Evaluation of Payer Policies to Reduce Low-Value Medical Device-Based Procedure Use.

Abstract

Low-value care occurs when the harms or costs of care exceed the benefits. Such care includes when medical device-based procedures are favored over medical management, such as invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI) for stable coronary artery disease; endovascular intervention for lower extremity peripheral arterial disease with intermittent claudication; and nasal endoscopy with balloon ostial dilation and functional endoscopic sinus surgeries (collectively, sinus procedures) for chronic rhinosinusitis. To evaluate the association of enacting evidence-based clinical coverage policies for these low-value procedures with their use in Louisiana's Medicaid program. Louisiana Medicaid partnered with academic investigators to develop and enact evidence-based policies between December 2021 and February 2022. This study used an interrupted time series approach to evaluate use of the 4 identified procedures 12 months before and 18 months after policy enactment. For each procedure, best-fit curves were constructed of prepolicy utilization trends, which were used to generate expected postpolicy trends. These expected trends were then compared to observed postpolicy utilization. Three-way analysis (time × intervention period [pre or post] × procedure) was used to assess changes in utilization slope for each procedure relative to colonoscopy (which had no policy changes and was expected to show baseline use of procedures in Louisiana Medicaid). Final follow-up was in September 2023. Monthly outpatient procedural utilization per 100 000 Louisiana Medicaid members of ICA, PCI, endovascular intervention, and sinus procedures. There were 1 396 629 Louisiana Medicaid members with data at 1 year before any policy enactment and 1 548 265 at final follow-up. Overall, 14 940 individuals (mean [SD] age, 43.5 [13.7] years; 53.0% female) underwent one of these procedures before policy enactment, and 20 882 (mean [SD] age, 43.3 [13.7] years; 52.6% female) after enactment. Differences in monthly outpatient procedure rates in the postenactment compared with the preenactment period per 100 000 members were as follows: ICA, 0.65 (95% CI, 0.06 to 1.23); PCI, 0.15 (95% CI, -0.01 to 0.31); endovascular intervention, -0.01 (95% CI, -0.12 to 0.10); and sinus procedures, -0.23 (95% CI, -1.61 to 1.15). There was no significant change in the 3-way time × intervention period × procedure vs colonoscopy interaction for any procedure. In this quality improvement study, enactment of evidence-based clinical coverage policies for 4 common medical device-based procedures was not associated with a reduction in their use in Louisiana Medicaid. These findings suggest a need for more comprehensive strategies to improve evidence-based care for Medicaid through multipronged efforts that include education, policymaking, and value-based coverage implementation.