Assessing social values for California's efforts to reduce the overuse of unnecessary medical care

Abstract Background A partnership of large health‐care purchasers created a workgroup to reduce the overuse of harmful and wasteful medical care in California. Objective Employ a civic engagement process to identify the social values important to the public in considering different strategies to reduce overuse. Intervention Use of deliberation techniques for 3 case examples that explore possible strategies: physician oversight, physician compensation, increased patient cost‐sharing or taking no definitive action. Results Five themes were identified, including strong support for physicians’ leadership role to reduce overuse; nuanced enthusiasm for increasing patient cost‐sharing to discourage excessive demand; and marked disapproval of physician compensation as a motivator. Conclusion Most but not all of the perspectives voiced by participants are congruent with efforts to reduce overuse that is being initiated or discussed at the state, provider and health plan level. As health‐care policymakers and leaders consider more targeted approaches to reducing overuse, these findings will inform decision‐making.


| INTRODUCTION
The excessive use of unwarranted medical care has concerned health-care and policy leaders for many years. Policy experts contend that up to 30% of health-care dollars in the United States is inefficiently used, and a good proportion is linked to the overuse of unnecessary, harmful and/or wasteful medical care. [1][2][3] Health advocates increasingly aim to engage and activate consumers and communities in improving the health and health care of individuals and populations. 4 A significant aspect of this engagement is the use of medical evidence to inform and motivate actions that promote high-quality, affordable care. 5 Approaches for reducing overuse often reduce access to certain medical services, which may be alarming to those who equate more care with better care or are concerned about interference with doctor-patient decisions. The evolving health-care landscape calls for greater participation by the public to help specify the principles for attaining high-quality care as well as responsible use of resources. 6 Social values assessment is distinct from patient preferences. Most patient decisions concern the clinical care their physicians recommend, such as tests, treatments or procedures. The factors patients consider in deciding to accept or reject recommended individual care are an important aspect of patient-centered research. 7 However, when individuals are asked as citizens to consider broader health-care policy issues in which many people will be affected, their focus expands beyond their personal interests to weighing the economic, social and ethical impacts on the larger community in terms of collective, societal values. 8 Potential strategies to reduce overuse may threaten aspects of health-care delivery that the public highly values, such as physician autonomy or patient choice. Physicians' central role in the prevalence of overuse 9 suggests that patients' implicit trust in physician expertise may sometimes be misplaced. This discrepancy prompts such ques- Care California's overarching plan includes a deliberative process to capture the views of the lay public. 10 While California has long demonstrated efforts to identify the public's perspective on challenging health policy issues, 11,12 this was the first time that state policy leaders incorporated a social values assessment into their work plan.
Consequently, as part of this partnership, the Center for Healthcare Decisions (CHCD)-a non-profit specializing in civic engagement in health-care policy-developed Doing What Works (DWW), using a non-partisan, carefully structured qualitative process called public deliberation. 13 This article identifies themes resulting from DWW that are central to the public's views on reducing overuse of medical care and illustrates how these themes are consistent with or diverge from existing and proposed health-care policy.

| Methods design
This deliberative process asked the public to help address the problem of overuse by recognizing that they are responding as citizen decision makers providing input to policy decisions; considering the impact of overuse on society at large; and debating why various resolutions to the problem are more acceptable than others. 6

| Recruitment and sample
Experienced, non-partisan facilitators led 10 DWW sessions, each lasting 4 and a half hours, in 6 communities, urban and rural, across California. Five groups consisted of Medi-Cal members; 4 groups included individuals who purchased insurance through Covered California; and one group of individuals was insured through CalPERS. These groups were chosen because they are insured members of the project sponsors. To establish commonality among the groups, all participants would be low-to-moderate income individuals, those most likely to be sensitive to higher cost-sharing or reduced coverage. 1 Professional recruitment companies and community-based organizations recruited the 117 participants. Inclusion criteria were limited to individuals between the ages of 30 and 60 years to capture the perspectives of those who are more likely to have had experience interacting with their health-care system and are not on Medicare. Each participant received a $200 incentive to participate. Table 1 shows the demographics of the participants. 1 All Covered California and CalPERS participants had an annual income below 400% of the Federal Poverty Level (FPL), and all Medi-Cal participants had an annual income below 138% of the FPL-a requirement to qualify for this program.

| Ethics
The California State University, Sacramento Institutional Review Board approved this project (IRB 14-15-126).

| Data collection
During each session, participants completed a pre-and post-survey to capture demographic data as well as assess and determine shifts in beliefs and attitudes regarding the use of evidence to inform treat- a The percentages are determined by the number of votes for this strategy divided by the number of potential votes (number of participants, 117, times the number of scenarios, either 2 or 3, where the strategy was available.) The total percentages sum to greater than 100% because participants could choose more than one strategy for each case scenario.

| Physician leaders are responsible for resolving the overuse problem
Across all 3 scenarios, monitoring of physicians by physicians was chosen by 72% of the participants, far more often than the other strategies. The key rationale is that physicians must be in control of instituting their own corrective actions. Although participants were concerned about administrative burden, few doubted that the task of reducing overuse rested with the medical profession. Participants were willing to overlook the administrative burden if corrective action is the most effective, retrospective review is a fairer approach than pre-approvals, and physicians were willing to judge and be judged by each other.

| Monetary incentives are inconsistent with medical professionalism
Only 5 participants supported the option of rewarding physicians for reducing overuse (a strategy offered in 2 of the scenarios), representing 2% of the total votes. There was almost universal opposition to paying doctors more for "doing what they should be doing." Many saw this approach as contrary to medical professionalism that purports to embrace standards of excellence and allegiance to patient well-being and not the self-interests of practitioners. 16 Rewarding doctors to improve their performance seemed demeaning for a profession the participants hold in such high regard. Participants believed that doing their best for their patients, not increasing their income, must motivate doctors.
Interestingly, with 23% of the votes, participants were more accepting of the strategy not to compensate doctors for chronic overuse. While most felt strongly that physicians' treatment decisions should not be tied to compensation in any way, the Caesarean birth example indicated that the overuse problem in California is largely driven by physicians and hospitals and not by patients. It appears that this fact (and the cost and number of unnecessary procedures) elicited atypical enthusiasm for denying provider payments.
However, the majority still preferred using strategies that relied on medical professionalism.

| Higher patient cost-sharing may be justified to maintain freedom of choice
The option to increase patient cost-sharing for unnecessary interven-

| Responsible use of shared resources dominated the discussions
Although each case scenario emphasized medical harms (individual and, at times, societal), participants tended to focus almost exclusively on the waste of communal resources as a motivator for action. These low-to-moderate income Californians seemed acutely aware of increased health-care costs and the impact this has on the services they receive. While many were aware of and alarmed by the problem of antibiotic resistance and its impact on society at large, the statistics associated with the individual harms of unnecessary Caesarean births and MRIs did not resonate with participants.
Their concern about wasting societal resources, however, was not limited to overuse, per se. The strategies that are intrusions into independent doctor-patient decision-making must be justified by evidence that these strategies are, in fact, effective in reducing waste.

| The citizen voice is not the same as the patient voice
Participants made it clear that their views reflected the role they were asked to assume as follows: that of policymaker, not of patient. Many stated, " if I am responding as a patient, I would take no action and continue to leave it to the doctor and patient to decide." Conversely, they acknowledged that as a citizen decision maker, they were responsible to many more people and most endorsed actions that might, in fact, hamper the doctor-patient autonomy that they, as patients, preferred.
There was considerable discussion on the need for more education to help both patients and the general public fully understand the problems of overuse. Educating patients in the context of their own medical care must be matched by a broader societal emphasis on financial and medical harm.

| Implications for policymakers
In reviewing the DWW results and themes that emerged, health-care leaders were especially interested in how the findings are congruent with and/or depart from existing strategies to reduce overuse. As Smart Care California develops and implements approaches to reducing overuse, the DWW findings can help inform their activities and decision-making. The following describes some of the overuse strategies now being used.

| Reduce overuse through physician-led efforts
As noted earlier, participants regard these clinical decisions as ones "belonging to the profession" and thus, it is the profession that must remedy problems among its members.
This perspective is consistent with and widely endorsed by state and national initiatives. [18][19][20] Most visible is Choosing Wisely ® , a national programme sponsored by the American Board of Internal Medicine Foundation in partnership with more than 75 national medical societies. 21 CW believes that changing physician practice must be grounded in professionalism with actions that the profession itself must determine and control; it rejects the policy of non-payment or lowering compensation to change practice patterns. 21 Nationally, the launch of CW has modestly decreased overuse of key low-value services. 22 Hospitals in California have initiated programmes that focus on physicians working with their colleagues to improve practices. 10 For example, Cedars-Sinai Health System incorporated 26 of the CW specialty society campaign recommendations into its electronic medical records system using alerts to physicians when they order an overused intervention. The number of electronic medical record alerts specific to unnecessary imaging was significantly reduced over an 18-month period and they estimate that together all CW alerts saved their health system $200,754 in unnecessary services over a 6-month period. 23 In an effort to broaden CW initiatives, 2 medical groups, a physician organization and a consumer group collaborated to integrate CW recommendations into clinical practice. These medical groups began tracking and reporting site-level change to clinicians over time on imaging for uncomplicated headache to provide comparative performance feedback. 24

| Influence physician practices through reduced compensation
DWW participants only marginally supported reducing compensation for physicians who consistently prescribe low-value care, but were more inclined to do so for unnecessary C-sections. In

| Influence physician practices through increased compensation
Of all the strategies proposed, this one elicited the strongest opposition from DWW participants with only 2% of participants supporting this option.
Ironically, California has been a long-standing leader in Pay-for- The jury may still be out on whether physician practices can be meaningfully influenced through professionalism alone or whether financial motivation-sticks or carrots-is needed.

| Reduce patient demand by increasing patient cost-sharing for unnecessary care
With 26% of the votes, this strategy was not a dominant one in DWW.
Those who supported it did so because it retained patient authority, even over ineffective and harmful medical treatment. Patient choice is a long-standing, well-engrained value in American health care. 28 California policymakers have indicated interest in ways to reduce patient demand for unnecessary care 10 but to date, the practice of charging patients more for low-value care has been used sparingly. 29

| Increase the visibility of low-value care, its harms and costs
Participants conveyed their strong support for disseminating more information to patients and to consumers in general about the harms and costs of unnecessary care.
There is a growing volume of patient materials about the harms associated with the use of unnecessary medical care. Although CW has included some information in its patient-facing materials about wasting resources, 21  Health-care policymaking typically involves 4 major groups: purchasers, health plans, regulators/legislators and providers.
The findings from DWW suggest value in including another stakeholder group: the informed citizen. Just as purchasers and providers have different priorities and perspectives, DWW illustrates that citizens approach the problem of overuse from distinct vantage points.

| Limitations
The sample size of 117 lower-to-moderate income California residents does not necessarily represent the views and values of the state's population at large. The overrepresentation of females does not reflect the population, but it is common and often expected in social research studies." 34 The problem of overuse is complex and longer deliberation on the topics of evidence-based medicine and the meaning of value-based health care might generate different results.

| CONCLUSION
Most of the perspectives voiced by the DWW participants are congruent with efforts to reduce overuse that are being initiated at the state, provider and health plan level. The public's disapproval of programmes that reward doctors for good quality care suggests that consumerfacing communications should focus on recognition of excellence rather than monetary rewards. Increasing patient cost-sharing to maintain patient choice without jeopardizing shared resources is appealing to many but not feasible to implement in Medicaid. The lay public also shares the concern of many medical professionals on the ethics of prescribing unneeded, potentially harmful care, regardless of who is paying.
Civic deliberation of complex health-care topics is not a common practice in the US. Yet, as long as health-care reform continues to focus on cost containment policies, the public voice will play an important role in balancing the tension between cost and benefit.
Harmonization of evidence-based practices, responsible use of resources and patient preference is not easily achieved. Future research on public values might explore more closely how to best reconcile these often-conflicting values.