Are Limited Networks What We Hope And Think They Are?



There has long been an imperative to find ways to reduce health care spending, but the advent of public exchanges pressured the industry to find ways to offer health insurance at a more affordable premium. Health plans hoping to participate in public exchanges responded by creating insurance offerings that gave patient members access to a smaller pool of providers—limited or narrow networks. These smaller networks give payers leverage in negotiations and may eliminate more expensive providers. They have also caught the attention of employers and other health care purchasers and are growing in prevalence in the commercial market.

But what exactly are limited or narrow networks, and are they what we want them to be? We set out to understand how health plans form limited networks, postulating that the criteria to select providers for participation in limited networks across health plans would be fairly consistent. We thought we might be able to conclude, for example, that a limited network is one in which health plans exclude providers whose prices are one standard deviation above the mean or that don’t meet minimum quality thresholds.

In addition, we wanted to learn how health plans determine who among certain provider types is eligible to participate (primary care physicians, specialists, hospitals). Is there a consistent process for selecting providers? Does the health plan, for example, generally start by selecting primary care physicians and then assess the hospitals with which those physicians are affiliated?

An Elusive Concept

Catalyst for Payment Reform (CPR) reached out to a dozen health plans, diverse in size and geography, to learn more about how they form narrow networks. We began by querying them about their use of cost and quality thresholds to select providers for their limited network products.

Across health plans, CPR found no consistent formula for selecting providers by type, below a certain price point, or above a specific level of quality. We learned that health plans primarily consider which hospital or provider group will agree to a certain price (based on a premium analysis), whether excluding others is feasible given each provider’s market power or “must have” status, and whether exclusions create access issues. It is notable that among the health plans we spoke to, none used provider quality as the primary selection criterion. Health plans may consider quality while developing a limited network, but it is secondary to other criteria.

Local market characteristics significantly influence how payers define a network. The design of a limited network depends on the number of providers available as well as the level of competition among them. If a health plan develops a limited network with few providers, consumers may have to travel significant distances to receive care. When there are more provider options, competition helps health plans find a provider group willing to offer a better price. The selected provider group assumes it will make up the potential lost revenue with an increase in patient volume. Therefore, health plans perceive the presence of competition among providers as critical to the development of a limited network product. In circumstances in which health plans have greater market power, they may also consider whether providers are willing to take on some financial risk—now or in the future.

CPR’s search also revealed wide variation in the types of providers health plans focus on when they begin narrowing their networks. While most start with the hospital and then select affiliated primary care physicians and specialists, others start with the primary care physicians and look at affiliated hospitals. Some health plans include all primary care physicians in the limited network and then tier the hospitals and specialists based on cost and sometimes quality criteria. The only consistency we found was that there is no consistency! The only commonality among the narrow networks we examined was that they all contained fewer providers than a given health plan’s broadest network.

A Strategy That Is Here To Stay?

Employer and other health care purchasers’ awareness about the variation in quality and payment amounts has steadily grown, as has their need for savings. Purchasers also recognize that threatening to exclude providers from a pool of patients will strengthen their negotiating position as well as that of other payers. The latest survey data suggest that narrow networks are becoming more prevalent—a trend that is likely to continue.

According to the Henry J. Kaiser Family Foundation’s 2017 Employer Health Benefits Survey, 12 percent of benefit-offering firms with 50–999 workers, 23 percent of firms with 1,000–4,999 workers, and 31 percent of firms with 5,000 or more workers offer a high-performance or tiered network. In addition, 6 percent of firms offering benefits said that they or their insurer eliminated a health system from a network to reduce the plan’s cost during the past year.

Furthermore, the 2017 Willis Towers Watson Best Practices in Health Care Employer Survey found that more than half of employers with more than 1,000 employees said that they might add high-performance networks by 2019.

Are Providers Likely To Participate In Them If Selected?

In markets where providers lack competition, they may easily push back on the formation of narrow networks. But in markets where there is competition, providers will likely want to be included instead of risk a loss of patient volume. For providers entering into new delivery models and accepting new forms of payment, they may see narrow networks positively, giving them a greater ability to manage and coordinate patient care as there is less “leakage” of patients to a broad pool of providers. In turn, participating providers may be more willing to take on financial risk for their patients if they know it is easier to control where they seek care, minimizing exposure to particularly high-priced providers.

Are Consumers Likely To Select Them?

The experience with the public exchanges suggest that consumers are willing to make the tradeoff of choice for affordability. By seeking care from a defined group of providers, consumers pay lower out-of-pocket costs and have a straightforward benefit design that clearly distinguishes between in- and out-of-network providers and accompanying cost sharing. Consumers may save further by receiving care from high-value providers who are more likely to provide effective and efficient care the first time.

Some of the employers in CPR’s membership that offer limited or narrow networks, such as an accountable care organization product, find they are meeting or exceeding their enrollment expectations—an indicator that certain consumers will choose price over choice.

Americans are willing to make tradeoffs for now, but they may become skeptical if there isn’t an explicit effort to ensure quality and the perception grows that narrow networks are only about cutting costs. With more experience, Americans may find that physicians with targeted expertise (for example, subspecialists in oncology) or individual members of a care team (for example, anesthesiologists) may not be included in the narrow network, preventing access or resulting in surprise bills for consumers.


Through their use of limited networks, payers may be indicating to health care providers that affordable care will be rewarded with more patients (quality of care could also be a criterion). In markets where providers perceive a higher volume of patients as favorable, the introduction and presence of these networks can send a strong economic signal to providers to improve efficiency and lower prices. It may be too early to identify patterns in how health plans design limited networks; perhaps a standard formula will never materialize. As CPR learned, viable approaches depend on market-specific nuances.

Sick and Alone: High-Need, Socially Isolated Adults Have More Problems, but Less Support

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High-need adults — those with two or more chronic medical conditions and physical or cognitive limitations — are more likely to feel socially isolated than those who do not have these health issues, according to a previous Commonwealth Fund analysis.1 The higher rate of isolation among high-need adults is particularly concerning since previous research has shown isolation and loneliness can exacerbate health problems, increase mortality, and cost Medicare more.

To explore how isolation affects high-need adults, we analyzed data from the Commonwealth Fund Survey of High-Need Patients conducted from June to September 2016. We found that high-need adults who are socially isolated (defined as people who report often feeling a lack of companionship, left out, or isolated from others) are more likely to have mental, emotional, and financial issues. They are also less likely to receive timely, good-quality care than high-need adults who do not report feeling alone.

Reviews published in Health Affairs and BMC Public Health of several interventions targeting social isolation have shown that increased access to social supports can improve patient physical and mental health outcomes and lower costs. Providers working with high-need adults should consider the impact of isolation on their patients, and connect those who feel alone to evidence-based support groups or social services.

High-need, isolated adults are more likely to:

  • Have mental health issues. Approximately three of four high-need, socially isolated adults currently have or have previously received a mental health diagnosis or report experiencing emotional distress in the past year.
  • Worry about their condition and being a burden to loved ones. High-need, isolated adults are also more likely to be somewhat or very concerned about being a burden to family or friends (70% versus 52%) and are three times more likely to lack confidence in their ability to manage their health than high-need adults who are not isolated (34% versus 11%).
  • Be financially vulnerable. Forty percent of high-need, isolated adults have incomes below $15,000 a year, and 80 percent worry about having enough money to pay bills or afford nutritious meals. They are also more likely than those who are not isolated to avoid taking medications or filling a prescription because of cost.
  • Experience barriers to health care. High-need patients need good access to quality care to manage their health issues. However, high-need adults who are isolated are more likely to report trouble getting care after hours or on weekends without using the emergency room (65% versus 51%). They also, not surprisingly, were more likely to report using the emergency room two or more times in the past two years (54% versus 42%). This is consistent with research that has shown that social isolation is associated with increased preventable hospitalizations. Additionally, they were significantly more likely than high-need adults who are not isolated to delay care. Finding a way to get to medical appointments appears to be a major barrier: nearly three times as many high-need, isolated adults delayed care because of a lack of transportation.
  • Report poorer quality of care and communication with providers. When high-need, isolated adults do access care, it is often of lower quality. They are significantly less likely than those who do not feel isolated to report that their provider was always or usually well informed about their medical history (76% versus 90%), involved them in decisions (72% versus 88%), or listened carefully to them (76% versus 90%). Only half reported that all three statements were always or usually true (50% versus 66%). This may be a missed opportunity, as patient-centered communication has been shown to reduce costs and improve outcomes for complex patients.


High-need adults appear to be especially vulnerable to the damaging effects of social isolation. The health care system, which is increasingly focused on improving care for high-need patients who account for nearly half of all health care spending, can play a role in identifying and addressing isolation among their patients.

Providers should assess high-need patients for social isolation, evaluate the impact it has on their health, mental health, and access to health care, and refer them as needed to appropriate supports. Connecting isolated adults to evidence-basedcost-effective programs, such as support groups and social services like transportation assistance, could not only improve outcomes for high-need patients themselves, but also has the potential to lower the cost of care for this population by reducing unnecessary hospitalizations.



Florida wipes inspections of troubled nursing homes from its website

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On a good day, Olga Vasquez would dress up in the morning, apply makeup and stand in the hallway at her Hialeah Gardens nursing home, helping other residents get in and out of wheelchairs or offering unsolicited advice. On a bad day, her depression got the best of her and she would remain in bed in her nightgown.

May 31, 2012, was a very bad day.

Vasquez — who hadn’t seen a psychiatrist in weeks despite instructions to the contrary — hoisted herself out of the window of Room 310, and hurled herself to the concrete courtyard 39.4 feet below.

This is the type of thing you might want to know about before your mom, dad or spouse moves into a nursing home. And such documented events were readily available on the website of state health regulators.

They aren’t anymore — part of the latest erosion in what is supposed to be ready access to public records in Florida.

 A little under three months ago, the state scrubbed its website. No longer can you go online and view the 83-page report that found Vasquez’s death to be the result of misconduct and that determined other residents of Signature Healthcare of Waterford were in “immediate jeopardy.”

The document can still be obtained from the state Agency for Health Care Aministration, although you have to know what to ask for and whom to ask — and you may be required to pay and wait. Online, AHCA now refers consumers to a separate website managed by the federal Centers for Medicare and Medicaid Services, though that site does not include as much material as the state previously provided. AHCA does maintain spreadsheets online that rate homes on a host of criteria, and allow consumers to compare.

For many years, AHCA’s website included links to inspections of nursing homes, retirement homes and hospitals. They were available with a few keystrokes with very few redactions. The agency then began to heavily redact the reports — eliminating words such as “room” and “CPR” and “bruises” and “pain” — and rendering the inspections difficult to interpret for families trying to gauge whether a facility is suitable for a loved one. AHCA says the redactions were necessary to protect medical privacy, though patients were identified only by number. Vasquez was “Resident 239.”

Carmen Veroy’s 89-year-old parents, Libia and Gabriel Giraldo, survived the ordeal — but Veroy said she could not fathom the overheated conditions in the rehab center until her sister sent her a video of the hallway scene during a visit Tuesday night.

The Veroy Family

In the past year, the state spent $22,000 for redaction software that automatically blacks out words the agency says must be shielded from the public. Those same words were available on a federal website unredacted. Elder and open-government advocates said the newly censored detail did more to protect the homes than patients.

In September, 13 frail elders died miserable deaths at the Rehabilitation Center at Hollywood Hills in the sweltering aftermath of Hurricane Irma, which knocked out the home’s cooling system. The Miami Herald and other media wrote extensively about Hollywood Hills’ troubling regulatory history. And the Herald also reported on AHCA’s decision to heavily redact reports.

Soon after, with no announcement or notice, AHCA wiped its website clean of all nursing home inspections, shielding the industry to the detriment of consumers.

“I’m just stunned,” said Barbara A. Petersen, who is the president of the First Amendment Foundation in Tallahassee, an open-government group. “Government serves the people. They are doing a disservice, and one with potentially grave consequences.”

Barbara Petersen

Barbara Petersen, president of the First Amendment Foundation, a Tallahassee-based group that promotes open government, said the removal of online nursing home records makes it difficult for consumers to make informed choices.
Miami Herald file photo

In recent weeks, Petersen needed to find a nursing home for her 96-year-old father in Colorado. The assisted living facility where he lived had become inappropriate, and Petersen had only 48 hours to move him.

“If I was in that situation here, and I had to do that without the information that used to be online, I’d have to submit a public records request for it. And, as we know, it takes a long time for them to produce public records. Meanwhile, I’d be stuck with the hardest decision I’ve ever made in my life without any information.”

“We put a tremendous amount of trust in these homes, and we need to make the best decisions for our families. Honestly, this makes no sense,” Petersen added.

A spokeswoman for the healthcare agency said both AHCA’s website and the federal site at allow consumers to compare homes along a range of indicators, including quality of life, nutrition, dignity and abuse.

“AHCA goes above and beyond Florida law in the amount of information we make available online,” said spokeswoman Mallory McManus. “AHCA’s website allows consumers to compare nursing homes by their inspection rating. Consumers can search by county, Zip code and even by services offered at every nursing home in Florida. This gives families more information to make informed healthcare decisions for their loved ones.”

“In fact,” McManus added, “in 2016 won a Digital Government Achievement Award from the Center for Digital Government in the “Government-to-citizen State and Federal government” category, showing that Florida is a leader in getting information about healthcare facilities to consumers. is an excellent tool for consumers, and a national leader in transparency.”

The award was given before the state removed nursing home inspections from AHCA’s site.

The Herald was unable to speak with administrators at the Hialeah Gardens home. Representatives from the corporate Signature HealthCARE did not return requests for comment. McManus said health regulators removed the “immediate jeopardy” label from the nursing home days after Vasquez’s death after administrators demonstrated they had improved the home’s safety. “Our Agency expected quick action to remove the potential risk to others. During a revisit on July 5 [2012], it was determined that the facility had implemented measures that removed the threat of serious risk to patients,” McManus said.

“Our Agency held this facility accountable, and all deficiencies were corrected,” McManus said.

The home’s plan of correction included a long list of actions administrators took to improve safety, including a comprehensive review of all residents’ medical records, new policies to ensure doctors’ orders are carried out, better monitoring of the symptoms of psychiatric patients, and an audit of records for all patients on mental health drugs to “ensure that they were seen by the psychiatrist as ordered.”

Though reports on Vasquez’s death are no longer available on AHCA’s website — or that of the federal Medicare program — a copy of the inspection obtained by the Herald is heavily redacted. The words “neglect” and “abuse,” for example, are removed from one of the report’s findings — and the definition of abuse from the Florida statutes is redacted.

A separate 50-page AHCA report on the same incident recites a portion of Florida law: “[Redacted] means any willful act or [redacted] act by a caregiver that causes or is likely to cause significant [redacted] to a [redacted] adult’s physical, [redacted] or emotional health. [Redacted] includes acts and omissions.” The portion is drawn directly from the state’s elder abuse law, a public record, and is the definition of abuse.

AHCA’s move is far from the only restriction in what records the public can see. The Herald wrote about an emergency management plan from the Hollywood Hills rehab center that was filed with — and approved by — Broward County, which included portions that were copied and pasted from a prior year, and failed to say how residents would be kept cool during a power outage. Broward and Palm Beach counties then refused to release any plans, though both had originally said they were public record. Miami-Dade released 54 plans, all heavily redacted.

Vasquez, who migrated to Florida from Cuba, first began to suffer from depression about a decade before her death, when her husband died, relatives told the Miami-Dade Medical Examiner’s Office. “Due to her depression, she was placed in” the nursing home, the report said. In addition to depression, Vasquez also was diagnosed with anxiety, chronic insomnia, heart disease and hypertension.

AHCA’s report on Vasquez’s death, dated June 14, 2012, said the 82-year-old former factory worker last saw her primary psychiatrist on March 1, 2012, for treatment of clinical depression. Staff at Signature never told him, the report said, that Vasquez’s condition had worsened.

Vasquez, the report said, “was very depressed at times.”

Vasquez’s primary doctor had ordered a psychiatric consultation around April 30, 2012. But a constellation of lapses led to the home’s failure to ensure Vasquez actually was treated. The psychiatrist Vasquez was to see left the nursing home, a report said, and the nurse who was trying to help Vasquez never was told who would fill in. Meanwhile, a psychiatrist who regularly saw patients on Vasquez’s floor reported “he never saw [her] and [she] was not on his caseload.”

Complicating matters: there was a 15-day gap in nursing notes in Vasquez’s chart, the report said, and the home’s administrator told an AHCA inspector he “had no idea” why no notes were made during those two weeks.

AHCA concluded: “There was no documentation to demonstrate the [psychiatric] consultation was completed, as ordered.”

Three days before Vasquez died, the report said, she “was observed to be sitting in the hallway or lying in bed; she was not wearing any makeup, and the resident told [a nurse] she did not feel like doing anything.” Vasquez needed help to fill out her menus.

A short report from the Miami-Dade Medical Examiner said that, on May 31, 2012, a maintenance worker noticed that the window in Vasquez’s room was open. The widow was found in the courtyard underneath her bedroom window, 14 feet from the building. The medical examiner’s office ruled Vasquez’s death a suicide.

Six months before Vasquez plunged from her window, the U.S. Department of Housing and Urban Development faulted the home for failing to maintain the windows safely. Windows, HUD said, were secured only with screws, and a corrective action plan required Signature to install window locks within all residents’ rooms.

The AHCA report is unclear as to whether the windows in Vasquez’s room were fixed, though an unspecified relative told AHCA she had noticed the day before Vasquez died that “the window clamp was not in place.”

A Hialeah Gardens police report confirms some of AHCA’s account, noting Vasquez wasn’t breathing by the time she arrived at Palmetto General Hospital. A doctor pronounced her dead at 4 p.m.

Vasquez’s niece, Maria Salgado, who handled Vasquez’s affairs, told police she had been taking 10 medications for her depression, some of which are listed in the AHCA report, though the names and dosages are largely redacted.

Staff at the nursing home told Salgado that something happened to her aunt while she was walking in the garden — exactly what Salgado was told is redacted — according to the AHCA report.

Salgado, 53, called her aunt’s death and the ordeal that followed painful to talk about.

She felt very close to her aunt, she said.

“It was such a horrible time,” she said. With a long breath, she added, “I don’t want to relive it.”


To request an inspection report for a Florida nursing home, use this form and submit it to this web address. Here are tips from the Agency for Health Care Administration.

CMS finalizes 340B drug program cut

Dive Brief:

  • The CMS on Wednesday released a final rule that will significantly cut drug payments to hospitals that use the 340B Drug Pricing Program. The changes to the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Program take effect Jan. 1, 2018.
  • The rule also puts a moratorium on enforcement of the direct supervision policy in certain cases, increases outpatient payments by 1.35%, removes six measures from the Outcome Reporting Program and removes total knee arthroplasty from the inpatient only list.
  • The American Hospital Association released a statement blasting the 340B cut, saying it “will dramatically threaten access to healthcare for many patients, including uninsured and other vulnerable populations.” AHA, America’s Essential Hospitals and the Association of American Medical Colleges plan to sue the administration over the change.

Dive Insight:

The cut to drug payments in the 340B program, which is mostly used by safety net hospitals, is dramatic. Instead of being paid the average sales price plus 6%, they will now be paid 22.5% less than the average price. Children’s hospitals and community hospitals in rural areas are exempt from the reduction.

Hospitals that use the program say it is necessary to helping them care for vulnerable populations, and have cautioned the cut will jeopardize that. There is little oversight, however, over how hospitals track and use the savings generating through 340B. Some lawmakers have said hospitals should be required to make this information readily available.

A controversial study released last month showed hospitals participating in 340B had more of a decline in charity care than other hospitals. AHA said the report is misleading and doesn’t take into account other community benefits hospitals provide.

Hospitals will also be angered by the CMS decision to allow total knee replacement surgeries to take place in outpatient settings. The agency is following the lead of commercial payers, who are pushing for care to move away from more expensive inpatient settings. CMS has said the change will let Medicare beneficiaries get a knee replacement at lower cost, but hospitals say the quality of care for those procedures could decrease.


4 in 10 healthcare professionals work when they’re sick, risking patients


Patients who are exposed to a sick healthcare worker are five times more likely to get a healthcare-associated infection.

A new study suggests that healthcare professionals should heed their own advice: Stay home when sick.

Some four in 10 healthcare professionals work while experiencing influenza-like illness, according to findings published in the November issue of the American Journal of Infection Control, the journal of the Association for Professionals in Infection Control and Epidemiology.

As in all workplaces, contagious employees risk infecting others when they turn up for work. But with higher concentrations of older patients and individuals with immunosuppression or severe chronic diseases in healthcare facilities, flu-like transmission by healthcare workers naturally presents a public health hazard.

The research pointed to an earlier study showing that patients who are exposed to a sick healthcare worker are five times more likely to get a healthcare-associated infection.

The annual study, conducted via a national online survey, collected data from from 1,914 professionals during the 2014-2015 flu season. Respondents self-reported influenza-like illness, defined as the combination of a fever and cough or sore throat, and listed factors that prompted them to turn up for work.

The survey assessed a variety of health occupations across multiple institutions: physicians; nurse practitioners and physician assistants; nurses; pharmacists; assistants/aides; other clinical pros; nonclinical pros; and students. Four types of work settings were assessed: hospitals, ambulatory care or physician offices, long-term care facilities and other clinical settings.

Of the 1,914 professionals surveyed, 414 reported flu-like illness. Of these, 183 — or 41.4 percent — reported working for a median duration of three days while experiencing flu-like symptoms.

Hospital-based healthcare professionals had the highest frequency of working with flu-like illnesses (49.3 percent), compared to those at long-term care facilities (28.5 percent). Clinical professional healthcare workers were the most likely to work with the flu (44.3 percent), with pharmacists (67.2 percent) and physicians (63.2 percent) among those with the highest frequency.

The survey found that assistants and aides (40.8 percent), nonclinical workers (40.4 percent), nurse practitioners/physician assistants (37.9 percent), and other clinical workers (32.1 percent) worked while sick.

The most common reasons for healthcare professionals to opt from taking sick leave included feeling that they could still perform their job duties; not feeling “bad enough” to stay home; feeling as if they were not contagious; sensing a professional obligation to be present for coworkers; and difficulty finding a coworker to cover for them. Among the workers who felt they could still perform their job duties, 39 percent sought medical attention for their symptoms, as did 54 percent of those who didn’t think they were contagious. Almost 50 percent of workers in long-term care settings who reported for work when sick reported doing so because they couldn’t afford to lose the pay.

Healthcare professionals with self-reported flu symptoms missed a median number of two work days. Of those, 57.3 percent visited a medical provider for symptom relief; 25.2 percent were told they had influenza. The Centers for Disease Control and Prevention recommends that anyone with such symptoms wait 24-hours after a fever breaks before returning to work.

Previously published results from the survey showed that only 77.3 percent of respondents reported getting a flu shot.

Robotic surgery comes with a hefty price tag, but studies show it’s often no more effective

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Over the past decade, hospitals have invested significant dollars in robotic surgical equipment, often to keep pace with their regional competitors.

But the costs associated with robotic systems don’t always pay off, according to two new studies published in JAMA last week that show robot-assisted surgeries cost more but are just as effective as certain laparoscopic surgeries. The results led one surgeon to question how hospitals should track the value of robotics, particularly as the industry transitions to value-based reimbursement models.

In one study, researchers at Stanford University Medical Center, Brigham and Women’s Hospital and the University of California San Diego reviewed 13 years’ worth of data linked to nearly 24,000 patients that had a kidney surgically removed. Although just over 5,000 of those patients underwent robot-assisted nephrectomies, the use of robot increased dramatically from 1.5% in 2003 to 27% in 2015, surpassing the percentage of laparoscopic surgeries.

But researchers found that robotic surgeries were often longer and more expensive than laparoscopic surgeries. Over the 13-year period, robotic surgeries cost approximately $2,700 more per patient without any notable difference in post-operative complications.

“There is a certain incentive to use very expensive equipment,” Benjamin Chung, M.D., associate professor of urology at Stanford and one of the study’s authors said in a release. “But it is also important to be cognizant as to how our health care dollars are being spent. Although robotic surgery has some advantages, are those advantages relevant enough in this type of case to justify an increase in cost?”

A second study by researchers in the United Kingdom, Germany, Italy and New Zealand found surgeons performing resection for rectal cancer were just as likely to convert to open surgery whether they were using a laparoscopic or robot-assisted technique.

In an accompanying editorial, Jason Wright, M.D. chief of gynecologic oncology at Columbia University Medical Center said the new research highlights the need for hospitals to balance the costs associated with new devices and their potential impact. While hospitals currently absorb most of those costs, that dynamic could change with new reimbursement models.

“The implementation of alternative payment models, particularly those with two-sided risk, may heighten the awareness of surgeons of these costs if reimbursement is more directly affected,” he wrote.

Wright also pointed specifically to the promise of the Food and Drug Administration’s new National Evaluation System for Health Technology (NEST), established by the new Medical Device User Fee agreements authorized in August. The system looks to use real-world data buried in EHRs and health registries to conduct post-market surveillance,  which could offer a more comprehensive look at device functionality after its approved by the agency.

Professionalism And Choosing Wisely

The US health care system is plagued by the use of services that provide little clinical benefit. Estimates of expenditures on overuse of medical services range from 10–30 percent of total health care spending. These estimates are typically based on analyses of the geographic variation in patterns of care. For example, researchers at the Dartmouth Institute focused on differences in care use between high-spending and low-spending regions with no corresponding reductions in quality or outcomes. An analysis by the Network for Excellence in Health Innovation (formerly known as the New England Healthcare Institute) identified significant geographic variation in the rates of both surgical and non-surgical services such as coronary artery bypass grafting, back surgery, cholecystectomy, hip replacements, diagnostic testing, and hospital admission.

This variance-based approach to estimating overuse has been very useful at highlighting the problem of inefficiency in the health care system but has done little to direct initiatives designed to reduce unnecessary tests and procedures. The aggregate approach does not help clinicians or managers identify exactly how they should change their practice patterns. As a result, it has been hard to reduce overuse. Identifying the significant overuse of medical services in the health care system is only the first step; now we need to develop evidence-based solutions to reduce unnecessary services and improve efficiency.

The History Of Choosing Wisely

The Choosing Wisely initiative, announced in 2012 by the ABIM Foundation and Consumer Reports, was designed to spark conversations among physicians, patients, payers, and purchasers about the overuse of tests and procedures, and to support physician efforts to help patients make smart and effective care choices. Specialty societies identified specific services that were unnecessary in specific situations. With more than 80 participating specialty societies, Choosing Wisely has identified more than 500 commonly overused tests and procedures and published recommendations for their proper use. For example, the American College of Emergency Physicians recommends avoiding computed tomography (CT) scans in low-risk patients with minor head injury.

The Choosing Wisely campaign began in an environment when efforts to reform health care were polarized by discussions of “rationing” and “death panels.” The initiative focused on quality, safety, and doing no harm to counter suspicions of dual agency and cost reductions motivated by profit; this allowed both the public and clinicians to begin to see reducing unnecessary care as in the best interest of the patient.

Choosing Wisely appealed to the professionalism of physicians and other clinicians as articulated in the Physician Charter on Medical Professionalism, which included a commitment to manage health care resources. The campaign was conducted in a way that respected the autonomy of physicians, relying on and enhancing their professional pride and sense of mastery, instead of functioning as yet another quality initiative imposed from above. Specialty societies took a leadership role in partnership with a wide swath of consumer and patient groups, helping physicians and patients accept the message of “more is not always better.”

Through Choosing Wisely, physicians were socialized toward a new norm in the culture of medicine against low-value care, which was reflected in the medical literature. From 2014 to 2015, the number of articles on overuse nearly doubled. The adage that “culture eats strategy every day” became a guiding light. Manya Gupta, MD, from Rush University Medical Center, summed it up as, “Once culture change starts, improvements become expected.”

The unexpected nature of societies taking the lead on this issue, potentially in conflict with their members’ economic self-interest, helped make the campaign stick. Similarly, the simplicity, concreteness, and credibility of the recommendations allowed them to be deployed in a variety of settings at a variety of levels in the organization.

Implementation has been accelerated through the support of the Robert Wood Johnson Foundation (RWJF), which has provided two grants to support putting the Choosing Wisely recommendations into practice.

Choosing Wisely In Action

The front line empowerment fostered by Choosing Wisely was evident when the University of Vermont Medical Center asked faculty and residents to submit ideas for high-value care projects targeting tests and treatments that could be performed less frequently. Interventions on seven projects were completed. Key reported outcomes included:

  1. a 72 percent reduction in the use of blood urea nitrogen and creatinine lab testing in patients with end-stage renal disease who were on hemodialysis and hospitalized;
  2. a 90 percent reduction in dual-energy x-ray absorptiometry (DEXA) screening on women ages 65 and older without clinical risk factors for osteoporosis; and
  3. a 71 percent reduction in the use of portable chest x-rays in mechanically ventilated patients who were not intubated that day and did not have a procedure performed.

Vanderbilt University Medical Center drove cultural change through a “challenge” to all house staff and residents aimed at reducing unnecessary daily lab orders. After educational sessions, teams were sent weekly emails on tracking use in a friendly monthly competition. This resident-originated focus and intervention resulted in significant reported decreases of daily blood counts and basic metabolic panels.

Crystal Run Healthcare, a multispecialty practice with 350 clinicians, also sponsored a contest designed to advance Choosing Wisely recommendations. Eric Barbanel, MD, a practicing physician at the clinic, was the champion for the winning project, which focused on four recommendations from the American Academy of Family Physicians. The interventions included peer education, clinical decision support, and data feedback. Decreases in annual electrocardiograms (EKGs), magnetic resonance imagings (MRIs) for low back pain, and DEXA screening were reported.

The campaign has also relied on regional health collaboratives to help drive local public awareness of the issue of overuse. Two grantees supported by RWJF, HealthInsight Utah and Maine Quality Counts, have used town hall meetings to engage in conversations with patients and the broader public about Choosing Wisely.

The Choosing Wisely campaign has focused first on adaptive change—on “why” there is concern about overuse by clinicians and patients, and on developing a consensus set of common values and purposes. The campaign has emphasized evidence about benefits and harms and the pursuit of enhancing quality, safety, and doing no harm. The aim has been to win both the hearts and minds of physicians so that they would be more engaged in improvement efforts, something often missing in efforts to change behaviors in clinical practice. The rapid introduction of purely technical solutions (that is, clinical decision support through electronic medical records) often alienates clinicians who don’t know the values and motivation behind the need for such solutions.

Remaining Challenges

Choosing Wisely has had some success in raising awareness of overuse and incorporating recommendations into practice. But results from national studies have been mixed, highlighting the need for further formal evaluation of the initiative’s impact.

More importantly, other strategies needed to complement Choosing Wisely must be jumpstarted. Specifically, more needs to be done to address some of the other underlying drivers of overuse in the health care system, notably perverse payment incentives; eliminating unnecessary services will be challenging as long as providers face financial incentives to provide more care and patients have no incentives to avoid care. Choosing Wisely is an attempt to change attitudes and mindset, but changing attitudes is hard when incentives are misaligned.

Payment reform can play a role in changing physician behavior by minimizing rewards for doing unnecessary tests and procedures. In fact, some evidence suggests population payment has disproportionately reduced use of potentially unnecessary tests and procedures. But it is not always easy to design payment reform such that the incentives are fully experienced at the point of care. Moreover, although evidence suggests these payment models lower spending without sacrificing quality, the effects have generally been modest and surely more could be done. And reinforcement works both ways: Just as payment reform can make the task of changing attitudes through Choosing Wisely easier, winning hearts and minds can amplify the effectiveness of any payment reform strategy.

Benefit design can also help reduce use of potentially unnecessary services by increasing patient out-of-pocket spending for those services. However, higher out-of-pocket spending can be a significant financial burden on patients, and in many cases they are not well suited to make nuanced decisions about care. Most evidence suggests that when faced with higher cost sharing, patients reduce use of appropriate and inappropriate care in similar proportions. Value-based insurance design (VBID)—which aims to increase cost-sharing for less effective treatments and decrease cost sharing for more effective treatments—can help encourage patients to specifically reduce overuse of low-value care. However, VBID is not a panacea and must be implemented in a way that avoids adverse selection and excessive complexity. Engaging clinicians in explaining and implementing benefit design changes will be necessary to help patients better navigate the choices they will confront.

Even if Americans were not grappling with high health care spending, avoiding potentially unnecessary services would be important. But with fiscal pressures driving changes by private and public purchasers that often have deleterious consequences, eliminating potentially unnecessary services—and thus delivering cost savings while increasing quality—is more important than ever. Choosing Wisely exemplifies efforts of the professional societies to engage on the issue; by appealing to the professionalism of physicians and other clinicians, it can provide the foundation for promoting delivery of appropriate care.

Professionalism as a force to improve quality has an opportunity to show its value along with the technical approaches and the environmental changes needed (for example, payment reform). The design of Choosing Wisely, which included few rules, much autonomy for engagement and design, and little central control, produced an activated professionalism. Appealing to the intrinsic motivations of physicians offers an underused path to achieve widely shared policy goals such as reducing the cost of our health care system while enhancing its quality. Professionalism can also appeal to patients and give them confidence in their physicians’ counsel that unnecessary care truly is unnecessary. Given the activity that has been unleashed in health systems and clinical practices throughout the United States, professionalism should not be overlooked as part of our broad health care transformation strategy.