OP-ED

Avoiding low-value care: Learning to be an empowered consumer when you need a medical test or procedure

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Recently, I received a call from one of our members. Her daughter, while away at college, had visited an urgent care clinic for a suspected urinary tract infection, or UTI. The member was shocked to receive a bill for $800. How is that possible? Here’s how: The visit included tests that were low value, according to guidelines from the American College of Obstetricians and Gynecologists. Those guidelines note laboratory analysis (in particular, urine culture) is not usually needed to treat premenopausal women with lower UTI symptoms.

We call this low-value care, and unfortunately, the experience of our member’s daughter is not uncommon. In fact, there have been hundreds of studies examining the volume of low-value or inappropriate care and the results are astounding. According to the Center for Value-Based Insurance Design, low-value care contributes more than $345 billion annually in wasteful health spending. Examples of low-value care include Vitamin D testing and pre-operative testing. Nearly 90 percent of Vitamin D testing may be clinically useless. And most patients who undergo low-risk surgery do not require laboratory tests, such as blood counts, metabolic panels or coagulation studies.

An important role that health plans play in the care continuum is to ensure that patients get the right care, at the right time and in the right place. Health plans are advocates for appropriate care that helps patients. I think we would all agree that we want to receive care that helps, rather than harms us.

But how does anyone know if they’re receiving appropriate care? How do they know if tests that are ordered are necessary? And how do clinicians know they’re delivering appropriate care? Choosing Wisely, an initiative launched by the ABIM Foundation in 2012, is one place to look for recommendations about tests or procedures that may not be needed.

What can you do as a patient to avoid low-value care BEFORE you receive it?

Ask questions. Choosing Wisely recommends five questions that you should ask your provider before you get any test, treatment or procedure. They include:

Do I really need this test or procedure?

What are the risks and side effects?

Are there simpler, safer options?

What happens if I don’t do anything?

How much does it cost and will my insurance pay for it?

When your provider is ordering a test or a procedure, such as a Vitamin D screening test, or diagnostic testing or imaging if you are a low-risk patient before a low-risk surgery, ask if the test or procedure is really necessary. You should also ask questions about any medications you are prescribed. It’s fine to ask if a generic equivalent is available – always less expensive than a brand name drug. Low-value care not only adds unnecessary costs, but can also be inconvenient, stressful, and cause time away from home or work.

A fact that may surprise you is that while not necessarily an indicator of low-value care, the location where you receive care can greatly affect the cost of that care.

Location, location, location is certainly a familiar real estate industry mantra and we all know exactly what it means: That where a house is located is the top factor in determining its price and value. Well in many ways, the same holds true for health care. Where you choose to receive care matters big time when it comes to cost and, in some cases, quality.

The cost for some medical tests can vary by hundreds of dollars, depending on where you have them done. If it’s not an emergency, ask about the cost before having a blood test or imaging test (such as an X-ray, MRI or CT scan). If your doctor doesn’t know, ask the testing center or hospital directly. You can also compare costs by logging in to bcbsri.com and clicking on “My Cost Calculator.”

There are a lot of good reasons why guidelines about low-value care aren’t followed. It depends on the clinical situation and the potential for complications. However, there are some instances where care is not appropriate and should be recognized as waste.

As patients, the best defense against low-value care is to feel empowered to ask questions and have a better understanding of what healthcare services cost. Asking if there are less-expensive tests, treatments or procedures; researching what your insurance may cover; and being mindful about opting for generic drugs instead of brand-name drugs (when appropriate) can all help lower costs – and it’s perfectly okay for you to ask. Providers should welcome these questions – because we all want to take wasteful spending out of the system. For more information, visit rhodeahead.com/save/healthcare-it-pays-shop-around.

Matt Collins, M.D., MBA, is executive vice president and chief medical officer of Blue Cross & Blue Shield of Rhode Island.

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