A report by the Center for Health Solutions The right health care the right way Global case studies in reducing low-value care The right health care the right way Value-based payment models have the potential to upend traditional patient care and business models. What can your organization do to effectively make the shift and “win” in the new value- based care payment landscape? To learn more about Deloitte’s value-based care practice and our relevant insights, please visit www.deloitte.com/us/ValueBasedCare. Global case studies in reducing low-value care CONTENTS Executive summary | 2 Introduction | 4 The right care | 5 The right setting | 8 Providing care safely | 10 Providing care in the right way | 12 Conclusions and overview of lessons for adoption and innovation | 14 Endnotes | 16 1 The right health care the right way Executive summary OW-VALUE health care—services of low, no, or In these 10 case studies, and throughout the pa- even negative impact on patients, as well as per, we highlight where effective use of technology Lservices delivered in an unsafe or inefficient has made a difference, from seemingly simple fixes manner—is pervasive across the globe. Some widely such as including patient photographs in electronic used services are clinically inappropriate for most health records to improving clinician training with patients under most circumstances. Examples in- Wi-Fi-enabled robots that simulate patients. We clude doing an EEG for an uncomplicated headache also show where emerging applications could make or a CT or MRI for lower back pain in patients with- even more of an impact in the future in terms of im- out signs of a neurological problem.1 More examples proving outcomes or reducing costs. In other cases, of low-value care are the misuse of some medica- we show how seemingly simple ideas or process re- tions, including opioids and antibiotics, which have designs, such as regular review of elderly patients’ led to growing problems in opioid abuse and antibi- otic-resistant bacteria. Reducing low-value care has proved to be a hard and slow task.2 Nevertheless, doing so is likely es- THE HIGH PRICE OF LOW-VALUE CARE sential if we are to lower costs while also pursuing The full costs of low-value health care innovation and improving health quality and out- services, waste, fraud, and inefficiency comes. In the United States alone, the financial across the globe are difficult to gauge, but toll of low-value care is estimated in hundreds of researchers have estimated those costs for billions of dollars (see sidebar “The high price of the United States, and they are significant: low-value care”). In addition, low-value care aris- • USD 210 billion ing from medical errors and operational inefficien- Overuse and excessive discretionary use cies in service delivery can result in adverse patient • USD 130 billion outcomes, excessive costs (including fraud), and Mistakes, preventable complications, and poor patient experience. Reducing and ultimately care fragmentation eliminating low-value services are likely essential to achieving value-based care, in which a treatment’s • USD 190 billion effectiveness ultimately helps to determine its value. Excess administrative costs, including The Deloitte Center for Health Solutions con- inefficiencies due to documentation ducted extensive research and interviewed experts requirements and paperwork costs beyond to see what is working globally to reduce low-value benchmarks care. The resulting case studies, spanning 10 orga- • USD 105 billion nizations in five different countries, illuminate four Unnecessarily expensive care avenues for reducing low-value care: • USD 55 billion • Providing the right care: Curbing services that Missed prevention opportunities offer few or no patient benefits • Delivering care in the right setting: Curtailing • USD 75 billion unwarranted emergency department utilization Fraud • Delivering care safely: Tackling safety failures Source: Institute of Medicine, Best care at lower • Providing care in the right way: Rooting out cost: The path to continuously learning health care in America, National Academy of the Sciences, 2013. operational inefficiencies 2 Global case studies in reducing low-value care drug regimens by pharmacists or incorporating lean show how health care organizations can reduce low- principles throughout a hospital, can significantly value care in favor of the right care, in the right set- reduce costs or improve outcomes when imple- ting, safely, and in the right way. mented effectively. Taken together, these examples 3 The right health care the right way Introduction HE high costs of low-value health care—exces- Avoidable injury from adverse events related sive spending, waste of patients’ and clinicians’ to medical procedures, stress associated with false Ttime, and poorer patient outcomes—make a positives from unnecessary screening tests and in- stirring case for change. vasive follow-up procedures, and time and produc- Global awareness of the prevalence of low-value tivity costs can greatly add to the toll taken by inap- care has been increasing. More than 20 countries propriate or inefficiently delivered services. Misuse have initiated “Choosing Wisely” campaigns, in of antibiotics, for instance, is a contributing factor which health care specialty societies identify desig- to the rise of antibiotic-resistant bacteria, associat- nated services, tests, or treatments that are inappro- ed with over 20,000 deaths annually in the United priately used in certain circumstances, and work to States alone.9 reduce their use.3 Awareness of the issue is important but likely In the United States, the cost of services that not enough to effect change. Reducing low-value don’t necessarily benefit patients approaches USD care has often proved hard and slow. There is no 210 billion annually.4 In addition, safety shortfalls single, simple solution to reducing low-value care and operational inefficiencies, such as duplicating that organizations can put into motion by pulling the delivery of certain services due to inappropri- a lever. But some health organizations around the ate care coordination, amount to USD 130 billion world have been successful in finding solutions to yearly.5 reduce the prevalence of low-value care. Our case Similarly high costs associated with low-value studies from the United States, Brazil, Israel, Sin- care service delivery have been documented in- gapore, and the United Kingdom demonstrate that ternationally.6 For instance, an ongoing review technology has often made a difference. From seem- of public health care in Australia has identified ingly simple fixes such as including patient photo- potential savings amounting to AUD 409 million graphs in electronic health records to improving from implementing benefit changes to reduce low- clinician training with Wi-Fi-enabled robots that value care.7 In the United Kingdom, eliminating simulate patients, technology can serve a crucial unwarranted variations in care could save up to role in enabling solutions to reducing low-value GBP 5 billion.8 care around the globe, and promises to help even more in the future. 4 Global case studies in reducing low-value care The right care Curbing the provision of services that offer few or no patient benefits LTHOUGH progress on changes at the broad As a result, LAC+USC saw an 80 percent drop system level has been slow, our case stud- in unnecessary preoperative work for cataract sur- Aies—from the United States, the United gery over a six-month trial period as compared to Kingdom, and Brazil—highlight successful initia- another large public teaching hospital that did not tives to reduce the delivery of services that provide implement the same change. Without additional few or no patient benefits. In the United States, testing, average waiting time for surgery declined process change, education, and physician training by six months. have reduced unnecessary preoperative testing in Detailed results of an evaluation of this initiative California; in the United Kingdom, process change, showed that: education, and training to cut down potentially un- • Unnecessary preoperative medical visits fell necessary diagnostic procedures reduced their use; from 76 percent to 12 percent of patients after and in Brazil, training clinicians prevented exces- the program was implemented. sive use of C-sections. • Ninety percent of pre-intervention patients had unnecessary preoperative laboratory testing com- pared to 31 percent following implementation. • Patients waited a median of 245 days until sur- ase study 1 gery pre-intervention, compared to a median of Eliminating unnecessary preoperative testing 64 days following implementation. • Given that preoperative testing is estimated at USD 1,200 per case, LAC+USC Medical Center Los Angeles County-University of Southern anticipates significant cost savings with no ad- California Medical Center10 saw a six-month re- verse impact on patient care. duction in patient wait time for surgery and USD 1,200 in savings per patient. ase study 2 The Los Angeles County-University of South- Involving patients in ern California Medical Center (LAC+USC), a pub- decision-making lic teaching hospital, made changes in 2015 to eliminate routine preoperative testing that not all patients need before routine cataract surgery. The The UK Health Foundation’s MAGIC program changes were based on Choosing Wisely guide- involved patients in treatment decisions, which led lines.11 With just three additional keystrokes in the to more streamlined services and positive ordering system, doctors could identify patients satisfaction scores for both patients and health who did not need the expensive, time-consuming care professionals.12 testing because they did not meet specific clinical In 2010, the UK Health Foundation commis- criteria. The three additional keystrokes circum- sioned the MAGIC (Making Good Decisions in Col- vented an unnecessary radiology consult, leading to laboration) program to identify, design, and test fewer potential delays to scheduling the procedure. the best ways to embed shared decision-making 5 The right health care the right way (involving both patients and doctors) in health care.