Health Insurance Medicare

Avoiding unnecessary care: Does insurance coverage matter?

Consumer Reports‘ “Choosing Wisely” initiative aims to identify high-cost, low-value treatments that can often be avoided.  One question remains is why do providers still offer these services?  Do payer coverage policies or reimbursement rules affect these choices?

A paper by Colla et al. (2017) attempts to answer that question.  The authors used commercial payer claims data from the Health Care Cost Institute (HCCI) and Medicare administrative data to examine whether the use of low-value care is similar between Medicare and commercially insured populations within a hospital-referral region (HRR).  Both data sets covered the period 2009 to 2011.  The low-value measures of interest included: “imaging for back pain, vitamin D screening for low-risk patients, cervical cancer screening for patients over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval dual-energy X-ray absorptiometry (bone density) testing, preoperative cardiac testing in low-risk patients preceding low-risk (noncardiac) surgery, and a composite of these.”

The authors found that these low value services were provided fairly frequently.  About one in ten women over age 65 received a cervical cancer screening, but preoperative cardiac testing before low-risk noncardiac surgery occurred in 1 in 4 eligible commercially-insured patients patients and almost 1 in 2 insured patients that had surgery.  This reflects either that physicians are providing too much low-value care, or that Choosing Wisely’s conception of what low-value care is does not meet the definition of patients, physicians and/or payers.

Regarding the geographic variation in use of low-value services, the authors find the following:

We find a high correlation between overuse in the Medicare and commercially insured populations across HRRs (ranging from 0.54 to 0.90). The tendency to deliver or avoid low-value care appears largely independent of payer type (Medicare or commercial) and patient population attributes.


In short, it is likely that provider treatment practices rather than differences in payer policies drive use of these “low value” services.  Because many commercial plans follow Medicare policy and physicians likely treat most insured patients similarly regardless of the type of insurance, this finding should not be entirely surprising.


1 Comment

  1. Does this actually show that providers are the driver? It could be that there isn’t that much variation in policy. Could this not have something to do with state regulations that require insurers to cover “medically necessary” care and insurers unwillingness to reject claims due to the broad definition that courts seem to hold of “medically necessary”?

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