In 2014, US health care spending reached $3 trillion, 17.5% of the nation’s gross domestic product.1 Overutilization of medical services, especially unnecessary or minimally beneficial tests or procedures, has been cited as a large contributor to the high costs of health care in this country.2 As a result, efforts to curb the use of low-value services (defined as services in which the potential for harm exceeds the possible benefit3) are gaining traction in the form of evidence-based guidelines and campaigns, such as Choosing Wisely, that compile lists of medical services of little to no value.4
Recent research suggests many adults receive low-value services. In total, 8% of fee-for-service Medicare beneficiaries 65 and older received at least 1 low-value service (of 20 measured) in 2008, whereas 25% received at least 1 low-value service (of 26 measured) in 2009.5,6 Use of low-value services has been found among commercially insured patients as well. A study among commercial health plan enrollees ages 18 and older found that utilization of only 2 of 7 low-value services studied decreased between 2010 and 2013.7 The exclusion of older adults and Medicare Advantage (MA) enrollees, however, are major limitations of these studies.5,6,8–11 Both age and greater use of managed care used by private plans could affect the use of low-value services.
The objective of this study was to analyze trends in utilization of 16 low-value services among commercial and MA enrollees 50 and older between 2009 and 2014, to determine if utilization decreased during a time of intense national and international focus on the problem of overutilization of medical services.12 In addition, we aimed to quantify the annual amount MA and commercial enrollees and plans spent on these low-value services.
Data Source and Study Population
We conducted a retrospective analysis of the OptumLab Data Warehouse, which includes deidentified claims data for privately insured and MA enrollees in a large, private, US health plan. The database contains longitudinal health information on enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States. The health plan provides comprehensive full insurance coverage for physician, hospital, and prescription drug services.13 Claims contained International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) diagnosis and procedures codes; Current Procedural Terminology procedure codes; Healthcare Common Procedure Coding System procedure codes; and place and date of service. Additional variables included sex, birth year, insurance type, and enrollment dates.
Our analysis sample included adults ages 50 and older with commercial insurance and adults ages 65 and older with MA and who were enrolled between 2009 and 2014. There were >4 million commercial enrollees 50 and older and ∼1 million MA enrollees 65 and older annually, with 11% and 77% increases enrollment in commercial and MA plans, respectively, from 2009 to 2014 (Appendix A, Supplemental Digital Content 1, http://links.lww.com/MLR/B464). Our 2014 sample included 1.6 million MA enrollees ages 65 and older, ∼10% of the total 2014 MA enrollment of 16 million,14 and 4.9 million commercial enrollees ages 50 and older, ∼7% of commercially insured adults 50 and older in the US.15 The health plan under study had very limited involvement in the Affordable Care Act (ACA), with <1% of commercial enrollees obtaining primary coverage through ACA exchanges in 2014. As this study involved analysis of preexisting, deidentified data, it was exempt from Institutional Review Board approval.
Low-value Service Measures
We identified 16 insurance claims-based measures of low-value services that have been previously studied so that we could replicate the low-value service definitions and compare our findings with previously published results.5,6 The services were categorized into 3 groups: (a) cancer screening; (b) diagnostic and preoperative imaging; and (c) invasive procedures (Table 1). The supplemental online content (Supplemental Digital Content 2, http://links.lww.com/MLR/B465) provides more detailed information about the inclusion and exclusion criteria for each measure.
In 2012, efforts to discourage the use of low-value services were launched by the American Board of Internal Medicine Foundation in the form of the Choosing Wisely campaign. The campaign has compiled a list of over 400 services identified by clinician specialty societies as potentially low value. Nine of the 16 low-value service measures studied are Choosing Wisely measures (Table 1). We included low-value services measures that were not included on Choosing Wisely lists because the lists are far from exhaustive, especially with respect to invasive measures, of which several are identified as ineffective or unnecessary.16 For example, we included the use of bone growth material in cervical spine fusion because the US Food and Drug Administration issued a public health alert in 2008 cautioning that this procedure was associated with life-threatening complications.17,18
Low-value Cancer-screening Measures
We measured 3 low-value cancer screenings: (a) colorectal cancer screening among adults older than 7519; (b) cervical cancer screening among women older than 6520; and (c) prostate-specific antigen (PSA) testing among men older than 75.21 We included only the cost on the service line of the claim that met the inclusion criteria for each low-value cancer-screening measure; we excluded all other costs on the claim.
Low-value Imaging Measures
We evaluated 6 low-value imaging measures among adults ages 50 and older: (a) electroencephalogram, computed tomography (CT), and/or magnetic resonance imaging (MRI) for syncope22; (b) CT and/or MRI for headache23; (c) MRI of the lumbar spine for low back pain24; (d) CT for acute sinusitis25; (e) preoperative chest x-ray among patients undergoing anesthesia26,27; and (f) preoperative echocardiogram among patients undergoing select surgeries.28 We identified the claim lines containing both the professional and technical components for each type of scan, excluding technical component costs in batch or bundled claims.
Low-value Invasive Procedure Measures
We evaluated 7 low-value invasive procedure measures among adults ages 50 and older: (a) laminectomy or spinal fusion for low back pain29; (b) vertebroplasty or kyphoplasty for osteoporotic vertebral fractures30–32; (c) hysterectomy for benign disease33,34; (d) nasal endoscopy for sinusitis; (e) renal artery stenting35,36; (f) peripheral artery stenting37; and (g) use of bone growth protein in cervical spine fusion.38,39 We included all fees for facility and professional services that were provided on the same day as the low-value service.
We calculated annual utilization rates from 2009 to 2014. Numerators and denominators were specific to each low-value service measure and depended on the inclusion and exclusion criteria in the supplemental appendix. Some measures were applicable to all enrollees ages 50 and older. The denominator for those measures included adults ages 50 and older enrolled in commercial or MA plans for the full measurement year. Other measures were limited to specific age groups or to groups with certain conditions. To be eligible for the numerator and denominator of measures with exclusion criteria, subjects were required to be continuously enrolled in a plan the year before the measurement year (ie, enrolled in 2008 to be included in 2009 measure) in addition to the measurement year. Certain rates were limited to 1 contribution per enrollee per year (denoted “per enrollee” in Table 1), whereas others included multiple episodes per enrollee in 1 year (denoted “per enrollee per claim” in Table 1).
We extracted allowable costs (combined amounts paid by patient and insurer) from each claim on the date of the low-value service. To reduce the effect of outliers, we trimmed the top and bottom 5% of costs separately for the commercial and MA samples. Average per service costs were calculated for each study year and annual spending was calculated by multiplying the number of enrollees receiving the service by the average service cost for that year.
The use of low-value services varied substantially based on the type of service, the level of invasiveness, and patient age and insurance coverage (Fig. 1). The most commonly performed low-value service was imaging of the head for syncope, at rates of 33%–39% in the commercial sample and 44% in MA. The least common service was peripheral artery stenting in commercial enrollees and laminectomy and renal artery stenting in MA enrollees. Utilization of renal artery stenting decreased by 75%–78%, representing the largest decrease over the 6-year study period. One measure, nasal endoscopy for sinusitis, increased among all groups.
Low-value Cancer-screening Measures
Low-value cancer screenings declined between 2009 and 2014, with the exception of colorectal screening among MA enrollees which remained unchanged at 7% (Table 2). Colorectal cancer screening was the most expensive low-value cancer screening, with 2014 spending averaging $401 per enrollee and $1.4 million in commercial plans and $240 per enrollee and $8.3 million in MA plans.
Cervical cancer screening among women over age 65 declined by 35% (10%–7%) among commercial enrollees and by 45% (18%–10%) among MA enrollees. Cervical cancer screening among women over age 65 was inexpensive (2014: $38 per MA enrollee; $32 per commercial enrollee) but was performed frequently, costing MA enrollees and plans $1.6 million in 2014. PSA testing among men over age 75 also decreased considerably: 51% (24%–12%) among commercial enrollees and 24% (27%–21%) among MA enrollees. PSA testing among men 75 and older was the least expensive service studied (2014: $18 in MA; $31 in commercial).
Low-value Imaging Measures
Five of 6 low-value imaging measures declined from 2009 to 2014, with the exception of imaging for headache among MA enrollees (Table 3). Imaging for headache was common, especially among MA patients (26% in 2009; 30% in 2014) and was responsible for the highest aggregate imaging costs in 2014 among commercial enrollees and plans ($12.1 million). Preoperative echocardiograms, which had low utilization rates (12%–13%) in 2009, declined by ∼7% among commercial enrollees and by 13% among MA enrollees by 2014. Despite this decrease, preoperative echocardiograms accounted for the largest MA spending on imaging in 2014 at $1.3 million. The most expensive imaging service was MRI for low back pain, with average 2014 costs of $673 per commercial enrollee and $237 per MA enrollee.
Among MA enrollees with syncope, imaging (electroencephalogram, CT, or MRI) occurred after nearly half (44%) of all syncope events. Imaging was less common but still prevalent among commercially insured patients, occurring during 33% of syncope events among those ages 50–64 and 37% of syncope events among those ages 65 and older in 2014. The largest decline was in preoperative chest x-rays, dropping by 27% and 21% among commercial enrollees ages 50–64 and ages 65 and older, respectively, and dropping by 13% among MA enrollees ages 65 and older.
Low-value Invasive Procedure Measures
Nasal endoscopy for sinusitis was the only low-value service that increased in all study groups, rising 18%–23% among commercial enrollees and 16% among MA enrollees (Table 4). Only 3 of 7 low-value invasive procedures decreased for all age groups and insurance types: renal artery stenting, use of bone growth material during cervical spine fusion, and vertebroplasty. Renal artery stenting, though already relatively rare in 2009 at 0.05%–0.22%, decreased by 75% among MA enrollees and by 78% among commercial enrollees by 2014. Bone growth material was used in 8%–10% of all cervical spine fusions in 2009; by 2014, those rates dropped to 4%–6%. This was the most costly low-value procedure, averaging $38,000 per commercial enrollee and $17,000 per MA enrollee in 2014.
Three low-value invasive procedures decreased among commercial enrollees ages 50–64 and ages 65 and older while increasing among MA enrollees: laminectomy for low back pain (−16% and −7% vs. +20%), hysterectomy for benign disease (−9% and −20% vs. +4%), and peripheral artery stenting (−16% and −6% vs. +1%). Laminectomy in commercial ($117.1 million) and peripheral artery stenting in MA ($33 million) had the highest total spending in 2014.
Spending on these 16 low-value services in 2014 totaled $418.4 million, $317.6 million, and $100.8 million for commercial and MA enrollees and plans, respectively. Total spending from 2009 to 2014 dropped 4% for cancer screenings ($12.7–$12.5 million) and 36% for imaging tests ($56.0–$35.8 million), while increasing by 11% for invasive procedures ($334.7–$370.4 million). Because of increases in health plan enrollment and rises in allowable costs over the study period, total spending increased despite drops in utilization for the majority of services.
Between 2009 and 2014, utilization of low-value services among older adults declined for the majority of services studied. Only 1 low-value service, nasal endoscopy for sinusitis, increased among all groups examined, whereas 5 services (colorectal cancer screening in adults over age 75, imaging for headache, laminectomy, hysterectomy for benign disease, and peripheral artery stenting) increased among MA enrollees despite decreasing among the commercially insured.
The services we studied varied widely in terms of frequency, cost, and invasiveness. The Choosing Wisely campaign includes many “low-impact” services,16 whereas some lucrative services of questionable benefit, such as vertebroplasty,31 are omitted. Choosing Wisely brings the issue of overtreatment to the attention of policymakers and researchers, but awareness of the campaign among physicians is low and, moreover, awareness alone does not ensure changes in physician behavior.40 Robust scientific evidence is needed to support the recommendations, without which physicians may be unwilling to change practice patterns.41 Encouragingly, our results suggest physicians respond to scientific evidence promptly in certain cases. For instance, a study published in November 2009 showed that renal artery stenting did not provide worthwhile clinical benefit over medical therapy.36 Our data show that by 2014 the use of renal artery stenting, which is not a Choosing Wisely measure, dropped by ∼75% from 2009 rates.
The discrepancies we found in low-value service utilization rates between MA and commercial enrollees may be due, at least in part, to differences in age and case mix of these cohorts. For instance, higher utilization rates among MA plans are most likely due to MA plan enrollment of older, less healthy retirees compared with commercial plans enrollees who are typically younger and employed.42 Even though our data were derived from a single large private insurer, differences in benefit design among plans (eg, cost sharing and coverage criteria) could also account for differences in utilization rates. Differences in practice patterns among physicians who treat predominantly MA or commercial enrollees could also account for differences in low-value service use.
Some of our results were comparable with previous studies of low-value service utilization, conducted mostly among fee-for-service Medicare beneficiaries (Appendix B, Supplemental Digital Content 3, http://links.lww.com/MLR/B466). For example, in our sample, 6.7% of MA enrollees over 75 were screened for colorectal cancer in 2009, whereas Schwartz et al6 reported 7.7% of fee-for-service Medicare beneficiaries over 75 were screened in 2009. In other cases, our low-value service utilization rates diverged dramatically from previously published estimates. For instance, chest x-rays were performed before 12.8% of select surgeries among MA enrollees 65 and older in our 2009 sample, whereas others report rates of preoperative chest x-rays ranging from 21.9% in 2008 to 1.6% in 2009, respectively, among fee-for-service Medicare beneficiaries.5,6 Rosenberg et al7 found that low-value preoperative chest x-rays were performed on over 90% of commercial enrollees 18 and older between 2011 and 2013. Although factors like differences in demographics, case mix, and benefit design may also explain some of discrepancies between our findings among MA enrollees and previously published estimates from Medicare fee-for-service, variations in low-value service utilization rates in the literature are also attributable to differences in service definitions. For preoperative chest x-ray, for instance, Schwartz et al6 excluded patients with certain major procedures (as did we), whereas Segal et al5 excluded only patients with respiratory conditions, thereby including substantially more cases. Such inconsistencies underscore the need for consensus on the criteria for quantifying inappropriate use of medical services. Some researchers have proposed validating claims-based measures of low-value services with clinical data from electronic health records (EHR).6 The addition of EHR data to the development of measures of low-value services, however, may still not allow researchers to reliably and accurately identify low-value service utilization. Although particular services may be considered low-value on a population level, a service may be considered high-value in certain clinical circumstances. Even more troubling than the lack of agreement on the definitions of low-value services, is the lack of consensus as to what constitutes a low-value service at the patient level.
Experts have speculated that $226 billion of US health care expenditure is attributed to the use of low-value services annually,43 but the true financial burden is unknown. Although estimates of annual spending on low-value services may amount to billions of dollars, $1.2 billion (for 11 services)10,11 to $8 billion (for 26 services) in fee-for-service Medicare6 and $32 million (for 28 services) in a commercial sample,9 the researchers noted that these costs represented <1% of total annual spending. The services included in these studies only account for a small proportion of hundreds of potentially low-value services. Our study shares this limitation. The 16 low-value services we examined cost about $418.4 million ($317.6 million in commercial; $100.8 million in MA) in allowable costs in 2014. Moreover, increases in allowable costs from 2009 to 2014 offset potential savings from decreased utilization of the majority of low-value services we studied.
Using coverage and payment policies to discourage low-value service use has been suggested as 1 way to reduce waste in the health care system. However, it would not be in the interest of patients or insurers to introduce blunt policy tools, such as physician performance ratings based on low-value service use, to discourage inappropriate care that may inadvertently discourage appropriate use.44 Thus, as others have suggested, it seems premature to base insurance payment or coverage policy on low-value service use.12 Before policy tools can be useful, agreement is needed on which low-value services should be targeted so as to have the greatest impact on reducing waste.
The interventions that have shown the greatest likelihood of reducing utilization of low-value services are those that address both the patient and the provider.45 Clinical decision support is 1 strategy that has been effective at reducing low-value care at the point of contact.45 Shared-decision making, in which patients and physicians work together to choose an appropriate course of care, has the potential to move practice patterns in the right direction if physicians are taught how best to communicate risks and benefits to patients. Disseminating best practices in clinical decision support and shared-decision making could improve alignment between scientific evidence, treatment options, and patient values.
To minimize misclassification and err on the side of underestimation, we used conservative measures of overuse and costs. However, given the limitation of insurance claims data to accurately measure the appropriateness of medical care, it is possible that we may still have categorized cases of appropriate care as low value. Broader, more sensitive measures would have increased our utilization rates and cost estimates but would have miscategorized a larger share of appropriate care. Confirmation of our claims-based findings with detailed EHR data may provide more insight into which cases were indeed of low value. However, the benefits of adding EHR data are likely overestimated as different patients and physicians may reach disparate treatment decisions based on shared-decision making.
Our findings among adults ages 50 and older in the OptumLabs Data Warehouse may not be generalizable to the national commercially insured and MA populations. It is also important to recognize that our results focused on only 16 medical services. Because many more low-value services have been identified, the costs associated with additional low-value services would be substantially higher than our estimates. In addition, significant economic costs may be associated with potentially unnecessary “downstream” follow-up care following a positive screening test. For instance, the cost of PSA screening tests may account for only about 2% of the lifetime costs associated with PSA screening.46 Our cost estimates would be substantially greater if costs associated with follow-up treatments had been included. On the flip side, however, underuse of appropriate prevention and screening measures may lead to increased use of downstream services.
Finally, it was beyond the scope of this paper to determine which factors were the drivers of utilization trends we found. Nor were we able to determine why certain measures decreased in commercial enrollees while increasing among MA enrollees. Such differences could be the results of changes in benefit design, such as higher patient cost sharing, or changes in practice patterns, which may or may not be due to evidence-based guidelines or low-value lists.
Reducing the utilization of low-value services in the United States may improve health outcomes and save patients and insurers billions of dollars. Clinicians, researchers, and policymakers should strive to reach consensus on methods for more reliably and accurately identifying low-value service utilization. Greater consistency would facilitate monitoring use of low-value services and changing clinical practice patterns over time. In the meantime, interventions that encourage discussion between patients and providers, such as clinical decision support and shared-decision making, offer useful tools to help reduce low-value care while still ensuring appropriate care is not withheld from patients who would benefit.
The authors thank Henry (Joe) Henk, PhD, OptumLabs, who provided assistance with analysis and interpretation of the data. He did not receive compensation for his contributions.
1. Centers for Medicare and Medicaid Services. National Health Expenditures 2014 Highlights. 2015.
2. Emanuel EJ, Fuchs VR. The perfect storm of overutilization. JAMA. 2008;299:2789–2791.
3. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on Health Care Quality. JAMA. 1998;280:1000–1005.
5. Segal JB, Bridges JF, Chang HY, et al. Identifying possible indicators of systematic overuse of health care procedures with claims data. Med Care. 2014;52:157–163.
6. Schwartz AL, Landon BE, Elshaug AG, et al. Measuring low-value care
in Medicare. JAMA Intern Med. 2014;174:1067–1076.
7. Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely Campaign. JAMA Intern Med. 2015;175:1913–1920.
8. Charlesworth CJ, Meath TH, Schwartz AL, et al. Comparison of low-value care
in medicaid vs. commercially insured populations. JAMA Intern Med. 2016;176:998–1004.
9. Reid RO, Rabideau B, Sood N. Low-value health care services in a commercially insured population. JAMA Intern Med. 2016;176:1567–1571.
10. Colla CH, Morden NE, Sequist TD, et al. Choosing wisely: prevalence and correlates of low-value health care services in the United States. J Gen Intern Med. 2015;30:221–228.
11. Colla CH, Morden NE, Sequist TD, et al. Erratum to: Choosing Wisely: prevalence and correlates of low-value health care services in the United States. J Gen Intern Med. 2016;31:450.
12. Elshaug AG, McWilliams JM, Landon BE. The value of low-value lists. JAMA. 2013;309:775–776.
13. OptumLabs. OptumLabs and OptumLabs Data Warehouse (OLDW) Descriptions and Citation. Cambridge, MA: 2017. n.p. (PDF. Reproduced with permission from OptumLabs).
15. Smith J, Medalia C. Health Insurance Coverage in the United States: 2014. United States: Census Bureau; 2015.
16. Morden NE, Colla CH, Sequist TD, et al. Choosing wisely—the politics and economics of labeling low-value services. N Engl J Med. 2014;370:589–592.
17. FDA. FDA public health notification: life-threatening complications associated with recombinant human bone morphogenetic protein in cervical spine fusion. 2008.
18. Epstein NE. Complications due to the use of BMP/INFUSE in spine surgery: the evidence continues to mount. Surg Neurol Int. 2013;4 (suppl 5):S343–S352.
19. Whitlock EP, Lin JS, Liles E, et al. Screening for colorectal cancer: a targeted, updated systematic review for the US Preventive Services Task Force. Ann Intern Med. 2008;149:638–658.
20. Vesco KK, Whitlock EP, Eder M, et al. Risk factors and other epidemiologic considerations for cervical cancer screening: a narrative review for the US Preventive Services Task Force. Ann Intern Med. 2011;155:698–705. W216.
21. Lin K, Lipsitz R, Miller T, et al. Force USPST. Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the US Preventive Services Task Force. Ann Intern Med. 2008;149:192–199.
22. Task Force for the Diagnosis and Management of Syncope, European Society of Cardiology (ESC), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA), Heart Rhythm Society (HRS), Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J. 2009;30:2631–2671.
23. Douglas AC, Wippold FJ, Broderick DF, et al. ACR Appropriateness Criteria Headache. Reston, VA: American College of Radiology; 2013.
24. Chou R, Fu R, Carrino JA, et al. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009;373:463–472.
25. Cornelius RS, Martin J, Wippold FJ 2nd, et al. ACR appropriateness criteria sinonasal disease. J Am Coll Radiol. 2013;10:241–246.
26. Joo HS, Wong J, Naik VN, et al. The value of screening preoperative chest x-rays: a systematic review. Can J Anaesth. 2005;52:568–574.
27. Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012;156:147–149.
28. American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, Douglas PS, Garcia MJ, Haines DE, et al. J Am Coll Cardiol. 2011;57:1126–1166.
29. McConnell CT, Wippold FJ, Ray CE, et al. ACR Appropriateness Criteria Management of Vertebral Compression Fractures. Reston, VA: American College of Radiology; 2013.
30. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361:557–568.
31. Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361:569–579.
32. McCullough BJ, Comstock BA, Deyo RA, et al. Major medical outcomes with spinal augmentation vs conservative therapy. JAMA Intern Med. 2013;173:1514–1521.
33. Alternatives to hysterectomy in the management of leiomyomas. Washington, DC: American College of Obstetricians and Gynecologists (ACOG). ACOG practice bulletin; no. 96. 2008.
34. Management of abnormal cervical cancer screening test results and cervical cancer precursors. Washington, DC: American College of Obstetricians and Gynecologists (ACOG); ACOG practice bulletin; no. 140. 2013.
35. Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370:13–22.
36. Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med. 2009;361:1953–1962.
37. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45 (suppl S):S5–S67.
38. Chrastil J, Low JB, Whang PG, et al. Complications associated with the use of the recombinant human bone morphogenetic proteins for posterior interbody fusions of the lumbar spine. Spine (Phila Pa 1976). 2013;38:E1020–E1027.
40. Gonzales R, Cattamanchi A. Changing clinician behavior when less is more. JAMA Intern Med. 2015;175:1921–1922.
41. Howard DH, Gross CP. Producing evidence to reduce low-value care
. JAMA Intern Med. 2015;175:1893–1894.
42. Newhouse JP, Price M, Huang J, et al. Steps to reduce favorable risk selection in medicare advantage
largely succeeded, boding well for health insurance exchanges. Health Aff (Millwood). 2012;31:2618–2628.
43. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307:1513–1516.
44. Request for information regarding implementation of the merit-based incentive payment system, promotion of alternative payment models, and incentive payments for participation in eligible alternative payment models. Vol 80 (190): Federal Register; October 1, 2015:59102–59113.
45. Colla CH, Mainor AJ, Hargreaves C, et al. Interventions aimed at reducing use of low-value health services: a systematic review. Med Care Res Rev. 2016;74:507–550.
46. Shteynshlyuger A, Andriole GL. Cost-effectiveness of prostate specific antigen screening in the United States: extrapolating from the European study of screening for prostate cancer. J Urol. 2011;185:828–832.