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The Value of Low-Value Lists

The Issue

To enhance patient safety, reward physicians for using evidence-based practices, and reduce waste, a number of quality improvement campaigns—like the American Board of Internal Medicine Foundation’s Choosing Wisely initiative—are promoting awareness of health care services that provide little or no benefit or are potentially unsafe. In this Commonwealth Fund–supported article, researchers examine the challenges to developing lists of “low-value” services and ensuring that insurers and provider organizations put them to optimal use.

What the Study Found

  • Deciding whether health services offer value requires consideration of the clinical context. For example, while routine stress tests for asymptomatic patients are clearly of low value, such tests can be crucial when given to patients with symptoms of ischemic heart disease.
  • Medical claims data do not always include sufficiently detailed information about clinical contexts to allow researchers to assess the prevalence, appropriateness, and comparative effectiveness of treatments. 
  • In the face of heterogeneity of treatment effects, benefit designs that deny coverage for potentially low-value services can be blunt instruments, since they cannot take into account specific clinical contexts or evolving care guidelines. 
  • Health care organizations that reward providers for delivering cost-effective care are well positioned to implement low-value lists. Providers will need decision-support systems and other tools to reliably identify low-value services at the point of care.


The emergence of novel approaches is making it possible to explore the comparative benefit and value of various treatment options. For example, bundled payments, which cover all services provided to a patient for treatment of a specific illness or injury, may be combined with incentives to help health care organizations and physicians distinguish low-value from high-value care..

Publication Details



A. G. Elshaug, J. M. McWilliams, and B. E. Landon, “The Value of Low-Value Lists,” Journal of the American Medical Association, Feb. 27, 2013 309(8):775–76.