The Utilization and Costs of USPSTF Grade D Services in Medicare, 2007‐2016
Authors: Oronce C.I. , Fendrick A.M. , Ladapo J. , Sarkisian C. , Mafi J. 
Published: August 2020

Research ObjectiveLow‐value care (LVC), or patient care that offers no net benefit in specific clinical scenarios, leads to unnecessary spending and patient harm in certain circumstances. The U.S. Preventive Services Task Force (USPSTF) Grade D Recommendations exemplify LVC, given the very high certainty that the expected clinical benefits of these services do not exceed the expected harms. We estimate the utilization and related costs of ten USPSTF Grade D Services among U.S. Medicare beneficiaries.Study DesignWe conducted a cross‐sectional analysis of data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of U.S. outpatient visits. NAMCS uses a multistage probability sampling design, and data are abstracted directly from the medical record. Eligible visits included those by beneficiaries 18 years of age or older for whom Medicare was listed as the primary expected payer. Ten USPSTF Grade D Services were selected based on feasibility of case identification using diagnosis codes and recorded symptoms. These included the following: (1) cervical cancer screening for women older than 65, (2) prostate cancer screening for men 75 and older, (3) colonoscopy for adults older than 85, (4) vitamin D screening, (5) screening for cardiovascular disease among low‐risk adults, (6) COPD screening among asymptomatic adults, (7) screening for asymptomatic bacteriuria, (8) vitamin D supplementation for primary prevention of fractures among postmenopausal women, (9) hormone therapy for primary prevention of chronic conditions among postmenopausal women, and (10) vitamin E or beta‐carotene supplements for primary prevention of cardiovascular disease or cancer. The annual volume of these services was determined and then multiplied by per unit costs obtained from separate claims and actuarial sources to calculate annualized costs.Population StudiedOffice‐based visits by Medicare beneficiaries, 2007 to 2016.Principal FindingsFor the 10 services measured, over 30 million were provided to Medicare beneficiaries annually. The direct costs ranged from $649,604,514 to $862,159,707 annually. The three most frequently used services were (1) screening for asymptomatic bacteriuria, (2) vitamin D supplementation, and (3) screening for vitamin D deficiency screening, comprising 83% of the measured services and 46% of the calculated LVC spending. Three services (1) screening for asymptomatic bacteriuria, (2) cervical cancer screening among women older than 65, and (3) colonoscopies among adults older than 85 comprised 53% of measured LVC spending.ConclusionsThe USPSTF provides a D rating for services for which there is a moderate or high certainty that the service has no benefits or that the harms outweigh the benefits. Ten Grade D Services were provided frequently to Medicare beneficiaries, costing nearly $1 billion in Medicare spending annually. The negative clinical impact and total costs associated with the use of D‐rated services are likely larger as these findings do not capture all D‐rated services, as well as the downstream health care utilization after their use.Implications for Policy or PracticeThe implementation of policies that reduce LVC use offers an important opportunity to improve patient‐centered outcomes while safely reducing U.S. health care spending. Resultant savings could be used to expand access to high‐value care using value‐based insurance design.Primary Funding SourceThis study was supported by the Department of Veterans Affairs.