研究显示，医生过度使用‘低价值’的Medicare服务

《JAMA Internal Medicine》5月12日在线发表的一份研究报告显示，临床医生可能过度使用了一些对美国的老年保健医疗制度（Medicare）受益人作用不大或没有作用的“低价值”医疗服务。

美国哈佛大学的研究者从低价值临床服务的循证列表中提取了26项基于理赔数据的指标。种类包括低价值的癌症筛查、诊断性和预防性检查、影像学检查以及手术操作。这项研究总共追踪了超过130万Medicare受益人2009年以来的理赔数据，分析了接受过这类服务的受益人比例，每个受益人的平均服务使用率以及用于这类服务的总花费所占的比例。

研究所确定的26项低价值服务指标包括：针对年龄大于或等于65岁女性的宫颈癌筛查、针对无并发症的急性鼻-鼻窦炎的鼻窦计算机断层扫描、针对无并发症头痛的头部影像学检查、术前心脏应激试验以及针对非特异性腰背疼痛的背部影像学检查。研究者根据年龄、症状和服务部位对指标进行了调整，形成了每项指标不同的敏感度水平（即基线定义的敏感度高、特异性低；而带有附加限制条件的定义敏感度低、特异性高）。

据研究者估计，全美共有25%~42%的Medicare受益人接受过低价值服务，总花费高达84亿美元，占Medicare A部分和B部分所覆盖服务年花费的2.7%（JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.1541]）。

作为该研究的第一作者，在哈佛医学院就读MD-PhD的Aaron Schwartz在接受采访时说：“现在我们有了这一测量工具，我们可以借助该工具更好地了解过度使用发生在什么时候，我们可以做些什么来减少这种情况。”

Schwartz表示，我们在制定低价值医疗服务指标时尽可能地考虑全面，希望它可以用于长期追踪以及评估各种改革计划。“对于绝大部分服务而言，它是‘低价值’还是‘高价值’其实是取决于具体的患者情况和临床情况。”在分析不同地理区域各种服务的使用情况时，研究者发现即便Medicare服务花费较少的地理区域“在低价值服务上仍花费较多”。

Schwartz称，支付改革，比如总额或捆绑支付模式，可能有助于促使临床医生在识别低价值服务以及主动避免这类服务方面更加慎重。他说：“我们基本上更支持那些仍然让临床医生在提供服务时作出自己判断的改革提议。”

Schwartz指出，该研究“即便只纳入了26项指标，也反映出了系统内普遍存在的过度使用问题。”不过，他也提醒道，许多基于理赔数据的过度使用指标可能不够准确，还不足以支持有针对性的覆盖范围或支付改革政策，以免引起意外的后果。

阿肯色州Medicaid负责人William Golden博士表示，这项研究的结果并不让人意外，不仅仅是Medicare服务，医生过度使用“低价值”服务的现象其实是普遍存在的。不过新的支付策略和财政刺激政策，比如他所在州的Medicaid计划所采用的一些政策，似乎有助于改变这种实践模式并控制医疗服务的总成本。

Golden博士在接受采访时说：“低价值服务其实是贯穿医疗保健的整个常规过程的。自阿肯色州Medicaid计划让医疗保健提供者对医疗服务总成本承担责任，并且纳入了节余共享和成本分担制度之后，医疗界的确花了时间和精力对医生的临床行为进行了再教育。就我们州而言，有效的改革方案加上财政刺激政策是很有前景的策略。”

Schwartz声明无相关利益冲突。

（编者按：Medicare是一项美国政府专为65岁以上老年人提供的廉价医疗费减免制度）

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By: JUDY PACKER-TURSMAN, Oncology Practice Digital Network

Clinicians seem to be overusing "low-value" medical services that provide little or no benefit to Medicare beneficiaries, according to a report published online May 12 in JAMA Internal Medicine.

In the study, Harvard researchers developed 26 claims-based measures drawn from evidence-based lists of services providing minimal clinical benefit. Categories included low-value cancer screening, diagnostic and preventive testing, imaging, and surgical procedures. In all, the study tracked more than 1.3 million Medicare beneficiaries’ claims from 2009, analyzing the proportion of them receiving such services, mean-per-beneficiary service use, and the proportion of total spending devoted to the services.

Among the study’s 26 designated measures of low-value services: cervical cancer screening for women 65 years and older, computed tomography scanning of the sinuses for uncomplicated acute rhinosinusitis, head imaging for uncomplicated headache, preoperative cardiac stress testing, and back imaging for patients with nonspecific low back pain. Researchers tweaked measures by age, symptoms, and site of care, creating different levels of sensitivity for each measure (i.e., a more sensitive, less specific baseline definition, along with a less sensitive, more specific definition with additional restrictions).

 

Nationwide, between 25% and 42% of beneficiaries received low-value services, accounting for as much as $8.4 billion, or 2.7% of annual spending for services covered by Medicare Parts A and B, the researchers estimated (JAMA Intern. Med. 2014 [doi: 10.1001/jamainternmed.2014.1541]).

"Now that we have this measurement tool, we can use it to try to better understand when overuse is happening and what can be done to reduce it," Aaron Schwartz, the study’s lead author, who is in the MD-PhD program at Harvard Medical School, Boston, said in an interview.

Researchers sought to "cast a broad net" in creating a low-value medical services index that could be tracked over time and used to evaluate various reform efforts, Mr. Schwartz said. "For the vast majority of services, whether it’s ‘low value’ or ‘high value’ really depends on the patient and the clinical setting," he said. Analyzing the use of different services within various geographic areas, researchers found that even geographic areas spending less on low-value Medicare services "still spent a lot on them," he said.

Payment reforms, such as global – or bundled – payment models, could afford greater discretion to clinicians in identifying low-value services and in finding incentives to eliminate them, according to Mr. Schwartz. "Our team generally favors proposals that retain provider discretion at point of care," he said.

The study’s results are "consistent with extensive overuse in the system ... even with just 26 measures," Mr. Schwartz noted. But many claims-based measures of overuse may not be accurate enough to support targeted coverage or payment policies without resulting in unintended consequences, he cautioned.

Arkansas Medicaid Director Dr. William Golden said the Harvard study’s findings are not surprising, with physicians’ overuse of "low-value" services extending beyond Medicare. But new payment strategies and financial incentives, such as those employed by his state Medicaid program, seem to be helping to change such practice patterns and manage total cost of care, he said.

"Low-value activities are embedded throughout the routine orders of health care," Dr. Golden said in an interview. "Since Arkansas Medicaid has made health providers accountable for total cost of care and included shared savings and cost sharing, the health care community has invested the time and energy to retrain clinical reflexive behavior. Delineation of effective strategies coupled with financial incentives has promise to be a promising strategy in our state."

Mr. Schwartz reported having no conflicts of interest.