Background on Employer Initiatives to Reduce Low-Value CarePrivate and public employers have a significant incentive to reduce the utilization of low-value care. As the true "purchasers" of healthcare for the majority of covered Americans in the United States, public and private employers are critical to advancing the low-value care agenda. The Low-Value Care Task Force was founded with this in mind. Purchasers, especially those with self-funded plans, are uniquely positioned to identify, measure, reduce, and report low-value care.
- Purchasers can negotiate with third-party administrators, their carriers, or even Pharmacy Benefit Manager (PBM), to establish policies tackle low-value care goals.
- Purchasers have financial incentive to reduce the costs of health care to maintain profits (private industry) or balance budgets (state and local governments).
- State employers specifically may have APCD data from which to measure low-value care, a powerful tool addressed in the video above.
The Task Force released a Health Affairs blog post and a list of "Top Five" low-value care services, low-hanging fruit for purchaser action, as a call to action for purchasers to address low-value care. Quick resources regarding those Top Five can be found on the right and similar information can be found on the Top Five page. These resources provide background information (e.g., what, why, financial burden) and some tools to address these services.
Below is a toolkit of resources for employers to start a general conversation around low-value care. For support, questions or comments, please contact firstname.lastname@example.org.
Develop a 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 - a purchaser should establish a concise rationale base on both financials and harm to their employees.
- Are there specific services we want to tackle first? (If you are not sure, we suggest the Task Force Top Five
- What is our current burden of these low-value care services? (The Health Waste Calculator can help, along with other resources to measure and report low-value care.)
- What are the benefits (in terms of finances or health) associated with acting?
- What are the costs associated with acting?
- 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 acting impact business operations?
We created a general low-value care template that can be used to start an internal conversation about low-value care, including our Top Five. The template provides useful background information and outlines suggested headers.
A business case example using one of the Task Force's Top Five - imaging low back pain.
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 (e.g., prior authorization);
- Use of non-financial, provider facing best practices and performance improvement (e.g., profile reports or clinical decision supports);
- Use of patient-facing initiatives (e.g., value-based insurance design); and,
- Use of provider-facing financial incentives, performance measurement, and network design.
A Health Affairs blog post on the Top Five and levers for purchaser action has more information.
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 (e.g., clinical red flags).
Considerations to improve levers:
- Do you use a member service that could serve as a catalyst for LVC reduction? (e.g., 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)
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 (i.e., 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 low-value care.
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
Example: Lower-Back Pain model RFI language and talking points:
The language below is specific to imaging for lower-back pain within the first 6 weeks, but an expanded document of suggested RFI language for all of our Top Five services can be found here.
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.
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. VBID Health developed a list of data specifications.
Lower-back pain - codes and specifications (for claims-analyses):
Find the full list of ICD-10 codes here
Establish a Communication Plan with Employees or Members
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
Measure and Share Progress
Any organization that takes substantial steps to address low-value care is welcome to contact the Low-Value Care Task Force or our members. We continuously seek stories, case studies, news, events, and action regarding low-value care. VBID Health is also involved in the Research Consortium for Health Care Value Assessment (the "Value Consortium"), in partnership with Altarum. The Consortium seeks to provide resources to organizations seeking to evaluate, measure, and report their utilization of and spending on low-value care.