To help members stay as healthy as possible, it's essential they receive the right medical care — no more, no less. That means asking important questions like:
- Are they missing any needed care?
- Will the recommended treatments or procedures truly improve their health — and could they cause any unintended harm?
- If care is needed, is there a better or more effective way to provide it?
“To achieve the best outcomes, these are the three domains to think about, and they roughly correlate to underuse, overuse, and misuse of medical services,” said Eric Gratias, MD, National Physician Executive, Medical Benefit Services, for EviCore by Evernorth® in a recent webinar. “By approaching these domains holistically, we can ensure that members are getting care that’s going to help them return to good health or maintain their current good health.”
Is the member missing any care they need?
Underuse occurs when members miss out on necessary, effective care. One of the clearest examples is preventive care. Despite its proven power to catch chronic conditions early when they’re easier and less costly to treat, only about 5% of adults get the recommended evidence-based preventive care based on their individual risk factors.
This is especially concerning when six in 10 Americans have at least one chronic disease and four in 10 live with two or more. Addressing the underutilization of preventive care is a national health imperative.
There are several factors that contribute to this low adherence. Many people don’t have a primary care provider, or they may lack understanding about what services are recommended and whether they’re covered by insurance. In fact, only a little over one-third of English-speaking adults in the United States feel confident in their ability to understand, evaluate and effectively use health care and services.
One of the most effective ways to overcome these barriers is through direct member outreach. For example, EviCore’s Preventive Care Outreach team engages members to address their cancer screening needs and assist them with appointment scheduling and other barriers to care.
Increasing participation in preventive care is essential to reducing the burden of chronic disease and catching serious conditions like cancer early when they’re most treatable. Personalized outreach and timely communication are powerful tools for increasing adherence to recommended screenings and ultimately improving long-term health outcomes.
Will the recommended tests or treatments truly improve the members health — and could they cause any unintended harm?
Today, nearly four in 10 members don’t get care that meets the latest evidence, leading to lower quality treatment, higher costs, and even patient harm in some cases.
For example, there is a 55-year-old woman who is struggling with neck pain. When her symptoms worsened, her provider ordered an MRI. But when the request was reviewed against evidence-based guidelines, it became clear that the woman was experiencing an acute flare-up of a chronic condition, without any red flag symptoms like neurological deficits or infection that would indicate the need for imaging. As a result, the recommended course of action was to begin with conservative management, including physical therapy.
Ordering imaging in this scenario is a textbook example of overuse in health care, and unfortunately, it happens all too often. Research has shown that 60% of lower back MRIs and over 30% of MRIs for shoulder pain and knee pain are inappropriate. Unnecessary imaging can lead to false positives and more tests and treatments that don’t help patients and may be harmful. It can also mean higher out-of-pocket costs. Average copays for advanced imaging are $319 and $630 for in-network and out-of-network, respectively.
Fortunately, in this case, the woman’s health plan had a partnership with EviCore’s Spine corePath program, which specializes in coordinating and navigating spine care. With a 66% voluntary participation rate, the program shows that members are willing to engage when approached proactively. By connecting directly, the program helped her avoid unnecessary imaging and receive effective treatment that reduced her pain.
Overuse — like imaging that doesn’t follow evidence-based guidelines — can delay truly appropriate care, expose patients to harm, and inflate health care costs for individuals and the system as a whole. Tackling this issue requires a shift toward evidence-based decision-making, patient education, and care models that prioritize the right care at the right time.
If the care is needed, is there a better or more effective way to provide it?
Even when care is appropriate, misuse of how and where it’s delivered can lead to unnecessary spending without improving outcomes. A recent analysis of claims data from two major insurers examined pricing across 2,700 hospitals and 3,500 surgery centers and found as much as a nine-fold variation in cost among common surgeries. Even within the same state, hospital prices varied up to three-fold.
For example, the cost of a total knee replacement ranged from $12,870 to over $100,000, while ankle replacement charges spanned from $22,000 in Austin to nearly $200,000 in New Jersey.
The kicker? There was no link between higher prices and better outcomes, even among hospitals ranked as the nation’s best.
The lesson: a bigger price tag does not necessarily mean better care. This is true for a variety of services from preventive care to musculoskeletal procedures to advanced imaging.
EviCore is working to address this challenge in a variety of ways, including through our SmartChoice program. SmartChoice is an educational initiative that empowers members to choose the diagnostic testing location that suits their needs. Within an hour of an MRI, CT, or PET scan approval, members receive outreach by phone or text from the SmartChoice team, often before they’ve even learned their test was authorized.
The SmartChoice team acts as a concierge to the member, providing information including the availability of same-quality facilities and the cost of services at those facilities, as well as appointment coordination. The SmartChoice team also helps the member find the most convenient facility locations (e.g., near work, home, or school), and share which sites are in- or out-of-network.
Once the appointment is scheduled, the SmartChoice team sends reminders to ensure members follow through with their appointment, which helps ensure they get the care they need.
Misusing health care, such as paying more for identical services, creates unnecessary financial strain. By helping members make informed choices, more affordable care can be delivered without compromising quality.
Asking the right questions to get to the right care
Asking these questions matters because members deserve to get the right care in the best setting with the least risk of harm.
“When people are supported with clear information and expert guidance, they’re empowered to make choices that protect their health—and avoid unnecessary risks,” said Ken Silverstein, MD, MBA, Chief Medical Officer. “That kind of support isn’t just helpful; it’s essential for delivering truly exceptional outcomes.”
Want to learn more about tackling underuse, overuse, and misuse in health care services and hear more member stories? Check out the webinar with Dr. Gratias and Dr. Silverstein here.
