Choosing Wisely: Reducing Low-Value Services for Medicare Beneficiaries

The United States spends upwards of $220 billion annually on low-value healthcare services that confer little or no clinical benefit while exposing patients to unnecessary risk, and research indicates that over 40% of Medicare beneficiaries received low value care.

Choosing Wisely® is a national initiative of the American Board of Internal Medicine Foundation that promotes informed shared decisions between clinicians and patients regarding many types of low-value healthcare. Under a Special Innovation Project awarded by CMS, Qualis Health designed and implemented a project to bolster the Choosing Wisely initiative in Washington, making innovative use of Medicare claims data in Washington State to promote alternatives to low-value healthcare, including a new set of claims specifications to assess treatment of dementia using antipsychotics. Qualis Health selected four low-value services on which to focus based on the degree of variance in clinical practice, the number of Medicare beneficiaries potentially affected, and alignment with local priorities.

Qualis Health identified clinicians who ordered one or more of the selected low-value services at a rate that was statistically higher than the state average. We mailed confidential feedback to 174 high utilizers. First, a generic letter introduced the Qualis Health Choosing Wisely project to raise awareness and create a non-threatening context for the individualized performance feedback. A week later, a second letter was sent that again framed the feedback in non-threatening terms and compared the recipient’s utilization of a low-value service with the Washington state average for using the same service, measured as a percentage of qualifying patients who received the service.

Using administrative data along with individualized clinician performance feedback to promote Choosing Wisely goals will help reduce utilization of low value healthcare services and provide savings in direct annual treatment costs. If the identified high-utilizing clinicians respond to peer comparison feedback by reducing utilization to the Washington average, there would be 166 fewer instances of advanced imaging for syncope or headache (average of about $300 for a CT or MRI scan), 329 fewer prescriptions for antibiotics for URI (with an average cost of $7), and 709 fewer prescriptions for antipsychotics for behavioral symptoms of dementia (average of about $250 per month, $3,000 per year), for a conservative estimate of almost $2,179,103 in total savings of direct annual treatment costs.

Perhaps more important is the avoidance of adverse outcomes. Research indicates that 709 fewer prescriptions for antipsychotics would result in eight fewer strokes and one less injury fall in this population annually. If 329 fewer prescriptions resulted in even one less instance of clostridium difficile infection, as much as $24,000 in hospital charges would be avoided. The probability that an antibiotic prescription will result in an emergency room visit is four times greater than the probability of gaining clinical benefit for treating URI with antibiotics.

Initial responses from clinicians who received feedback from Qualis Health supported the efficacy of this approach in raising awareness of issues.

This project was recognized as a national honorable mention winner in the 2017 DecisionHealth Platinum Awards in the Physician/Clinician Engagement and Education category.