MedPAC urges CMS to curb low-value care

WASHINGTON – Prior authorization, clinical decision support, provider education, altered cost sharing, and evidence review can and should be employed to reduce the volume of low-value services paid for by Medicare, according to a staff presentation at a meeting of the Medicare Payment Advisory Commission.

At the commission’s April meeting, MedPAC staff presented data from various literature searches, noting a “substantial use of low-value services in Medicare.” For example, they found that about 20% of Virginians, across all payers, received a low-value service in 2014, while 15% of Medicaid patients and 11% of commercially insured patients in Oregon received a low-value service in 2013.

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MedPAC Commission Meeting, April 6, 2018.

Similarly, 23%-37% of Medicare beneficiaries received at least one low-value service in 2014, based on analysis of claims data, for an expenditure of $2.4 billion to $6.5 billion, although MedPAC staff said that was probably an underestimate.

“It is very hard to know at the beginning of coverage that something is going to be low value,” MedPAC commission member Kathy Buto, former vice president of global health policy at Johnson & Johnson, noted. “It may be covered for something narrow for which it is high value and then spreads. It’s important to have those kinds of tools once technologies and procedures are covered to be able to actually monitor what is going on and assess.”

But, she added, the Centers for Medicare & Medicaid Services needs to do more to routinely reexamine its coverage decisions.

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Kathy Buto

“Part of the conversation needs to be about revisiting the coverage after a certain amount of time,” she said. “I think that will prompt additional evidence development. Whether it is done at the beginning where the agency says, ‘We are not going to cover this unless you give us more evidence,’ or whether it is done on an ongoing basis … there will be greater evidence development. That is part of what’s missing.”

Ms. Buto noted that noncoverage decisions are rarely issued and suggested that “there is an opportunity for us to take a look at whether we would advise CMS to take a look at using more of those tools more aggressively.”

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