Reporting Framework for Value Based Care
Learn how a provider's relative performance, or 'value', can be evaluated through three key components in an equation: quality, efficiency, and cost.
Globally, policy makers and payers are focusing on services that are regarded medically unnecessary and do not yield useful results. In the United States, these are referred to as low- or no-value services and are considered wasteful. A significant percentage of the services considered wasteful are medical imaging when done without appropriate indications. Inappropriate use of imaging services contributes to unjustiﬁable healthcare costs and may lead to irrelevant incidental findings, exposing individuals to unnecessary radiation doses.1
We set out to research wasteful eye imaging services because there is very limited literature or analytical research in this area. According to the American Academy of Ophthalmology Preferred Practice Pattern® guidelines, in the absence of symptoms or significant pathology, a comprehensive history and physical examination should suffice and imaging is not indicated. Advanced eye imaging (optical coherence tomography, visual field testing, fundus photography, or eye photography) should be reserved for malignant neoplasms of the eye, retinal detachments, and injury to eye, optic nerves, or optic chiasm.2
Similar views are advocated by Choosing Wisely® from the American Academy of Ophthalmology, which states: “Don’t routinely order imaging tests for patients without symptoms or signs of significant eye disease in the absence of symptoms or signs of significant disease pathology.”3
We used Milliman MedInsight’s Health Waste Calculator (HWC) to identify wasteful eye imaging services. The HWC ‘Imaging Tests for Eye Disease’ measure identifies eye imaging as wasteful unless the patient has symptoms or signs of significant eye disease such as neoplasms of the eye, choroidal detachment, optic atrophy, glaucoma, diabetic retinopathy, macular degeneration, etc., where imaging is considered medically necessary. We calculated the HWC ‘Imaging Tests for Eye Disease’ measure for one of our clients, a commercial health plan with approximately 2,091,517 members, using claim data from calendar year 2015. As shown in Figure 1, 67% of eye imaging services measured were wasteful and cost nearly $8,198,169.
Figure 1: Pattern of Eye Imaging Services
|Service Type||Number of Services||Percentage of Services||Aggregate Allowed Amount||Percentage of Allowed Amount|
|Total Eye Imaging||157,308||100%||$12,736,798||100%|
|Necessary Eye Imaging||51,888||33%||$4,538,629||34%|
|Wasteful Eye Imaging||105,420||67%||$8,198,169||66%|
Figure 2: Percentage Distribution of Wasteful Eye Imaging
Figure 2 profiles the distribution of the various advance eye imaging modalities that have been identified as wasteful. For each modality, the figure identifies the percentage of services that are wasteful and the corresponding percentage of wasteful total allowed dollars. Optical computed tomography has the highest rate of wasteful services and wasteful costs in the eye imaging service waste category. Analysis highlighted that it was performed for an array of inappropriate diagnoses including but not limited to headache, dizziness, and routine eye exam visits. This supports the proposition that eye imaging is being overused and is often done inappropriately in the absence of significant underlying disease pathology.
Another interesting finding revealed that 41.9% of members with wasteful services had a repeat service for eye imaging in a year, which was also determined wasteful.
It is important to note that claim data alone allows only an approximate identification of wasteful eye imaging. Even so, we were able to confirm a high prevalence of wasteful eye imaging for our client that allowed them to target potentially avoidable utilization and costs.
1 Sorenson C, Drummond M, Bhuiyan Khan B. Medical technology as a key driver of rising health expenditure: Disentangling the relationship. ClinicoEconomics and Outcomes Research, 2013:5 223–234.
2 American Academy of Ophthalmology Preferred Practice Patterns Committee. Preferred Practice Pattern Guidelines. Comprehensive Adult Medical Eye Evaluation. Ophthalmology. January 2016. Volume 123, Issue 1, Pages P209–P236.
3 American Association Ophthalmology. Choosing Wisely. Five things physicians and patients should question. February 21, 2013. Accessed at http://www.choosingwisely.org/clinician-lists/american-academy-ophthalmology-routine-imaging-for-patients-without-symptoms-or-signs-of-eye-disease/