The United States spends more on health care, per-capita, than any other country, according to the Organization for Economic Co-operation and Development. But our patient-centered outcomes are not better and don't account for or explain the extreme variance in spending. A. Mark Fendrick, M.D., professor of internal medicine, has spent years investigating this discrepancy and has found that health care providers in the U.S. devote billions to unnecessary services that do not improve care. Recently, he served as senior author on a Health Affairs article delineating these costs, and, as director of the U-M Center for Value-Based Insurance Design (VBID), has proposed steps to circumvent consistently prescribed but sometimes inconsequential services.
Medicine at Michigan spoke with Fendrick, also a professor of health management and policy at the U-M School of Public Health, about the study and his work. This interview has been edited for length and clarity.
How did you become interested in value-based care?
The main emphasis of my research and policy efforts has been to transform our health care delivery system to make it easier for Americans to access the full potential of what modern medicine can offer. These life-changing advances — some developed by my Michigan Medicine colleagues — often come at a high cost. Therefore, we struggle as a society to determine what we should buy and what we can afford. We have available Star Wars medicine, but work in a Flintstones delivery model.
There's some reason to be optimistic about a close in the gap. We're spending billions of dollars on services that do not make Americans any healthier. Thus, to create financial "head-room" to allow us to devote more time to the limitless potential of Star Wars science, my colleagues and I have embarked on a national initiative to eliminate the use of low-value care, so that the savings incurred can be used to buy more services that make Americans healthier.
How do you define low-value services, and what are some examples of them?
This question of how to define these services gets right to the crux of the challenge of how we can better spend our health care dollars. It is important to realize that the value of any specific clinical service is not always high- or low-value. Instead, it depends on who receives it, who provides it, and where it is delivered. We refer to these distinctions in value as "clinical nuance," because the same service that is lifesaving for one person, like emergent back surgery for a spine fracture, can be harmful to someone who's getting it inappropriately for acute muscular back pain.
The services that contribute to unnecessary spending range from commonly ordered blood tests, like vitamin D levels; to inappropriate screening intervals, such as too-frequent pap smears or colonoscopies; to imaging, either premature, like in the setting of acute musculoskeletal back pain, or duplicative services, in which the patient gets similar testing across providers or venues when one would suffice.
Why should more attention be paid to low-cost and low-value interventions instead of those that are high-cost and low-value?
While much of the deliberations on low-value care focus on "big ticket" items, such as procedures and high-cost imaging, we were surprised to find that nearly two-thirds of the money spent on low-value care were on fairly low-cost items — less than $550. This is important because these services are not typically used by a specific provider group nor do they generate a significant portion of an individual clinician's income. It is our hope that our efforts to reduce the use of these "under-the-radar" little ticket services will draw little to no attention from either patients or clinicians.
What were some of the biggest challenges or hurdles you faced when conducting this study?
This question gets right to the crux of the challenge of how we can better spend our health care dollars. It is important to realize that the value of any specific clinical service is not always high- or low-value. Instead, it depends on who receives it, who provides it, and where it is delivered. We refer to these distinctions in value as "clinical nuance," because the same service that is life-saving, like emergent back surgery for a spine fracture, can be harmful to someone who's getting it inappropriately for acute muscular back pain. The concept of nuance is not just for items like CTs and surgery, but also holds for something as simple as a clinician visit or an antibiotic. For example, if I prescribe an antibiotic to someone with a bacterial infection, it is potentially life-saving. However, if I prescribe that same antibiotic to someone with a viral infection, the antibiotic does not help that person since antibiotics do not treat viral infections. Moreover, unnecessary prescribing subjects that person to unnecessary cost, a risk of medication side effects, and perhaps, most importantly, contributes toward future antibiotic resistance.
What changes — at the infrastructural, administrative, and other levels — do you think need to take place before this information can affect individual practices?
Stakeholders have known for decades that low- and no-value care — and even harmful care — have been used frequently. The clinical nuance concept — that the same service can be both high- and low-value, depending on the specific clinical situation — has made eliminating unnecessary care particularly difficult. So, we have focused on a number of ways to make this more actionable. The first is to take better advantage of electronic medical records to prevent the ordering of services that are highly likely to be over-utilized. For example, we are implementing an order-entry alert here at Michigan Medicine before a clinician can order a test to measure a vitamin D level. Second, we could change payment systems, so that we don't reward clinicians just for doing things because they can. Instead, we should put incentives in place that reward clinicians for using those services that improve outcomes that are meaningful to patients. Last — and most ambitious — is to educate patients that sometimes more care is not always better care, and that less care can often be more desirable.
In June, you testified before the U.S. House of Representatives Ways and Means Health Subcommittee regarding ways to better spend taxpayer dollars in the Medicare program. Do you think having the chance to address such an audience indicates a shift in perspective?
Whatever your political leanings, it's become quite evident that we no longer have the luxury of providing every clinical service to everyone, regardless of whether it improves health. It was a great honor to provide testimony on V-BID — a University of Michigan concept that implements the tenets of clinical nuance into public and private health plans. V-BID was included in the Affordable Care Act and is one of the very rare health reform ideas with bipartisan political support. V-BID has already been implemented by Medicare, TRICARE, and commercial insurers. Moving forward, my hope is that decision-makers will continue to advance V-BID, the aim of which is to provide aligned incentives for researchers, providers, and patients to improve quality of care, enhance patient experience, and contain cost growth.
Disclosures: The researchers used the Milliman MedInsight Health Waste Calculator, a software program developed by the Milliman company in cooperation with VBID Health, a startup company launched by Fendrick to help employers, government entities, and insurers in developing health care benefits packages. Fendrick receives royalties from the product's sale, and also serves as consultant to AbbVie, FMS Inc., Geisinger Health Plan, Janssen, Lilly, MedZed, Merck, Risalto, Sanofi, Sempre Health, Takeda, TriZetto, Wellth, and Zansors.