List of overused services a gift to payers seeking to curb costs


Payers have been working to reduce the healthcare industry's ever-rising costs, starting with shifting reimbursements to focus on quality care instead of volume.

Well, payers were handed a gift-wrapped present to help them attain their payment reform goals in the form of doctors' own admission of wasteful services and procedures. Last week, 17 medical specialty societies laid out 90 overused tests and procedures that should be avoided. That brings the total list of unnecessary services, which are part of the "Choosing Wisely" campaign that pinpoints major sources of unnecessary care throughout the country, to 135.

By admitting that many of the procedures they perform, including early elective induction of labor C-section, CT scans for children with head injuries, vitamin D deficiency screenings and prescribing antibiotics for common respiratory illnesses, aren't necessary, the doctor groups handed payers a blueprint to reduce costs.

And if that long list of 90 overused services wasn't enough, a new study published in JAMA Surgery has found that weight loss surgery doesn't result in long-term savings. Patients who underwent such an operation still had average annual claims up to $9,900, and those costs were either higher than or the same than patients who didn't have bariatric surgery.

Now, payers are in a position of power to help dial back the amount of unnecessary medical tests and procedures that doctors provide. They could, for example, limit reimbursements for these services, require doctors to provide justification before performing the services or even deny coverage of these services.

At the very least, though, payers have in hand a definitive set of guidelines they can use to steer their networked providers away from these unnecessary tests and procedures, thereby lowering costs and helping ensure medical care is based in quality not quantity.

It's time that payers took the reins and steered the healthcare crisis themselves, even if that means withholding payments for certain tests and procedures. Of course, they must clearly communicate any new reimbursement practices to doctors and hospitals; otherwise, any unpaid claims inevitably would end up becoming the patients' burden. And that's certainly not the goal of payment reform. Rather, they want doctors to advise patients against these unhelpful tests and procedures.

If payers need more incentive to take this ball and run with it, a report from UnitedHealth Group's Center for Health Reform & Modernization found that if payers can dramatically change how they pay doctors, healthcare costs could decrease by $200 billion to $600 billion during the next 10 years.

Initiatives by WellPoint and UnitedHealth that tie doctor fees to quality care are a giant step in the right direction toward rejecting the traditional fee-for-service payment model. By launching an initiative to increase reimbursement for primary care doctors who meet certain quality goals when they keep patients healthier and lower costs, WellPoint is leading the industry toward payment reform. And UnitedHealth's "value-based" provider contracts pay doctors more when they deliver high-quality and efficient care.

My hope is that we will be seeing many more of these changes implemented throughout the industry. And maybe, in turn, we'll also see those exorbitant healthcare costs go down.  - Dina (@HealthPayer)

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