Healthcare cost for employer-sponsored health plans are largely driven by the 80/20 Rule.  Eighty percent of a group’s healthcare spend is driven by 20 percent of the plan’s participants.

That 20 percent of plan participants typically has annual healthcare costs more than $25,000… through a combination of medical and pharmacy claims.

Almost by definition, those 20 percent of participants are under the care of physician SPECIALISTS.  Some of that specialist care is great, of high quality and cost effective.  Fantastic.

However, much of that specialist care is LOW VALUE, i.e. low quality, price-gouging.

What Low Quality Specialist Care Looks Like

Low quality specialist care falls outside of the guidelines of care recommendations of a specialty’s OWN GUIDELINES.  For example, the American Society of Nuclear Cardiology (ASNC) states that “low-risk patients account for up to 45 percent of inappropriate stress testing” (1).

The ASNC guideline go on to state, “Performing stress radionucleotide imaging in patients without symptoms on a serial or scheduled pattern rarely results in any meaningful change in patient management.  This practice may lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes.”

Accordingly, the ASNC recommendation is as follows: “Don’t perform radionucleotide imaging as part of routine follow-up in asymptomatic patients.”

Not only does an unnecessary nuclear stress test expose patients to radiation that is not needed, it also costs upwards of $9,000… even after the insurance network discount.  Nine thousand dollars for an unneeded test.

What’s worse is that abnormal results in a nuclear stress test are not definitive.  They are often nebulous and require a cardiac catheterization to confirm the findings.  Cardiac catheterizations are lifesaving procedures, but they can also have complications such as stroke. 

I have personally seen a patient suffer a major stroke as the result of 1) a cardiac catheterization after 2) a nebulous abnormal finding on 3) an unnecessary initial nuclear stress test.  The stress test started a tragic cascade of events that could have been avoided by not performing it in the first place.

The point of this story is not to fearmonger.  In the right clinical situation, nuclear stress tests and cardiac catheterizations are immensely helpful.

The point is that low value care exists and significantly impacts employer-sponsored health plans and their members.

The Solutions to Low Value Specialist Care

The solution to low value specialist care is to steer plan members to high-value specialists. The consistency with which specialists follow their own guidelines is HIGHLY VARIABLE from one specialist to the next.  The key is to steer plan members toward those specialists that follow their own guidelines and away from those specialists that do not.

That steerage can be accomplished through:

1) Primary Care

2) Plan Design

3) Navigation

4) Centers-of-Excellence

These solutions will be addressed in detail in a future blog post.  Thank you for reading!

Sources:

https://www.asnc.org/Files/Guidelines%20and%20Quality/Choosing%20Wisely%20Campaign(1).pdf