Cutting the expenses associated with "low-value" medical tests and treatments -- such as unnecessary imaging tests and antibiotics for viral infections that won't benefit from them -- will require a multi-pronged plan targeting insurance companies, patients, and physicians, according to a JAMA Viewpoint article published this week by researchers from the Perelman School of Medicine at the University of Pennsylvania. These efforts transcend economic impact, however, and may also be essential for improving health care quality and patient safety.

The piece follows last spring's launch of the "Choosing Wisely" initiative, a project of the American Board of Internal Medicine and Consumer Reports magazine. This public and physician education campaign identifies procedures and tests that add little value and may be unnecessary or even cause harm. The campaign encourages stakeholders to improve consideration and discussion of the proper uses of these services.

Several seemingly promising strategies have been proposed to encourage the use of high-value services and discourage low-value services, but they yielded mixed results. For example, a study aimed at improving medication adherence among heart attack patients by eliminating co-pays for medications such as statins appeared to make conceptual sense, but in the end failed to show a significant reduction in subsequent cardiac problems or health care spending. And other studies involving higher co-pays resulted in prescription-drug cost savings, but led to higher rates of emergency room visits and hospitalizations -- so no money was saved overall.

The Penn researchers suggest, however, that these "value-based" strategies could be designed more effectively in order to cut the use of low-value services or drugs. Bringing cost sharing strategies in line with evidence-based screening guidelines, for instance, might play a role in reducing expenditures. If prostate-specific antigen testing -- no longer supported by the U.S. Preventive Services Task Force -- were no longer covered by insurance plans and physicians were instead required to discuss why the service may actually harm patients, they write, it would "send a powerful signal to patients, who may generally assume that all health care services provided are of high value."

"Incorporating insights from psychology and behavioral economics that help reveal how patients make these decisions is also important," says lead author Kevin Volpp, MD, PhD, director of Penn's Center for Health Incentives and Behavioral Economics and a professor of Medicine and Health Care Management at the Wharton School. "That process is quite nuanced, and while insurance benefits can be designed to help steer patients away from low-value care, in many cases patients will need help from their providers in determining which care falls into that category and why."

In addition, the authors recommend that the underlying financial incentives for clinicians to provide or prescribe certain tests and treatments should be connected to their value. This could disincentivize the use of low-value services that are aren't backed by evidence showing that they are worth using, or that the benefits they offer outweigh the potential risks associated with their use.

Currently, committees that create testing and treatment guidelines within the Centers for Medicare and Medicaid Services and other organizations are barred from including assessments of cost and value in their work, though this practice has become customary in parts of Europe.

"The trouble with 'choosing wisely' is that it is not just hard for patients, it is also hard for physicians," says senior author David Asch, MD, MBA, executive director of the Penn Medicine Center for Innovation. "If 'choosing wisely' were easy, we wouldn't be in the mess we're in right now."

But, as the authors point out, eliminating the use of low-value services is ultimately what the health care system must do in order to keep supporting the use of high-value, often lifesaving, services.