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Business of Pathways

Eliminating Low-Value Health Care: Where Pathways Approaches Have Succeeded

Authored by

Ira Klein, MD, MBA, FACP—Column Editor


Healthcare Quality Strategy, Strategic Customer Group, Janssen Pharmaceuticals, Titusville, NJ


Dr Klein owns stock in Johnson & Johnson and Aetna, Inc.


J Clin Pathways. 2019;5(2):24-27. doi:10.25270/jcp.2019.02.00058

Low-value health care continues to put stress on the US economy, as 20% to 40% of all health spending is designated as wasteful. To date, there have been few broad and sustained efforts to reign in wasteful spending. One reason may be that health care is late in developing industrial process control mechanisms when compared with other industries. Pathways represent a method to attack low-value health care waste. The Institute for Healthcare Improvement and others have shown that a mechanistic problem-solving approach, codified in pathway-like modules, can be successful. Recently, the precepts of the Choosing Wisely campaign have been utilized by the Low Value Waste Task Force to focus employers on health care waste interventions. Tools that can be used as pathways are part of this initiative, framing the problem as an industrial process control issue. Pathways, along with effective employer payer mobilization, can be a major step to reducing wasteful health care spending, leaving funds for productive innovation and technology.  

Low-value health care, defined as treatment and testing that exposes patients to costs, harms, and risks that outweigh any benefits conferred based on the clinical situation, costs the United States between $158 and $226 billion (2011 dollars) annually.1 Wasteful clinical care drives much of the inefficiency in the US health care system. Estimates of wasteful spending range from approximately 20% to 40% of all US health spending.2 Much of this waste harms patients; all of it harms purchasers’ bottom lines; and no American benefits when money is wasted that could be put to more valuable ends, including medical care and medical innovation.3

Frameworks exist to manage low-value health care, yet it continues to defy systematic resolution. Every segment of the US health care system has assessed the problem from its own business perspective—payers, providers and delivery systems, pharmaceutical and medical device manufacturers, pharmacy benefit managers and group purchasing organizations. These organizations agree on 2 things: that there is a lack of aligned incentives and regulatory harmony in the US health care ecosystem, and that the problem is someone else’s fault. The ways in which other industries identify and manage waste in the context of specific alignments and governance could inform a path forward for health care. For example, health care can learn from the way manufacturing has, over time, improved processes, raised productivity, and eliminated waste. The American worker in manufacturing today continues to improve in productivity year over year (the effects of the Great Recession notwithstanding). Today, the Bureau of Labor Statistics Index of Labor Productivity for manufacturing is two and a half times higher than it was in 1987.4 The increase reflects several factors: greater investment in new machinery; an increase in worker training and skills; and process streamlining and improvement. 

We should seek to not only understand how other industries identify and eliminate useless and low-value spending but also look within health care to see where early adopters of innovative strategies are succeeding.  

What We Can Learn From Current Efforts to Reduce Waste

Current efforts at waste reduction in the US health care system have been making important first steps, yielding best practices in some cases and important lessons for the future. Some have led to meaningful changes in hospital processes. 

Institute for Healthcare Improvement (IHI) Codifies “Do no Harm”

IHI codified changes to hospital processes affecting infections, adverse drug events, and other complications that hospital patients endure. Launched December 2006, the IHI “5 Million Lives Campaign” built upon the success of the “100,000 Lives Campaign” in which 3100 participating hospitals reduced inpatient deaths by an estimated 122,000 in 18 months through overall improvement in inpatient care.5

The hallmark of the IHI campaign was a set of protocols that incorporated pathways. These pathway-style protocols are discrete ways of working to manage inpatients at high risk for highly morbid or fatal events, often across short time horizons. It requires identification and avoidance of preventable errors using standardization of best practices and processes that require precision and clinical skill. Such capabilities include: deployment of rapid response teams for patients at the first sign of cardiac or respiratory decline; protocols for evidence-based, step-wise, team-based care of myocardial infarction; central line placement (to prevent infection); surgical wound care (to prevent infection); mechanically ventilated patients (to prevent infection), and prevention of adverse drug event through medication reconciliation at care transitions. In addition, pre-built root cause analyses allow small teams to optimally manage critically ill patients in an acute care environment filled with complexity, communication and documentation challenges, and resource and time constraints.

Notably, the pathway-style protocols utilized by hospitals succeed by using industrial management science process control: problem identification, alternative generation, and, finally, choice of the best evidence-based alternative. Broadening these learnings has led to the adoption of best practices throughout the hospital industry. Today, these best practices are hardwired into daily operations. They are tangible and measurable, and they are aligned to diagnostic related grouping payment mechanisms and Centers for Medicare & Medicaid Services (CMS) quality measurement. 

National Quality Forum (NQF) Targets Unnecessary Care

Encompassing more than hospital care, the NQF in 2010 convened a National Priorities Partnership (NPP) to improve health care across all settings, including attention to low-value health care in the form of overuse of care. This came in response to a request for proposal from the Department of Health and Human Services, seeking a better way to manage care and more affordable care, resulting in healthier people/healthier communities.  

The 6 areas of focus were: Patient and Family Engagement, Safety, Care Coordination, Palliative and End-of-Life Care, Elimination of Overuse, and Population Health.6 NPP targeted the following specific areas: inappropriate medication use, unnecessary lab tests, unwarranted maternity care interventions, unwarranted diagnostic procedures, unwarranted procedures, unnecessary consultations, preventable emergency department visits and hospitalizations, inappropriate nonpalliative services at end of life, and potentially harmful preventive services with no benefit. All these areas are amenable to some form of evidence-based guidelines, pathways, or “playbooks.” Since 2010, each of these areas of focus have received additional attention and scrutiny, but none have created system-wide changes to reliably eliminate the low-value care within their scope of work. Maternity care in the form of unnecessary C-sections has made significant progress in the form of hospital-level benchmarking, and CMS has implemented programs scrutinizing readmission rates, but these are not complete fixes to the problems.

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