Behavioral Economics CFP: Low-Value Care? Why Now?
Mar 6, 2013, 6:58 PM, Posted by Lori Melichar
To help those who want to respond to our recent Call for Proposals, Applying Behavioral Economics to Perplexing Health and Health Care Challenges, I sat down with Drs. Kevin Volpp and David Asch, co-directors of the Foundation’s Behavioral Economics Initiative at the University of Pennsylvania, to talk about low-value health care, why we are doing this CFP and what we are seeking from applicants.
Why are we doing this CFP now?
Kevin: There’s enormous concern about the growth in health care spending—both in the public and private sector. We can’t afford to keep increasing spending the way we have. But health care spending shouldn’t be defined as too high simply because it’s high. The question should be “How much value are we getting?” There is a widespread belief that there is too much health care that doesn’t provide value that’s commensurate with the costs—to individuals or to the government.
What’s particularly exciting is that, while health policy experts have acknowledged the problem of low-value health care for a long time, influential physician groups are becoming vocal about their belief that society would be better off — from both a quality and patient safety standpoint — if less of this care was provided. And they’re creating lists of health care services and procedures that they consider to be of low value that are available to the public.
Reducing use of low-value care is what’s going to be able to allow us to continue to fund high-value care for large portions of the American population.
What is low-value health care?
David: Nearly all of the examples that we could identify as being low-value health care started out as well-meaning interventions; people wanted to improve care and there was a strong conceptual grounding for what they did. This isn’t about people being evil. This is about habits, practice, and intuition and—in some cases—payment mechanisms. And, of course, people often think more is better. Any number of factors may be contributing alone or in combination.
Kevin: Take a look at Choosing Wisely, where a number of specialty societies like the American College of Cardiology each provided five examples of low-value care. So, for example, the American College of Cardiology thinks annual stress cardiac imaging qualifies as low-value health care. The technology exists and it’s not difficult to provide, but it rarely results in any meaningful change in patient management, and may lead to unnecessary invasive procedures and excess radiation exposure, without any real impact on patient outcomes.
David: Let me give you another example. Lower back pain is a prevalent and disabling condition. And many people end up with an MRI. It’s easy to see why that’s appealing; you get a picture and there appears to be little associated risk because there’s no radiation. But there’s a cost involved and there’s a great deal of normal variation. The MRI might reveal a bulging disc. But, it turns out that lots of people without back pain have bulging discs, and it’s not clear that the bulging disc is the cause of the back pain. But now you have this picture of something that looks like it’s part of the problem, and it looks like it’s solvable in a mechanical way, and that may lead people to get surgery, which has limited effectiveness in the management of back pain. So even diagnostic tests that have no clinical risk have costs and risks that are far above what that initial step involves. You basically get on the train and you end up where that train is going.
What do we want to learn?
Lori: I’m interested in answering a number of questions. How does a service that is not evidence-based, that could potentially be harmful, that the patient or the physician may perceive as being unnecessary or duplicative—how does that get provided anyway? Is it that folks don’t know that is something of low value? Is it perverse incentives? Is it pressure? Is there something that happens in the patient-provider interaction that could be changed?
Behavioral economists have helped us to see that our assumptions about the way people make decisions have been wrong and have developed practical solutions that can have dramatic impacts on the way that people save money for retirement, for example. But behavioral economists have done relatively little work in the field of health care. What we’re really hoping for is that, by applying this lens of behavioral economics to perplexing problems in health and health care, we may come up with some truly surprising insights and breakthrough ideas.
I also want applicants to think about different kinds of patients: people who are facing different kinds of diagnoses or who are at different stages of their lives. Established behavioral economic principles may not apply across all populations.
Finally, we want to encourage applicants to focus on providers AND patients as well as interaction between the two. We’d also be interested in hearing ideas that address the role of surrogates—family members, parents and partners—in decision-making.
Kevin: Absolutely. So much of what we do is influenced by what others around us advise us to do. And there’s an opportunity here to think about how that could be applied within the context of health care interventions.
David: Maybe some of the most creative and pioneering applications won’t target patients or physicians or other providers, but might instead target their influential social networks in which they’re embedded.
Are there other resources to which you can refer?
Kevin: There are two resources that might be helpful in thinking about what type of health care is considered to be low value. One is ChoosingWisely.org, which we’ve already mentioned. But there’s also a nice collection of articles on low-value health care from the Annals of Internal Medicine on “high value” care. Check both of them out.
One last note…
Lori: We’re not asking for brief proposals. We’re just asking for ideas. In this first stage of the application process, that is what you’re going to be judged on—your idea. Wow us. Show us that this is an unconventional way of thinking about this problem. We’ll handle the logistics later.
This commentary originally appeared on the RWJF Pioneering Ideas blog.