Contra-Indicated Care: High with For-Profit Providers, Low with Strong Primary Care

January 19, 2022

Summary: A new study of all Medicare beneficiaries examined health system factors associated with “low-value care” – medical services that are contra-indicated (shouldn’t be done) because they hurt patients far more than helping them. Low-value care also wastes money. The study found that investor ownership is linked with more low-value care, while higher primary care physician presence predicts less low-value care. We need fewer investors and more primary care providers!

Factors Associated with Overuse of Health Care Within US Health Systems: A Cross-sectional Analysis of Medicare Beneficiaries From 2016 to 2018
JAMA Health Forum
Jan 14, 2022
By Jodi B. Segal et al.

From Abstract:

DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional analysis, we identified occurrences of 17 low-value services in 3745 hospitals and affiliated outpatient sites. Hospitals were linked to 676 health systems in the US using the Agency for Healthcare Research and Quality (AHRQ) Compendium of Health Systems. The participants were 100% of Medicare beneficiaries with claims from 2016 to 2018.

RESULTS … Health systems that were primarily investor owned had an Overuse Index (OI) that was 0.56 standard deviations [SD] higher than those that were not investor owned. … Health systems in the upper third of primary care physicians, upper third of teaching intensity, and upper quarter of uncompensated care had an OI that was lower by 0.59 SD, 0.45 SD, and 0.47 SD, respectively.

CONCLUSIONS AND RELEVANCE In this cross-sectional study of US health systems, higher amounts of overuse among health systems were associated with investor ownership and fewer primary care physicians.

Comment by: Jim Kahn

“Low-value care” refers to medical services for which the potential for harm far outweighs the potential for benefit. There has been a huge effort in medicine over the past 10 years to identify and reduce this unwise overuse of care, because it wastes resources (which would be better used for individuals with too little care!) and harms patients (due to procedure side effects). But changing provider behavior is difficult. Old patterns die hard, and the challenge is greater if the wrong incentives are in place.

The Segal team studied all Medicare patients and health systems. They compared features of the health systems with use of 17 low-value services (such as MRI for routine low back pain, nasal endoscopy for sinusitis, hysterectomy for benign disease, and meniscus removal for degenerative knee joint). They found that primarily investor-owned health systems had more low-value care. This may harm patients, but presumably yields nice profit margins.

A higher concentration of primary care physicians was associated with less low-value care, consistent with the patient-centered orientation of primary care. The study also found less low-value care with more medical teaching (with a focus on keeping up with the best recent evidence) and more uncompensated care (presumably due to restricted opportunities to profit from unnecessary procedures).

Single payer would eliminate investor-owned health systems and would incentivize primary care. It would also use reimbursement rules to encourage higher quality and more efficient medical practice. All of these factors would mean less low-value care, which would mean money redirected to real care needs and no patient harm from contra-indicated interventions.