Unnecessary health care services represent 27.5 percent of theexorbitant costs of healthcare—$750 billion is spent annually onunnecessary or inefficient care. For employers looking to bringtheir health care spending into check, bringing these numbers downis a good place to start.

A recent webinar presented by Catalyst forPayment Reform tackled the issue of inappropriate care andstrategies major employers are successfully using to combat theissue—and save money.

“This is a problem that's not going to go away on its own,”noted Catalyst's Suzanne Delbanco. “There's a lot we need to putinto place in terms of structure, process and even the rightincentives.”

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Inappropriate care covers a variety of services, fromunnecessary tests and surgeries to over-prescribing antibiotics topainkillers. One of the main problems, however, is that there's nodefinite line that separates “appropriate” from “inappropriate”care—there's a grey area that might be deemed appropriate in onecase but not another. “Studying appropriateness is challenging: itrefers to any individual patient, not the population,” Bob Berensonof the Urban Institute told the webinar audience. “One needs a lotof clinical detail that isn't available from administrative datasuch as claims.”

Berenson pointed to a long list of causes perpetuating theprevalence of inappropriate care, including fee-for-service paymentmodels, defensive medical practices, cultural practices, and evenconsumer marketing. Then there's the disconnect between theconsumer and the entity ultimately responsible for paying the bill:“When somebody else is paying, both the doctor and patient may beless concerned about the cost,” Berenson said.

All of this points to a greater need for accountability on thepart of providers, education on the part of consumers, greaterprice transparency, and financial incentives. There are a varietyof ways to approach these issues, and representatives from Walmart,Google, AT&T, and Washington State Health Care Authority allshared ways their organizations are tackling inappropriatecare.

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1. Walmart sends employees to centers of excellence.

One way to minimize spending on unnecessary or inappropriatecare is to start with a provider that has a reputation of highvalue to begin with.

“We're serving about a million plan participants on our healthplan,” Lisa Woods, senior director healthcare benefits for Walmart,said. “We talk a significant amount about appropriateness of care.For us, diagnosis has to be right and treatment plan has to beright.”

Walmart has created its own proprietary tool to identify what itconsiders centers of excellence (COEs), based on a long list offactors. When an employee needs to have a procedure done, they'reencouraged to use a facility that meets the criteria. There's afinancial incentive, of course: If they opt for care at a COE, itwill be 100 percent covered, but if they opt for their ownprovider, they have to pay a share.

“We have seen where associates who were told in their homecommunity that they needed surgery and traveled to a COE, more than50 percent were told they did not need surgery,” Woods said.“Making sure we get the diagnosis right is absolutelycritical.”

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2. Google focuses on redirecting low-value services.

While Walmart focused on high-dollar surgeries, Google is tryinga strategy that is more in line with its company demographics—mostare younger and healthy—and its own tech-savvy resources.

After realizing that its employees were averaging 10office-visit claims each—compared with Anthem's average of 6 forother companies—the company launched an initiative to encourage itsemployees to take advantage of higher-value but under-utilizedprograms like telemedicine, said Rob Paczkowski, calculating thatredirecting 50 percent of visits could result in an 8 percentsavings.

But how to get employees to change their behavior? The companychanged how it communicated with employees about services,including allowing the healthcare vendors to message employeesdirectly, sending out more-targeted communications, and, notably,using its own Google Assistant and Google Home hardware to helpemployees find care and answer questions.

“What we've been able to do, just in this 12-month period, isredirect 10,000 visits for a savings of $1.4 million,” Paczkowskisaid.

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3. AT&T brings in expert second opinions.

With misdiagnoses playing such a significant factor inhealthcare waste, encouraging consumers to get a second opinionjust seems like a no-brainer. Given the complexity of thehealthcare system, however, such a task is daunting and confusingfor many consumers. That's why AT&T decided to create a programthat would make the process easier and ensure the second opinionwas coming from a reputable expert.

Through the program, members are able to reach out privately torequest an expert second opinion, granting access to relevantmedical information for a team to review. “Once all the data isgathered, the expert can start the review and provide a writtenreport,” explained Cynthia Almanza, noting the process takes two tofour weeks, depending on the complexity of the case. “From there,you can take the review and share it with your local physician anddetermine what is the best course of action.”

Since launching earlier this year, the program has provided 200second opinions; diagnoses were revised in 30 percent of cases andtreatment plans adjusted in 70 percent. Notably, the most commonsecond opinions were related to back and spine issues, and theservice saw the highest utilization within the 55-64 age group,Almanza said.

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4. Washington State Health Care Authority's shareddecision-making program.

While healthcare spending is a significant aspect of businessfor the other companies represented in the webinar, the forWashington State Health Care Authority, it is the business. Itpurchases healthcare on behalf of more than 2 million Washingtonresidents who are Medicaid recipients, public employees, andeducation workers.

One strategy the Washington State Health Care Authority has hadsuccess with in reducing healthcare waste is shareddecision-making, which associate medical director Emily Transueexplained is “a process in which clinicians and patients worktogether to make decisions and select tests, treatments, and careplans based on clinical evidence.”

The collaborative approach not only reduces overutilization ofhealth services but can also correct for underutilization, Transuenoted. “If you give patients the opportunity to really think aboutwhat's worth it them and understand what they're getting into, theywill make appropriate choices.”

It sounds like a simple approach, but it requires a lot ofrethinking and rewiring on the part of the provider. “If you walkinto a group of physicians and ask if they do SDM [shareddecision-making], they all raise their hands, but you have toreally delve into what it is before the light bulb goes off andthey say, actually I haven't really been doing that,” Transuesaid.

The Washington State Health Care Authority worked with providersat three sites to implement an SDM approach for OB care for itspublic employees. The project educated providers on the principlesof SDM and helped them adjust their workflows accordingly,resulting in better, more-informed healthcare decisions for thepatients involved.

From: BenefitsPro