A. Mark Fendrick, MD, is a practicing internist and directs the Center for Value-Based Insurance Design (VBID) at the University of Michigan. The Center leads efforts to promote the development, implementation and evaluation of health benefit designs that balance cost and quality. Its Task Force on Low-Value Care has created its own list of the top five low value clinical services that purchasers should target for reduction, which includes vitamin D screening tests, diagnostic tests before low-risk surgery, PSA screening for men 70 and older, branded drugs when identical generics are available, and low-back pain imaging within six weeks of onset.
We spoke with Dr. Fendrick recently about the state of his work on benefit design, the lessons learned from Choosing Wisely and other topics. An edited version of the conversation is below.
What do you think has been the most successful aspect of advancing VBID?
Americans have been asked to pay more and more out of their own pockets for their health care, both high- and low-value services, over the past two decades. The out-of-pocket cost instruments imposed by public and private health plans are very blunt, and as a result, have left a lot of people unable to afford the kind of essential medical services that I beg my patients to receive.
The foundational principle for VBID is basing patient out of pocket costs on the clinical benefit – not cost – of services, with the goal of reducing cost sharing and increasing access to essential, high value services. We have had a lot of success in removing financial barriers, most notably through section 2713 of the Affordable Care Act that mandates most health plans to cover nearly 100 preventive services at no patient cost, such as counseling for obesity and smoking cessation, screening for HIV, hepatitis C, and colorectal, breast, cervical and lung cancer. Notably, this section of the ACA was amended in the CARES Act to ensure that Americans receive the COVID-19 vaccines at no cost to them. Hundreds if not thousands of private payers have embraced the VBID concept, and CMS has implemented the Medicare Advantage VBID Model Test in all 50 states.
What has been the most challenging aspect of advancing VBID?
Although almost all high value services recommended in VBID programs are cost-effective, they are not cost-saving. As lower costs lead more people to get screened and treated for chronic diseases, the total cost of care goes up, not down, in the short term. Given these added expenditures, there are only three ways to pay for more high value care: 1) raise premiums for everyone, which is politically unpopular; 2) raise cost sharing at the point of service for care, which I refer to as a ‘tax on the sick’; or 3) having the courage to identify, measure, report on and reduce the billions of dollars spent every year on services that don’t make Americans any healthier. Once we realized that low value care would be an integral part of our “more of the good stuff, and less of the bad stuff” campaign, the launch of Choosing Wisely was born and was a gift from the heavens. What could give more credibility to a low value care agenda than a clinician-driven initiative, creating actionable lists of clinical services that don’t improve patient centered outcomes.
What about VBID promotes trust?
In our extremely complex and confusing health care system, the implementation of the VBID concept promotes an intuitive approach to cost sharing that could make it easier for patients to better understand the clinical value of recommended services. It is our hope that new payment models and value-based designs that incentive the use of care that improves health—not a financial balance sheet—will build trust.
What do you think the most important steps are for a hospital or health system that is looking to reduce the amount of low-value care it provides?
All providers like to think that every service they provide has clinical value. The Choosing Wisely campaign and the robust body of research it has inspired has clearly demonstrated the frequency and cost of low value care. No one will readily admit ordering lots of unnecessary Vitamin D tests or too many imaging tests on people with uncomplicated back pain. While communication, education and benchmarking are critical in starting a dialogue around reducing low value care, additional solutions are needed. Thus, while we support the further use of quality driven programs – for both providers and patients – hopefully leading to more high value care. We also strongly advocate for financial and non-financial incentives to mitigate the use low value services, such as those on the Choosing Wisely lists.
What have been your takeaways from the continuing release of Choosing Wisely recommendations?
The success and growth of the Choosing Wisely campaign reinforces the well documented fact that there is an extraordinarily large amount of utilization and billions of dollars spent annually in the US on services that clinicians deem to be of no value to patients. Unfortunately, even when a low value service is recognized on a Choosing Wisely list, it has been very difficult to significantly reduce overuse. This is largely driven by a “more is better” mentality and misaligned incentives in our current system.
What makes for an effective recommendation against overuse?
The best recommendations are very specific in describing the clinical scenario at issue. However, that specificity is a blessing and a curse: the more nuanced a recommendation becomes, the more difficult it is to implement from a health system perspective. A good example is “Don’t recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin.” Patients in this common clinical situation would be very difficult to identify in most administrative or claims databases.
The Choosing Wisely campaign has been in operation for almost nine years, and others have been working to reduce low-value care for even longer periods. What do you think are the most important things we’ve learned over the last decade about reducing overuse?
There is more than enough money in the U.S. health care system, and nearly everyone agrees that we spend much of it on the wrong services. In order to convince private and public payers to create ‘headroom’ to invest more on high-value care, we have no choice but to spend less on those services that do not make Americans healthier. Choosing Wisely provides a clinician-driven foundation on which to build our work to better identify, measure, report and reduce overuse. While we have made a lot of progress shining a light on the low value care issue, a tremendous amount of work needs to be done.