Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations

OBJECTIVE:
To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care.
DATA SOURCES:
2009-2011 national Medicare and commercial insurance administrative data.
DESIGN:
We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics.
METHODS:
We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these.
PRINCIPAL FINDINGS:
Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians.
CONCLUSIONS:
Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.