Study Offers New Insights into the Impact of Low-Value Care Received by Medicare Beneficiaries Outside of their Health Systems


Results from a new study conducted by a team of researchers at Dartmouth’s Geisel School of Medicine and Harvard Medical School/Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system, and published in the August issue of Health Affairs, show that a substantial portion—nearly half—of low-value care received by Medicare beneficiaries happens outside of their health systems.

The study also revealed that factors such as advanced age put beneficiaries at higher risk of receiving this type of care. Low-value care is defined as medical services that offer little or no benefit. For example, prostate cancer screening is considered low value for men older than age 75 who have no history of prostate cancer.

Policy makers and payers are increasingly holding health systems accountable for the cost and quality of the services they provide to their beneficiaries—typically through the use of financial incentives administered by accountable care organizations (ACOs)—regardless of where that care originates. But low-value care remains common and beneficiaries receiving it outside of their health systems pose a particular challenge for systems seeking to reduce spending and improve health outcomes.

“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,” explains Ishani Ganguli, MD, MPH, assistant professor of medicine at Harvard Medical School and the Brigham’s Division of General Internal Medicine and Primary Care who was lead author on the study. The study team included Elliott Fisher, MD, MHP, a professor of The Dartmouth Institute for Health Policy and Clinical Practice, medicine, and community and family medicine at Geisel, who served as principal investigator on the Arnold Ventures grant funding the study.

“To this end, we sought to answer two main questions,” the research team wrote in the paper. “First, how much of low-value care use and spending by these beneficiaries originates outside of 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?”

To accomplish this, the investigators used national Medicare claims data for fee-for-service beneficiaries ages 65 and older in 595 U.S. health systems, measured across 30 of the most common low-value services during 2017-18.

They found that 43 percent of low-value services received by the beneficiaries originated from out-of-system clinicians: 38 percent from specialists, 4 percent from primary care physicians, and 1 percent from advanced practice clinicians.

Recipients of low-value care who were older (age 75-plus), male, White, rural-residing, more medically complex, had less continuity of care, and were attributed to a system with lower market share were more likely than other beneficiaries to receive that low-value care outside of their system.

However, the ACO status of a beneficiary’s attributed system (that is, the percentage of that system’s physicians participating in an ACO contract) was not associated with the beneficiary’s likelihood of receiving low-value care out of system.

“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,” they wrote.

“Given the threat of out-of-system, low-value care to accountable care goals,” health system leaders might consider extending low-value care reduction interventions outside of system walls,” they wrote. “These interventions might include things like referral network management, patient education, and increased access to high-value, in-system specialists.”

Founded in 1797, the Geisel School of Medicine at Dartmouth strives to improve the lives of the communities it serves through excellence in learning, discovery, and healing. The Geisel School of Medicine is renowned for its leadership in medical education, healthcare policy and delivery science, biomedical research, global health, and in creating innovations that improve lives worldwide. As one of America’s leading medical schools, Dartmouth’s Geisel School of Medicine is committed to training new generations of diverse leaders who will help solve our most vexing challenges in healthcare.

Brigham and Women’s Hospital is a founding member of Mass General Brigham and a teaching affiliate of Harvard Medical School. With nearly 1,000 inpatient beds, approximately 50,000 inpatient stays, and over 2.6 million outpatient encounters annually, clinicians across the Brigham provide compassionate, high-quality care in virtually every medical and surgical specialty to patients locally, regionally, nationally and around the world. An international leader in basic, clinical, and translational research, Brigham and Women’s Hospital has nearly 5,000 scientists, including physician-investigators, renowned biomedical researchers and faculty supported by nearly $750 million in funding. The Brigham’s medical preeminence and service to the community dates to 1832, with the opening of the Boston Lying In, one of the nation's first maternity hospitals designed to care for women unable to afford in-home medical care. Its merger with the Free Hospital for Women resulted in the Boston Hospital for Women in 1966. In 1980, the Boston Hospital for Women, the Peter Bent Brigham Hospital and the Robert Breck Brigham Hospital officially merged to become Brigham and Women’s Hospital. With nearly 21,000 employees across the Brigham family – including the Brigham and Women’s Physicians Organization and Brigham and Women’s Faulkner Hospital – that rich history is the foundation for our commitment to providing superb care for some of the most complex cases, pursuing breakthroughs in biomedical research, training the next generation of health care providers, and serving the local and global community.