Imaging utilization figures prominently in an assessment of commercial-insurance claims that has found relatively modest use of low-value services—yet still much room for patients and physicians to choose more wisely and, in the process, save U.S. healthcare substantial sums of money.

Publishing their findings online Aug. 29 in JAMA Internal Medicine, Rachel Reid, MD, MS, of the Rand Corporation and colleagues describe their work analyzing insurance claims from a random sample of almost 1.5 million adults in a UnitedHealthcare database.

They found that, of these, 114,732 patients (7.8 percent) received at least one of 28 Choosing Wisely low-value services in 2013, resulting in $32.8 million in spending ($22.32 per capita), or 0.5 percent of total spending.

The most commonly received services included imaging for nonspecific low back pain (1.3 percent) and imaging for uncomplicated headache (1.0 percent), along with triiodothyronine measurement in hypothyroidism (1.5 percent).

The greatest proportion of spending was for spinal injection for lower-back pain at $12.1 million (37.0 percent), followed by head imaging for uncomplicated headache at $3.6 million (11.0 percent) and imaging for nonspecific low back pain at $3.1 million (9.4 percent).

Low-value spending was less among nonwhite and lower-income patients, reflecting “potential reverse disparities and underscoring the dichotomous contributions of disparities to waste in healthcare,” Reid and colleagues write.

“Underuse among less advantaged groups and overuse among more advantaged groups,” they add, “both warrant attention.”

They posit that enrollees’ overall modest spending on low-value procedures may point to an incentive built into consumer-directed health plans that gets people to avoid overuse.

However, they acknowledge that the potential for selection bias—coupled with prior evidence showing parallel reductions in both high- and low-value care in these plans—means the hypothesis warrants a closer look.

Either way, more than $750 billion of U.S. healthcare spending annually “represents waste, including approximately $200 billion in overtreatment,” the authors write. “Reducing overuse could improve quality and access while reducing spending and has been championed by clinicians through the Choosing Wisely initiative, as well as payers and policymakers.”

Reid et al. add that efforts to reduce waste may benefit by the development of measures that focus on overtreatment, insurance designs that discourage overuse, and programs that target groups and regions at greater risk of low-value care.

In invited commentary on the research, Anna Parks, MD, of UC-San Francisco and Patrick O’Malley, MD, MPH, of Uniformed Services University of the Health Sciences in Bethesda, Md., write that, despite the popularity of the Choosing Wisely campaign, the Reid et al. study “demonstrates the persistent disconnect between publicizing examples of waste and achieving value-based care in practice.”

The $32.8 million paid out for the 28 low-value services in the study represents “just a small segment of low-value care, and potential cost savings are likely much greater when extrapolated to the vast array of wasteful practices,” Parks and O’Malley add.

“Physicians at all levels of training,” they conclude, “must take on the additional professional obligation of communicating risk and benefits clearly to achieve care that is both high-value and in line with patients’ goals.”