Tracking Unnecessary Care Through Claims-Derived Measures

By Timmy Del Vecchio

As organizations continue the transition to value-based care, the need to (1) identify, (2) assess, and (3) eliminate wasteful spending continues to be a priority. From the identification perspective, initiatives like Choosing Wisely, started by the American Board of Internal Medicine, help both providers and patients take a deeper look at care options to ensure that the care is actually necessary and beneficial.

From the assessment perspective, there must be a way to use data to track compliance, financial impact in dollars saved, and quality impact via outcomes metrics. Thanks to the work of Schwartz et al and others, some of these unnecessary and low value services can be modeled using existing Medicare claims data, without the need for additional clinical context. Using the definitions provided by Schwartz et al, CareJourney has strived to implement some of these measures in our suite of products, which are highlighted with some membership-wide insights below.

Finally, from the elimination perspective, turning the needle in an organization to drive behavior change is not easy, nor does it happen overnight. Data collected on these low value measures must be used to support physician change, whether that be through knowledge sharing or setting regional and national benchmarks to compare physician patterns amongst peers.

Incorporating Unnecessary Care Analyses into ACO Strategy

For Accountable Care Organizations (ACOs) looking to lower the spend for their ACO population, finding the “secret recipe” for savings usually results in a laundry list of opportunities that require prioritization based on financial impact, quality impact, and feasibility. To add on to CareJourney’s existing functionalities including identifying avoidable ED instances and drug switching for treating age-related macular degeneration, eight unnecessary care measures are now coded up in our Population Insights tool:

• Preoperative Testing
  1. Preoperative chest radiology
  2. Preoperative echocardiography
  3. Preoperative pulmonary function testing
  4. Preoperative stress testing
• Cancer Screenings
  5. Cancer screening for patients with chronic kidney disease receiving dialysis
• Imaging
  6. Electroencephalogram for headaches
• Diagnostic and Preventive Testing
  7. Bone density test more than once every two years
• Cardiovascular Testing and Procedures
  8. Percutaneous coronary intervention with balloon angioplasty or stent placement for stable coronary disease

The first seven are derived from Choosing Wisely measures and the eighth is found in literature as listed in the JAMA article from Schwartz et al mentioned earlier. Assessing the total dollars across our CareJourney cohort in 2018, CareJourney has identified over $22 million in low value care, with over $9 million associated with ACO’s attributed patients.

To start reducing this unnecessary spending, there are two approaches that can be taken. The first is looking at which patients are receiving these low value care services. Are they mostly high risk or relatively healthy? If an ACO has limited resources to implement interventions, which patient cohort should they focus on? By running the low value care services at the claim line level against the high need high cost patient segmentation model, insights can be derived at the patient cohort level. For example, although Frail/Elderly patients make up roughly 8.6% of CareJourney’s membership’s attributed patient population, over 22% of low value care services in 2018 (13.1% of spend) were furnished on the Frail/Elderly population. Since Frail/Elderly patients are much more likely to be high cost (see our segmentation model overview on our Population Insights overview page), ACOs can focus on reducing low value care services on the Frail/Elderly population to drive down their Per Member Per Year spend.

The second approach is looking at the providers that are furnishing these low value services. Are these providers in network where you may have more control over their care coordination or are they out of network and changing referral patterns should be the main priority? Looking at the CareJourney membership, out of the $9 million spent on low value care for attributed patients, $4.8 million was furnished by in-network providers with the other $4.2 million furnished by out of network providers. By breaking down the in-network providers by practice group, users can quickly identify if there are outlier in-network practice groups and meet with them prepared with not just a literature reference, but benchmark metrics with other in-network provider groups.

Incorporating Unnecessary Care into Network Growth and Refinement

For many organizations, even if they have data on their own affiliated providers through claims, they struggle to obtain complete, actionable, and timely data for providers in their region or across the nation that are not affiliated. This makes the task of recruiting providers difficult if the data is stale or only touches on one aspect of a provider’s care. Expanding a network of providers needs to expand beyond just spend metrics. By incorporating unnecessary care metrics into market assessments, organizations can find providers and practice groups with fewer instances of low value care.

Using access to the Medicare all-claims database, unnecessary care metrics can be calculated for nearly every provider in the nation in CareJourney’s Network Advantage tool. In particular, the tool contains:

• Cardiology Preop Stress Test
• Low Back Imaging
• Preop X-Rays
• Screening for CAD in asymptomatic patients (coming Q3)
• PSA testing for patients aged > 75 years old and with no history of prostate cancer (coming Q3)
• Cervical cancer in women aged > 65 with no personal history of cancer (coming Q3)

Can these specific low value care metrics measured at the provider or practice group level indicate higher rates of spend overall? CareJourney’s newly released CareJourney Index, which looks at both cost and outcome metrics derived from patient episodes instead of simply individual treatments or procedures, ranks providers and practice groups on a scale of 1 (worst performing) to 5 (best performing). To see any correlation between one of the low value care metrics and CareJourney Cost Index, practice groups in the state of Virginia were pulled for calendar year 2018 and ordered by Preop Stress Test percentage. Practice groups with an unnecessary Preop Stress Test percentage greater than 50% had a CareJourney Cost Index average of 3.1, compared to the higher 3.48 average for practice groups with a percentage less than 50%. Using Network Advantage, correlations can be tested for other low value care measures as well. The significance of these correlations is that assessing these low value care measures might not just be useful for direct savings opportunities but may identify practice groups and providers with wider unnecessary spending patterns in general.

Wrapping Up – Let’s Work Together!

As mentioned in the beginning of this post, reducing unnecessary spend in Medicare requires (1) identifying opportunities (2) assessing providers from a utilization and spend perspective and (3) changing physician behavior to eliminate these low value encounters. Success in reducing wasteful spending in Medicare cannot happen without all of these three steps, and we look forward to working with our current and future clients to supply the data and insights required to start these discussions and monitor the impact.

Want to continue the discussion? Don’t hesitate to reach out or request a demo below.