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An analysis of data for 2014 about forty-four low-value health services in the Virginia All Payer Claims Database revealed more than $586 million in unnecessary costs. Among these low-value services, those that were low and very low cost ($538 or less per service) were delivered far more frequently than services that were high and very high cost ($539 or more). The combined costs of the former group were nearly twice those of the latter (65 percent versus 35 percent).

This cross-sectional study examines changes in low-value care use and spending from 2014 to 2018 among the fee-for-service Medicare population.

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Background Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. Objective To compare use of low-value services among U.S. APCs and physicians. Design Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office-versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient’s primary care provider (PCP). Setting National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. Patients Patients presenting with upper respiratory infections (URIs), back pain, or headache. Measurements Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). Results 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. Limitation NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. Conclusion APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians’ perceptions that APCs provide lower-value care than physicians for these common conditions. Primary Funding Source U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

IMPORTANCE Following reductions in US ambulatory care early in the pandemic, it remains unclear whether care consistently returned to expected rates across insurance types and services. OBJECTIVE To assess whether patients with Medicaid or Medicare-Medicaid dual eligibility had significantly lower than expected return to use of ambulatory care rates than patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance. DESIGN, SETTING, AND PARTICIPANTSIn this retrospective cohort study examining ambulatory care service patterns from January 1, 2019, through February 28, 2021, claims data from multiple US payers were combined using the Milliman MedInsight research database. Using a difference-in-differences design, the extent to which utilization during the pandemic differed from expected rates had the pandemic not occurred was estimated. Changes in utilization rates between January and February 2020 and each subsequent 2-month time frame during the pandemic were compared with the changes in the corresponding months from the year prior. Age-and sex-adjusted Poisson regression models of monthly utilization counts were used, offsetting for total patient-months and stratifying by service and insurance type.EXPOSURES Patients with Medicaid or Medicare-Medicaid dual eligibility compared with patients with commercial, Medicare Advantage, or Medicare fee-for-service insurance, respectively.MAIN OUTCOMES AND MEASURES Utilization rates per 100 people for 6 services: emergency department, office and urgent care, behavioral health, screening colonoscopies, screening mammograms, and contraception counseling or HIV screening.RESULTS More than 14.5 million US adults were included (mean age, 52.7 years; 54.9% women). In the March-April 2020 time frame, the combined use of 6 ambulatory services declined to 67.0% (95% CI, 66.9%-67.1%) of expected rates, but returned to 96.7% (95% CI, 96.6%-96.8%) of expected rates by the November-December 2020 time frame. During the second COVID-19 wave in the January-February 2021 time frame, overall utilization again declined to 86.2% (95% CI, 86.1%-86.3%) of expected rates, with colonoscopy remaining at 65.0% (95% CI, 64.1%-65.9%) and mammography at 79.2% (95% CI, 78.5%-79.8%) of expected rates. By the January-February 2021 time frame, overall utilization returned to expected rates as follows: patients with Medicaid at 78.4% (95% CI, 78.2%-78.7%), Medicare-Medicaid dual eligibility at 73.3% (95% CI, 72.8%-73.8%), commercial at 90.7% (95% CI, 90.5%-90.9%), Medicare Advantage at 83.2% (95% CI, 81.7%-82.2%), and Medicare fee-for-service at 82.0% (95% CI, 81.7%-82.2%; P < .001; comparing return to expected utilization rates among patients with Medicaid and Medicare-Medicaid dual eligibility, respectively, with each of the other insurance types).CONCLUSIONS AND RELEVANCE Between March 2020 and February 2021, aggregate use of 6 ambulatory care services increased after the preceding decrease in utilization that followed the onset of the COVID-19 pandemic. However, the rate of increa...

IMPORTANCE Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems.OBJECTIVE To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives.