Exposing vulnerable populations—who are at greater risk for poor outcomes than the general population—to low-value care magnifies the risks that these populations already encounter in the health care system or community. Low-value care can also have an insidious effect of causing patients and providers to pay less attention to aspects of health or health care that may be more important for maintaining or improving health, and can sap patients’ already limited time, energy, and resources. As health care organizations, leaders, and frontline clinicians make strides to reduce low-value care, vulnerable populations need to be specifically considered. While tending to the needs of vulnerable populations is likely to benefit broader populations, the reverse may not be true.
Why Focus On Vulnerable Populations
Low-value care (also known as unnecessary, overused, or inappropriate services) is care in which the potential for harm exceeds the possible benefits. In the past, “harms” have focused on undesired clinical consequences, but there is increasing awareness that harms extend beyond medical practices and into the emotional and financial spheres of patients’ lives. Such harms, in turn, can further diminish health. To date, most efforts to reduce low-value care have focused on specific services without particular attention to populations in need, such as vulnerable populations.
In addition to receiving lower-quality care than other populations, vulnerable populations also are more likely to receive low-value care. Racial and ethnic minorities insured by Medicare were more likely than whites to receive a number of inappropriate services, such as antipsychotics for patients with dementia, bone density and vitamin D screening, and cardiac testing before cataract and other non-cardiac surgeries. Medicaid and uninsured patients have also been shown to receive low-value services. To improve the health of vulnerable populations, our nation will need an explicit and effective strategy for reducing low-value services in vulnerable populations and ultimately replacing these services with high-value care.
Challenges To Reducing Low-Value Care
Some challenges to reducing low-value care will be common to vulnerable and non-vulnerable populations alike. For instance, both groups ask for and thus receive low-value care, and communicating why low-value services should not be used is a difficult message for frontline clinicians to convey and for patients and their families to hear. This challenge is magnified for vulnerable populations, who, inadvertently or intentionally, are often faulted for the types and quantity of services they use. For example, considerable attention has been paid to “inappropriate” use of emergency departments for low-acuity services, particularly by low-income and vulnerable populations, who seek services from emergency departments more frequently than high-income patients do. But high-income populations are often more expensive to the health care system overall than low-income ones—in one study, for instance, high-income populations spent more overall and used higher-price outpatient services and medications, which outweighed greater emergency service spending among low-income patients.
Frontline providers have the unenviable task of explaining to patients the ways in which “less” can be “more” in health care, with few evidence-based tools and techniques to do so. Given that vulnerable populations already struggle to access care even when it is needed, any attempt to reduce delivery of a service—even a low-value service—may be perceived as inappropriate rationing. At worse, it also can be perceived as discriminatory, especially for racial and ethnic groups in which there are deep-rooted historical reasons for mistrusting the system. Frontline providers must learn to recognize low-value care moments and convert them into opportunities to deliver high-value care. Effectively communicating the potential harms of low-value care and the importance of replacing it with high-value care means taking into account patients’ values, goals, and life circumstances—yet patients and communities have been missing from conversations that would help providers understand how to better express how, in some cases, “less is better.”
Crafting Effective Messaging
Different stakeholders within health care have different roles to play in reducing low-value care for vulnerable populations. For example, health systems could introduce general messaging about low-value care and its potential to cause harm. Researchers could experiment with how to put messaging into terms that the general public can relate to—for instance, discussing its impact on function, employment, or pain, instead of using medical terms such as morbidity, mortality, and disease-free progression. Clinicians could identifying the times when such messaging could be helpful or stigmatizing. To reach vulnerable populations and to help clinicians reduce low-value care at the frontlines, health care leaders and their organizations could invest in programs that supplement standard messages with tailored ones. This is not a matter of just simplifying messages (although that can be an important component of a larger intervention) but of genuinely improving an organization’s ability to engage vulnerable populations in effective, health-promoting activities and treatments. Research and on-the-ground experiences show that multifaceted interventions that are culturally and linguistically appropriate and use examples and language crafted with the input of relevant stakeholder and community partners can improve preventive and chronic disease care. Lessons from this research could inform interventions to reduce low-value services.
Efforts to reduce low-value care among vulnerable populations should be matched with an equally strong effort to ensure access to higher-value ways of managing the condition. Less low-value care could leave space for frontline clinicians to engage patients in shared decision making, tailor care to the needs of patients, and assist them more effectively in self-monitoring. However, clinicians need communication tools that have been tested for effectiveness.
Engaging patients and families in developing messaging is critical to success. Currently, the message to patients is pretty simple: Be open to the idea that “doing nothing” might be just what is needed. However, what is the most effective way to relay this message while taking patients’ values and motivators into consideration? Effective messaging about avoiding low-value services can focus on the benefits, including more focused time with their doctors about matters that truly affect health and less time wasted on receiving and waiting for the results of low-value tests. These benefits likely extend outside the health care system to include less time off work, fewer copayments, and perhaps even enhanced overall trust in the health care system. We need to develop and implement effective ways of communicating and engaging in a dialogue with vulnerable patients and families about low-value care.
As explored above, reducing low-value care for vulnerable populations requires sustained effort on a wide variety of fronts. We can still act while we build a better evidence base for how to reduce low-value care for these patients. For starters, clinicians and delivery systems can make sure that value issues are discussed in plain language and not in euphemisms. Second, we can consistently show patients that, for most health care interventions, pros and cons exist and need to be weighed against one another. Last, but not least, we need to find and acknowledge vulnerable patients’ strengths and empower them to share their preferences with providers regarding their care.
Fully maximizing the health of vulnerable populations requires reducing low-value care as much as it involves increasing the delivery of high-value services, and this should be done in a manner that does not further marginalize these populations.