the ability to reduce harm, and the possibility that care providers will be freed to spend more time with patients
Your specific communication plan will depend on the lever you choose.
Measure and Share Progress
Continue to measure progress on reducing low back pain (and low-value care broadly)
Another potential use of the Health Waste Calculator
Share these practices with others
Including business groups and nationally recognized Task Forces on Low-Value Care