Common Low-Value Services
| Service | Why Low-Value | VBID Intervention |
|---|---|---|
| Imaging for low back pain (first 6 weeks) | Rarely changes treatment; resolves spontaneously | Prior auth; higher cost-sharing |
| ER for non-emergency conditions | Same care available at lower cost elsewhere | Higher ER copay; telemedicine alternative |
| Branded drugs with generic equivalents | Same efficacy at lower cost | Higher tier cost-sharing; step therapy |
| Unnecessary surgeries (spine, knee) | High variation; conservative care often equally effective | Second opinion program; COE requirement |
| Duplicate testing | Same test ordered by multiple providers | Prior auth; care coordination |
Prior Authorization: The Double-Edged Sword
Prior authorization (PA) is the primary tool for reducing low-value care — but it must be applied carefully. PA requirements that are more stringent for mental health services than for comparable medical services violate MHPAEA. PA requirements that delay necessary care can harm patients. The goal is to apply PA to genuinely low-value services, not to create barriers to necessary care.
Second Opinion Programs
IQ Insight
Second opinion programs for elective surgeries consistently find that 20–30% of recommended surgeries are unnecessary or can be treated more conservatively. For a plan with 10 elective spine surgeries per year at $50,000 each, a second opinion program that prevents 2–3 unnecessary surgeries saves $100,000–$150,000 — often more than the cost of the program.