title: Low-Value Medical Services in the Safety-Net Population.
abstract: National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined.
  
  
  
  To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians.
  
  
  
  This multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics.
  
  
  
  Comparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non-safety-net physicians (seeing 1%-10%).
  
  
  
  Delivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit.
  
  
  
  Overall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non-safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services.
  
  
  
  Overuse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.
authors.affiliation: Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Barnett
authors.affiliation: Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Linder
authors.affiliation: Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Cheryl R
authors.initials: CR
authors.lastname: Clark
authors.affiliation: Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Sommers
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008484:Medicaid / Q000191:economics*; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008511:Medicine / Q000706:statistics & numerical data*; D008875:Middle Aged; D011203:Poverty; D010818:Practice Patterns, Physicians' / Q000191:economics; D011320:Primary Health Care / Q000191:economics*; D011787:Quality of Health Care / Q000191:economics*; D014481:United States; D055815:Young Adult