Person: Schwartz, Aaron
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Schwartz
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Aaron
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Schwartz, Aaron
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Publication Low-Value Service Variation and Physician Characteristics(2017-05-12) Schwartz, AaronImportance: Reducing spending on unnecessary medical procedures is a global priority. Understanding patterns of low-value service use across physicians can inform efforts to reduce wasteful care. Objective: To quantify the extent of physician-level variation within region and within provider organization in the rates of primary care related low-value health care services, and to assess for associations between low-value service rates and physician characteristics. Design, Setting, and Participants: Retrospective analysis of low-value service use in 2008‒2013 using Medicare fee-for-service claims and enrollment data for 4,797,293 beneficiaries served by 66,675 generalist physicians. We employed multilevel models to quantify the magnitude of service use across physicians, adjusted for patient clinical and sociodemographic characteristics, within region and within provider organizations. We examined associations between rates of low-value services and physician characteristics related to education, demography, academic status, pharmaceutical/device payment, and patient panel size. Main Outcomes and Measures Annual per beneficiary count of 17 primary care related services that provide minimal clinical benefit. Results: The average rate of low-value services among attributed beneficiaries was 35.6 services per 100 beneficiaries per year, with considerable variation across physicians (within region 90th/10th percentile ratio, 2.14; 95% CI, 2.12‒2.16; within organization 90th/10th percentile ratio, 1.57; 95% CI, 1.56‒1.58). Greater low-value service rates were associated with educational characteristics (DO credential, foreign medical graduate status), demographic characteristics (older age, female gender), academic status (lack of professorship), pharmaceutical/device company payment (both any payment and greater size of payment), and larger patient panel size. However, association magnitudes were generally minimal. Conclusions and Relevance: Although variation in low-value service use is substantial even within the same organization, physician characteristics are associated with only small differences in service use. Therefore, direct measurement of service use is likely to be superior to use of proxy measures in attempts to target physicians for waste-reduction interventions.Publication Choosing Wisely for Syncope: Low‐Value Carotid Ultrasound Use(Blackwell Publishing Ltd, 2014) Scott, John W.; Schwartz, Aaron; Gates, Jonathan D.; Gerhard‐Herman, Marie; Havens, Joaquim M.Background: The United States spends more than $750 billion annually on tests and procedures that do not benefit patients. Although there is no physiological indication for carotid ultrasound in “simple” syncope in the absence of focal neurological signs or symptoms suggestive of stroke, there is concern that this practice remains common for routine syncope workups. Methods and Results: We used a 5% random‐sample Medicare claims database to evaluate large‐scale national trends in utilization of low‐value carotid ultrasound imaging for simple syncope. We found that 16.5% of all Medicare beneficiaries with simple syncope underwent carotid imaging and 6.5% of all carotid ultrasounds ordered in 2009 were for this low‐value indication. These findings were complemented by a manual chart review of 313 patients at a large academic medical center who underwent carotid ultrasound for simple syncope over a 5‐year period. For the 48 (15.4%) of 313 patients with stenosis ≥50%, carotid ultrasound did not yield a causal diagnosis. Only 2% of the 313 patients imaged experienced a change in medications after a positive study, and <1% of patients underwent a carotid revascularization procedure. Conclusions: These data suggest that carotid ultrasound for patients with uncomplicated syncope are still commonly ordered and may be an easy target for institutions striving to curtail low‐value care.Publication Measuring Health Care Quality and Value: Theory and Empirics(2015-04-24) Schwartz, Aaron; Newhouse, Joseph P.; Chernew, Michael E.; McWilliams, John MichaelImperfect information is a pervasive feature of health care markets. Therefore, measuring the quality and value of health care services may inform efforts to improve health care delivery. This dissertation explores several applications of performance measurement in health care: describing national practice patterns, evaluating the effects of payment reforms, and contributing to policies that reward providers for measured performance. Chapter one describes the use of low-value services in fee-for-service Medicare. Drawing from evidence-based lists of services that provide minimal clinical benefit, I develop 26 claims-based measures of low-value services. Applying these measures to Medicare claims, I demonstrate that 42% of beneficiaries received at least one of these services in a year, which constituted 2.7 % of overall annual spending. When more specific and less sensitive versions of the measures were used, I detected low-value service use for 25% of beneficiaries, constituting 0.6% of overall spending. In adjusted analyses, spending on low-value services was substantial even in regions at the 5th percentile of the regional distribution of low-value spending. Adjusted regional use was positively correlated among five of six categories of low-value services. These findings are consistent with the view that wasteful practices are pervasive in the US health care system. The results also suggest that the performance of claims-based measures in supporting policies to reduce overuse may depend heavily on how the measures are defined. Chapter two examines the role of provider organizations in influencing the delivery of low-value services. In Part I of this chapter, I assess whether provider organizations exhibit distinct profiles of low-value service use in fee-for-service Medicare. In one sample of 3,137 large provider organizations and another sample of 250 provider organizations that entered the Medicare Pioneer Accountable Care Organization (ACO) Program or the Medicare Shared Savings Program, I demonstrate that provider organizations’ use of low-value services exhibits considerable variation, substantial persistence over time, and modest consistency across service types. In Part II of this chapter, I evaluate the effects of the Pioneer ACO Program on the use of low-value services. In a difference-in-differences analysis, I compare the use of low-value services between beneficiaries attributed to Pioneer ACOs and beneficiaries attributed to other providers, before (2009-2011) vs. after (2012) Pioneer ACO contracts began. During its first year, the Pioneer ACO program was associated with modest reductions in low-value services, with greater reductions for organizations that had provided more low-value services. The findings in this chapter suggest that provider organizations can influence the use of low-value services by affiliated physicians, and that organization-level incentives can reduce low-value practices. Chapter three analyzes the economic properties of performance measures used in both health care and education policy. Because observable outcomes constitute a noisy signal of performance in these settings, shrinkage estimators are often used to improve measurement accuracy. I demonstrate that these improvements in accuracy come at the cost of reducing a measure’s responsiveness to agent behavior, thereby diluting incentives for performance improvement. In a model of consumers sorting between agents, I show that welfare depends on two components: (1) accuracy of performance signals, which promotes efficient consumer sorting, and (2) incentives for performance improvement, which promote efficient agent effort. Using Monte Carlo simulation, I evaluate the accuracy and incentive properties of various techniques for estimating hospital performance in heart attack mortality. Shrinkage estimators entail substantial incentive distortions, particularly for smaller hospitals, which experience an approximate 50-70% “tax” on improvement. Several estimation techniques, including the methods currently used by Medicare, are dominated on the basis of both accuracy and incentive criteria. I discuss various policy alternatives to shrinkage estimation, such as increasing the timespan of measuring performance.