Medicare Enrollees Are Receiving Subpar Treatment

According to researchers, about half of Medicare users' low-value treatment occurs outside their health systems.

Medicare is a federal health insurance program available to those 65 and older and those under 65 with certain illnesses or disabilities.

The study, conducted by Dartmouth's Geisel School of Medicine and Harvard Medical School/Brigham and Women's Hospital, also showed that recipients are more likely to receive this kind of treatment if they are older, for example.

The results, published in the August issue of Health Affairs, also reveal that medical treatments that are either ineffective or low-value are referred to as low-value care; for males over 75 who have never had prostate cancer, prostate cancer screening is regarded as having minimal usefulness.

Regulators and payers are increasingly utilizing accountable care organizations (ACOs) to hold health systems responsible for the cost and quality of the services they provide to their beneficiaries, regardless of where the treatment is provided. Plans to save costs and improve health outcomes need help from members who get low-value care outside their health systems.

Understanding the scope and origins of out-of-system, low-value care use may help health system leaders design and implement effective interventions to reduce spending and harms to their attributed beneficiaries.

-Lead author Ishani Ganguli from Harvard Medical School

According to the study team, they set out to address two key issues.

"First, how much of low-value care use and spending by these beneficiaries originate outside their health system, and from which types of clinicians? And second, which beneficiaries are at greater risk of receiving out-of-system, low-value care?" said the team.

The researchers accomplished this by analyzing data from national Medicare claims for fee-for-service patients 65 and older in 595 U.S. healthcare systems to determine the prevalence of 30 of the most common low-value operations during 2017 and 2018.

They found that 43% of the low-value services the beneficiaries received were provided by 38% of the specialists, 4% of the primary care physicians, and 1% of the advanced practice clinicians.

If they were older (ages above 75), male, white, rural residents, more medically complex, had less continuity of care or belonged to a system with a smaller market share, beneficiaries of low-value care were more likely than other beneficiaries to receive it outside of their system.

However, there was no correlation between the ACO status of the beneficiary's assigned system and the likelihood that the beneficiary would get low-value care.

"Our results provide insights on the magnitude and sources of out-of-system, low-value care, which could inform health systems' efforts to reduce the use of these often costly, potentially harmful, and generally avoidable services," said the team.

They said that health system executives could think about expanding low-value care reduction strategies outside of system boundaries given the danger posed by out-of-system, low-value care to accountable care goals.

The team concluded: "These interventions might include things like referral network management, patient education, and increased access to high-value, in-system specialists."


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