By Timothy Garrett, MD

Dr. Timothy Garrett is the Chief Medical Officer of Zelis and a board-certified MD. He is a Fellow of the American Board of Quality Assurance and Utilization Review Physicians, as well as the American College of Healthcare Executives (FACHE), and the American College of Emergency Physicians (CHCQM). He’s certified in Health Care Quality and Management and a Diplomate of the American Board of Emergency Medicine. Prior to joining Zelis, he held senior management positions at HMS, Cotiviti, Optum, and was a practicing Emergency Physician and Physician Leader at Athens Regional Medical Center. He has an MD from the Medical College of Georgia at Augusta University, an MBA from Auburn University Harbert College of Business, and is the author of the novel A Place Called Jubilee.

A recent paper in the Journal of the American Medical Association raised again the topic of low-value care or, at the very least, continued the discussion. Though the paper focused on the validation of an overuse assessment tool, its publication allows for an opportunity to discuss how low-value care affects every American citizen and healthcare organization.

Low-Value Care Impacts Everyone

Low-value care has been defined as “the use of a health service for which the harms or costs outweigh the benefits.” The rapidly rising cost of healthcare reflects a key way that low-value care, in all its forms, affects payers, healthcare providers, and individuals. It is estimated that $12.8 billion to $28.6 billion per year could be saved if over-treatment and low-value care were eliminated.

Spiraling costs are not the only price that is paid, however. For example, inappropriately prescribing antibiotics for viral illnesses – a very common instance of low-value care – can lead to overgrowth of harmful bacteria in the patient’s intestine. Rushing to perform surgery when other treatments like physical therapy would be equally effective can unnecessarily expose a person to the risks of general anesthesia and post-operative complications. Ordering head CT scans for simple dizziness needlessly introduces radiation risk.

Confronting Low-Value Care

Though the escalating cost of healthcare has been a concern for decades, it was the Choosing Wisely Campaign, kicking off in 2012, that brought low-value care to the forefront of discussions.

Choosing Wisely, begun by the American Board of Internal Medicine Foundation, seeks to shine a spotlight on the overuse of tests and treatments without proven benefits to patients in certain clinical scenarios.

But it is not only overuse that drives low-value care. Some investigational and experimental therapies with unproven effectiveness should not be used outside of clinical trials, and thus, the cost should not be passed on to patients and payers not participating in such a study.

Aggressive coding of claims on the provider side and aggressive denial of claims in the payer realm can result in increased administrative cost and burden – though not technically an example of low value care, both still contribute to exorbitant healthcare spending and take resources away from patient care.

Some have pointed to shielding against malpractice risk with increased testing and therapy as a source of escalating cost, though studies have failed to consistently demonstrate the effect of defensive medicine on overuse. However, anecdotally, I have seen how the ever-present threat of malpractice litigation drives the over-ordering of tests. I believe that defensive medicine is not readily detectable because it has become such an integral part of the practice of medicine in the U.S. At any rate, there has been no proven significant effect of decreasing litigation threat on medical costs.

What Else Can Be Done?

Actions can be taken by providers, payers, and individuals to reduce low-value care.

Providers – clinicians, hospitals, clinics, surgery centers, etc. – have a variety of tools that can be used to lessen low-value care. Clinical practice guidelines are used to standardize the treatments that are provided in a facility, streamlining patient care and ensuring consistency in treatment. These guidelines can even establish a standard of care that can help make clinicians comfortable with not defensively ordering tests or treatments without established benefit. In addition, staff education around low-value care can be very beneficial, as can instituting policies and practices that control unnecessary healthcare costs.

Payers can have clear medical policies that spell out non-covered tests and treatments. High quality network management can also be utilized to preferentially guide patients to clinicians who tend to avoid the provision of low-value care.

Individuals are empowered now more than ever to make informed choices around healthcare and decrease low-value care by avoiding providers who have a track record of low-value care.

The No Surprises Act and Transparency in Coverage Final Rules that became law in 2022 provide unprecedented ability of healthcare consumers to access pricing information around procedures and other care. Individuals can take advantage of available tools to navigate the choices offered by their healthcare benefits, choose high quality providers, and recognize costs and minimize out-of-pocket expenses.

The Wrap Up

I’m honored to be a part of an organization that helps payers, providers, and individuals have an impact on low-value care.

The Zelis Network solution helps payers build and manage high value networks while the professionals in Zelis Payment Integrity help to ensure that charges are correct.

Zelis has been an industry leader in making the No Surprises Act and Transparency in Coverage Rule understandable. The recent acquisition by Zelis of Sapphire Digital has given rise to our Member Empowerment solution, whereby individuals will gain access to powerful tools that will allow informed decisions. Finally, Zelis Payments helps providers get paid faster and with reduced cost, allowing them to focus on what is most important – their patients.

At Zelis, we have one main objective – to pay for care, with care.For more information on how Zelis can help your organization minimize low-value care, contact us here.