Preventive cardiac care has made considerable strides in the past 30 years. Heart testing and monitoring has become progressively more sophisticated. Prospective studies have researched heart healing and aging. In that time, it has become common practice for people to undergo screening exercise electrocardiograms (ECG), stress testing, or annual ECGs starting in middle age. Moving forward, the trend tends toward fewer blanket cardiac testing and procedures. Instead, the decision point for testing has shifted to when a test or procedure indicates changes in clinical decision making. To assist with such decisions, the American Board of Internal Medicine developed its Choosing Wisely® guidelines in 2012, in conjunction with the medical specialty organizations. The guidelines were launched to help physicians, patients, and health care stakeholders think and talk about overuse of health care resources. Unnecessary testing is a key focus of the guidelines. And cardiac testing provides an example of the changes and new clinical considerations. Virginia Health Information has made the MedInsight Health Waste Calculator – it is built on the Choosing Wisely guidelines – available to All-Payer Claims Database (APCD) subscribers to examine the degree of low-value services being ordered. For this Research Corner, VHHA staff applied the calculator to common cardiac tests ordered in Virginia. What we found is the numbers of dollars spent on low-value testing might surprise you. Figure 1 below is a Low-Value Dashboard with eight columns:
- Low-Value Measure Rule: The type of service evaluated by the Health Waste Calculator with results defined as either necessary or low value. Low-Value Measure Rules also briefly outline the criteria for a potentially unnecessary service.
- Total Services Measured: The total number of services that were evaluated for a specific Low-Value Measure.
- Total Members: The distinct number of individuals who received a service that corresponded with a low-value measure rule, regardless of whether or not the service was categorized as low value.
- Low-Value Members: The distinct number of individuals who received a service that corresponded with a low-value measure rule and was categorized as low value.
- Low-Value Services: The total number of services that meet the necessary criteria outlined in the Waste Calculator methodology to be classified as low value.
- Low-Value Allowed: The total value of proxy payment allowed dollars associated with claims classified as low value.
- Average Proxy Cost per Service: The proxy payment allowed dollars associated with claims classified as low value divided by the total number of services classified as low value.
- Quality Index: The number of services classified as necessary divided by the total number of services measured.
Each row lists the low-value test and the conditions under which the test is classified as low value. A modest cost medical test can produce millions of dollars of wasted spending when it is overused. An example is the annual ECG in an asymptomatic person (row 4). The test averages $259 in payment from an insurer, a sum roughly equivalent to the monthly fee for a robust cable television, telephone, and internet service bundled package. In 2015, the test was ordered for 124,162 Virginians who did not have corresponding symptoms. That amounted to $33 million spent on testing that can be defined as wasted due to the fact that it did not provide any new information with regards to treatment decision-making. The silver lining is that those patients represented just nine percent of people who underwent that type of test. VHHA is making the analyses available to all its APCD subscribers. Please contact Barbara Brown at firstname.lastname@example.org or 804-965-5722 to learn which tests and procedures can be reviewed. (7/21)