WBB's Thought Leadership

The Global Problem of Low-Value Care

January 23

Several studies of low-value care show the problem to be widespread and frequent. The rate of low value care occurs at rates of 5-8% of cases overall, and at a rate of ~25-42% in the elderly.

Low-value care has several causes, including clinician, patient, and systems factors. Clinician factors may include bias in training, defensive medicine, and productivity and profitability pressures. Patient factors may include lack of knowledge or financial consequences. Healthcare system factors may include institutional culture, pricing, and fee-for-service payment models.

WBB Take:  A fundamental tenet of healthcare is to provide high value care. Healthcare products and services should be STEEEPA – safe, timely, effective, efficient, equitable, patient-centered, and affordable. Care that provides little or no net benefit to the patient raises costs, increases harm, and results in missed opportunities, that can be seen in lower life expectancy, increased disability, and lower quality of life.
An error rate of 5-8% represents a Process Sigma Level  of 3.14 - 2.91, which is a long way from the Six Sigma quality standard we would want it to be. In the elderly, the low-value care rates of 25-42% translate to a Process Sigma of 2.17 - 1.7. To place this into perspective, to be at a Six Sigma level of quality, we would want less than 0.0003% of cases of care to be low value, or over 16,000 times lower rate than the lowest prevalence of low value care found in the studies.
Cited by Matthew Loxton

Excerpt: “Low-value care, or patient care that provides no net benefit in specific clinical scenarios, remains one of the most pressing problems in healthcare across the world—namely because it raises costs, causes iatrogenic patient harm, and often interferes with the delivery of high-value care. Many have argued that above all else the primary cause of low-value care lies in an unchecked fee-for-service payment system, which creates a pervasive culture that rewards providers for delivering more care, not necessarily the right care.”
“Results reported by McAlister et al in this issue of BMJ Quality & Safety seem to up-end this belief.1 In their analysis of 3.4 million beneficiaries in the globally-budgeted health system of Alberta, Canada, they found that low-value care commonly occurred—at a rate of approximately 5% of beneficiaries seeking care, and as high as 30% among those aged >75 years. Notably, these rates are comparable to rates in America’s largely unrestrained fee-for-service system for both commercially insured (~8%) and older Medicare beneficiaries (~25-42%) seeking care, even while McAlister and colleagues used fewer low-value care measures (10) than the latter two American studies (28 and 26 respectively).2 3”

“While technology such as information-based computerized clinical decision support has demonstrated limited results in reducing low-value care,11 behavioural economics, or the field that posits that human beings (including physicians) predictably make irrational decisions due to known cognitive biases, has been heralded as an important new field of psychology and economics to apply to quality improvement. Low-cost and light-touch behavioural economic interventions (such as ‘nudges’)12 hold obvious appeal. Early results show promise, with Patel and colleagues demonstrating the power of the default in computerised order entry and Meeker and colleagues publishing two rigorous, well-designed cluster-randomised controlled trials leveraging physicians’ intrinsic motivation to maintain a professional reputation and conform with peers in 2014 and 2016.13–16 “
“Low-value care remains an intractable problem for a wide array of interrelated reasons, including clinician factors (eg, training, fear of lawsuit, time pressures, intolerance of uncertainty), patient factors (lack of knowledge or financial consequences) and healthcare system factors (institutional culture, pricing, fee-for-service payment models).26–39 Rather than implementing myopically top-down interventions (eg, mandating overly specific pay-for-performance policies), which may be virtually impossible to execute safely and effectively in complex, non-linear systems,40–42 we might instead propose an alternative strategy. It likely will require a combination of ‘light-touch’ top-down policies (eg, capitated payment arrangements that preserve clinician autonomy and access to care)43 44 as well as encouraging simultaneous bottom-up, pragmatic/trial-and-error-type local pilot initiatives that addresses multiple drivers of low-value care.24”

Source: British Medical Journal (Quality & Safety)


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