When a patient arrives in the doctor’s office with back pain, it’s become routine for some clinicians to immediately order an MRI, even when established guidelines don’t recommend imaging.
A prescription for opioids to manage the pain often follows.
According to a recent initiative by the Virginia Center for Health Innovation, similar patterns of unnecessary treatments have become ingrained across healthcare, driving up costs for patients and health systems.
But the center found it’s possible to change old habits. By the end of the initiative, which involved health systems across the state, patients experienced a 10.4% relative reduction in the likelihood of receiving unnecessary services, compared with patients in 12 control health systems.
The difference was statistically significant, and researchers this week published the findings in JAMA Internal Medicine, a peer-reviewed medical journal.
“I still have to pinch myself a little bit,” Beth Bortz, the center’s president and CEO, said during a Zoom interview on Friday.
Bortz launched the project in 2019, using insurance claims data and analytical tools to identify tests and procedures that providers might use more often than medically necessary.
She then worked with six major health systems in Virginia to measure how often patients received those services without a clear medical need. The health systems then worked to reduce the use of those procedures.
The results suggest that health systems can reduce unnecessary care without compromising patient safety — an important consideration for health leaders seeking to change long-established medical practices, according to Bortz.
Changing those practices can be difficult, particularly when protocols become habit across large healthcare systems.
Targeting nine commonly overused services
The participating health systems were Ballad Health, Carilion Clinic, HCA Virginia and Virginia Care Partners, Inova and Signature Partners, Sentara and Sentara Quality Care Network, and VCU Health System. Three sister networks also participated.
Together, the organizations represented about 4.5 million patients, more than 900 practice sites and 7,000 clinicians in one of the largest statewide efforts to reduce unnecessary care in U.S. history, according to a release from the Virginia Center for Health Innovation.
To start the project, Bortz’s team selected the nine most overused procedures: diagnostic imaging and opioids for acute back pain; preoperative lab work, imaging and cardiac testing; electrocardiogram/cardiac screening and cardiac stress testing; advanced diagnostic eye imaging; and peripherally inserted central catheter lines for patients with chronic kidney disease.
Bortz described these procedures as “low-hanging fruit” because most clinicians agree they are overused or can cause unnecessary harm to patients. Since her goal was simply to encourage change, she was comfortable starting with those measures.
The initiative did not require health systems to address all nine measures. Instead, each organization chose which areas to prioritize, giving clinicians a voice in the changes they pursued. The center also gave each participating organization $30,000 to establish a clinical leadership team that would work on the research initiatives.
Roanoke-based Carilion focused on imaging for low-back pain and the use of opioids to treat it.
[Disclosure: Carilion is one of our donors, but donors have no say in news decisions; see our policy.]
“It’s very important to understand how clinically nuanced this stuff is,” Bortz said. “It’s not that imaging for low back pain is never warranted.”
For example, a patient who reports back pain and unexplained weight loss may need an MRI sooner because those symptoms can indicate cancer. In that situation, early imaging is medically appropriate and would not have been classified as unnecessary by the study’s algorithm, said Michelle Rockwell, who led Carilion’s work on the project.
The distinction matters because reducing unnecessary care doesn’t mean withholding treatment when a patient needs it.
Rockwell said that unnecessary medical procedures sometimes have a cascading effect. An MRI ordered without a clear medical indication might reveal an unrelated abnormality, prompting further imaging, procedures or even surgery that the patient might not otherwise have needed.
How the initiative began
The American Board of Internal Medicine launched its Choosing Wisely campaign in 2012 to address the overuse of medical tests and procedures. The campaign encouraged physicians and patients to question whether certain services were necessary and to make more informed decisions about care.
Dozens of professional societies, including the American Academy of Family Physicians, joined the effort and developed lists of common medical practices that clinicians and patients should reconsider.
Around that time, Milliman, a global independent actuarial and consulting firm focused on healthcare, life insurance and other industries, created the Health Waste Calculator, which uses insurance claims data to identify potentially unnecessary medical services. Bortz saw an opportunity to apply the tool to Virginia’s healthcare system and requested an analysis of the state’s claims data, making Virginia one of the first states to take a comprehensive look at its healthcare waste.
“I started doing a roadshow. I’d go to every medical society, chamber of commerce with these statewide reports,” Bortz said.
Those conversations eventually helped lay the groundwork for the Virginia Center for Health Innovation’s Smarter Care Virginia initiative, which moved beyond identifying unnecessary care to working directly with clinicians to change how it was delivered.
No evidence of harm to patients
One of the researchers’ central concerns was whether reducing the use of these services could inadvertently harm patients.
To assess that risk, the study tracked several adverse health outcomes that could potentially result from reducing the nine services examined, including hospitalizations for heart attacks, opioid overdoses, dangerously high or low blood sugar, retinal tears and hospital-acquired pneumonia.
Researchers found no evidence of an increase in those outcomes, suggesting that the initiative reduced low-value care without compromising patient safety.
“That was really very important to us to make sure that we weren’t inadvertently causing harm and we took a very conservative approach to this,” Bortz said.
Changing the systems behind unnecessary care
Despite the results, Bortz said health systems may face challenges adopting similar initiatives, particularly as hospitals contend with financial pressures stemming from the federal spending law, previously known as the One Big Beautiful Bill.
Reducing unnecessary services isn’t always as simple as asking doctors to order fewer tests. Some procedures are built into larger care bundles, with pricing and reimbursement shaped by agreements among hospitals, insurers and manufacturers.
Preoperative testing, for example, can involve several laboratory tests and other services grouped together under a single payment arrangement.
“There’s a lot of bundling of labs, bundling of procedures, different things that are happening. These systems are complex,” Bortz said.
Claims data can help identify where those practices occur, but clinicians don’t always realize that certain services are being ordered automatically.
Rockwell said some Carilion clinicians were unaware that placing an order could trigger additional testing through the health system’s electronic health record.
“The Carilion clinicians didn’t even realize it was happening. When they would order a procedure, they didn’t know there was automatically a trigger in the electronic health record that would then send that patient to get labs or an X-ray or something,” Rockwell said.
In those cases, reducing unnecessary care requires changing the systems and workflows behind the decisions, not simply asking individual physicians to change their behavior.
Health insurers also have a role to play, Bortz said. Changing reimbursement policies could give providers a financial incentive to avoid services that aren’t medically necessary.
Health plans could also adjust financial incentives based on how well providers reduce unnecessary care.
“You could either earn bigger incentives or less based on your performance around some unnecessary care deliverables. Now that’s going to require more change. Our goal was to show that you can actually get systems to change,” Bortz said.
