Low-Value and No-Value Care in Healthcare: A Narrative Review

ABSTRACT

This narrative review summarizes the concepts of low- and no-value care (LNVC), the drivers behind them, and potential strategies for de-implementation, all with a particular focus on influential conceptual and empirical research. Low-value care (LVC) refers to healthcare services for which the costs outweigh the potential benefits, while no-value care (NVC) is a narrower definition that refers to healthcare services that provide no net clinical benefit for patients (regardless of the costs). A growing global body of research shows that LNVC is widespread and imposes substantial societal costs. Mitigating the provision of such care would reduce avoidable healthcare expenditures, improve the quality and safety of treatment by minimizing overdiagnosis and overtreatment, and improve overall health by reallocating resources to high-value care. LNVC arises from interrelated factors at the system, individual-provider, and consumer-demand levels, including system incentives, industry promotion, patient expectations, and physicians’ knowledge, habits, and fears. Despite increasingly intense efforts to address LNVC, several challenges persist in terms of identification, measurement, and intervention. Multicomponent interventions targeting healthcare providers have been shown to be effective at reducing LNVC from the supply side; such interventions may include recommendations from professional societies, quality metrics for LNVC, quality-improvement initiatives, clinical decision-support tools, and payment reforms (e.g., global budgets, prior authorizations, coverage policy). Given the uneven provision of LNVC, targeted strategies centered on high-volume providers could improve the efficiency of interventions. Importantly, eliminating NVC represents a clear and actionable starting point to facilitate coordinated, multi-level efforts and collaboration among a diverse range of stakeholders.

 INTRODUCTION

Low-value care (LVC) refers to healthcare services where the costs outweigh the potential net clinical benefits for patients, whereas no-value care (NVC) is a narrower definition that represents to healthcare services that provide no net clinical benefit for patients¹⁾. Despite growing efforts to reduce it, low- and no-value care (LNVC) remains a pervasive global challenge. Experts estimate that 20–30% of healthcare spending does not contribute to improved health, with LNVC being one of the major contributors^2),3). Beyond its unnecessary costs and consumption of limited healthcare resources, LNVC can harm patients physically, psychologically, and financially—for instance, unnecessary imaging exposes patients to radiation and may trigger further unwarranted interventions.

As healthcare costs rise, high-income countries face the dual challenge of containing spending while maintaining quality⁴⁾. LNVC mitigation can directly lower avoidable healthcare costs, improve safety and care quality, minimize overdiagnosis and overtreatment, and improve population health by reallocating resources to high-value services⁵⁾. Consequently, minimizing LNVC has become a priority for policymakers, insurers, health systems, and patients. Yet, a substantial gaps remain in understanding its definition, impacts, drivers, and mitigation strategies. This narrative review addresses these gaps by synthesizing key conceptual and empirical studies identified through PubMed and Google Scholar.

 CONCEPT OF LOW-VALUE CARE

Although the terms “low-value care” and “no-value care” have gained prominence in the last decade, concerns about unnecessary care are longstanding. In the 1970s, Wennberg et al.⁶⁾ reported substantial regional variation in surgical rates in Vermont—even between neighboring districts—that could not be explained by patient characteristics. Follow-up studies, visualized in the Dartmouth Atlas using Medicare data^6–8), revealed widespread geographic variation in surgeries, hospitalizations, specialist visits, and end-of-life care. Greater care utilization in certain regions generally reflected higher concentrations of local resources but was not associated with better patient outcomes. These findings highlight the lack of consensus among physicians on “appropriate” care and underscore the limitations of prevailing practice patterns, laying the groundwork for the contemporary debate around LNVC.

The rise of evidence-based medicine from the 1990s onward^9–11) reinforced concerns regarding care offering little or no clinical benefit. Reflecting this, the Institute of Medicine (IOM) introduced the term “overuse” in its 1998 National Roundtable on Health Care Quality report¹²⁾; adapted from RAND’s concept of “inappropriate care” dating back to the 1980s¹³⁾, this term referred to care “provided under circumstances in which its potential for harm exceeds the possible benefit.” In a subsequent 2010 IOM report, overuse was highlighted as a key driver of healthcare waste¹⁴⁾.

In the 2000s, the sharpening focus on value in healthcare shifted discourse to a patient-centered, value-based framework. A clearer conceptualization of “value” in healthcare laid out by Porter et al.^15),16)—defined as “health outcomes achieved per dollar spent”—laid the theoretical foundation for the concept of LVC. From this value-based perspective, LVC refers to healthcare services that offer patients minimal or no net clinical benefits, meaning that their costs outweigh their benefits. In other words, the concept LVC is inherently linked to cost-effectiveness analysis, demonstrating that even clinically effective interventions may be considered “low-value” if their costs exceed expected benefits. This notion of LVC successfully unified several previously distinct definitions of overuse promoted by the National Priorities Partnership¹⁷⁾, the American College of Physicians¹⁸⁾, and the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign¹⁹⁾.

According to the existing literature^5),20–26), LVC entails the following:

(1) Little or no clinical benefit

(2) Harms that outweigh their expected benefits

(3) Poor cost-effectiveness

(4) Less efficiency than alternatives

(5) Misalignment with patient preferences

Thus, LVC may be framed as a composite concept that involves at least one—but sometimes all—of the following three dimensions²⁷⁾: a trade-off between clinical benefits and harms, a trade-off between clinical benefits and costs, and alignment with patient values. For example, the Choosing Wisely LVC lists include services that have no clinical effect and may be harmful (e.g., arthroscopic surgery for knee osteoarthritis), those that are not harmful but provide minimal benefit and, thus, are not cost-effective (e.g., routine preoperative testing for low-risk surgeries without an indication of clinical need), and those that do not align with patient preferences (e.g., the provision of chronic dialysis without an initial shared decision-making process between patients, their families, and their physicians)¹⁹⁾. Of note, the Choosing Wisely campaign introduced a groundbreaking approach to addressing LVC by promoting patient–clinician conversations about potentially overused services. Its clinician-authored recommendations became the foundation for widely used measurement tools and spurred numerous initiatives, funding programs, and research efforts aimed at reducing LVC. It is worth noting that much of the literature on LVC does not consider the site of care or the price differences that come with it (e.g., outpatient vs. inpatient), whose inclusion could improve understanding of LVC’s financial impact.

Despite rising awareness and initiatives such as the ABIM Foundation’s Choosing Wisely, evidence suggests that reductions in LVC have been modest²⁸⁾. Conceptual complexity, inconsistent definitions of LVC, and evolving clinical evidence have hindered providers’ adoption of reduction efforts²⁷⁾. While clearly ineffective or harmful services are readily targeted, those with minimal benefit require subjective judgments about trade-offs between benefits, costs, and harms, which vary by stakeholder and individual patient values.

 Concept of No-value Care

A core challenge in identifying LVC is that a clinical service may be high-value for one person but entirely unnecessary for another. Appreciating this “clinical nuance” when determining the value of a specific service is important for several reasons. First, there is a considerable heterogeneity across patients in the benefits and risks associated with any service. Moreover, clinical evidence is often lacking for populations that are frequently underrepresented in clinical trials (e.g., older adults). Second, even if research could precisely quantify the risks and benefits associated with different care options at the individual-patient level, that which constitutes “appropriate” care ultimately depends on how individual patients weigh the trade-offs. Third, risks and benefits are often provider-dependent, reflecting not only provider skill but also the supportive resources available to them. Thus, on account of these uncertainties, many services fall into a “gray zone” between clearly high-value care and LVC, highlighting the challenges in creating of a practical and actionable definition of LVC that can account for value at the level of individual services.

Addressing these challenges, the concept of NVC—introduced in 2022 by Fendrick et al.²⁹⁾ at the Research Consortium for Health Care Value Assessment—provides a useful framework. NVC has a narrower definition, referring only to services for which high-quality evidence indicates that they offer no clinical benefits in specific scenarios and for which there is minimal or no patient demand (Fig. 1). Unlike LVC, there is broad consensus among stakeholders regarding NVC’s lack of clinical benefits. As a result, targeting these services as the initial focus of intervention is both feasible and politically acceptable, as the decrease in the use of such services in certain clinical scenarios is unlikely to compromise clinical outcomes, impact provider autonomy, or reduce patient satisfaction¹⁾.

Fig. 1  Conceptual framework for no-value, low-value, and high-value care

Note. “Net clinical benefit” refers to the overall impact of a healthcare service, weighing the expected clinical benefits against its potential harms.

Understanding that factors beyond clinical evidence influence clinical decision-making, the definition of NVC proposed by the Center for Value-Based Insurance Design at the University of Michigan¹⁾ includes aspects of patient demand and the degree of heterogeneity in clinical benefits of specific services, referring to services that meet the following criteria:

(1) Rigorous evidence demonstrates no clinical benefit or clinical harms that outweigh the benefits (i.e., no net benefit) when used in specific clinical circumstances by defined patient populations

(2) No or low patient demand (i.e., patient preference fails to overcome clinician reluctance)

(3) No or low variability in net clinical benefits based on patient characteristics (e.g., age, sex, disease severity, site of lesion, evolving diagnostic criteria, standard care, time-dependent care, baseline risks, dose-dependent effects) when used in a specific clinical scenario.

More precisely, NVC is demonstrated by clinical scenarios in which meta-analyses or multiple randomized controlled trials have revealed no clinical benefits with minimal outcome variability and low patient demand. NVC may be systematically identified by extracting services that meet these criteria from existing LVC lists. To minimize potential controversy, services designated as NVC should not conflict with expert consensus or clinical guidelines for defined patient populations. Examples include many of the services rated “D” by the U.S. Preventive Services Task Force (USPSTF)³⁰⁾, for which “there is moderate or high certainty that the service has no net benefit or that harms outweigh benefits.”

 IDENTIFICATION AND MEASUREMENT OF LOW-VALUE CARE AND NO-VALUE CARE

There are two main approaches to measuring LNVC: indirect and direct⁴⁾.

The indirect approach compares healthcare utilization across countries, regions, or hospitals after adjusting for patient factors (e.g., age, sex, comorbidities)³¹⁾. Although variation may suggest ineffective or unnecessary care, this method has several limitations: both overuse and underuse may drive variation, it cannot identify specific overused services, and it misses LNVC that are uniformly overused^32–34).

A direct approach that assesses the utilization of health services listed as LNVC could overcome these limitations and complement the indirect approach, at the cost of potentially underestimating unnecessary care. This approach requires the identification, measurement, and reporting of specific LNVC services. On top of the ongoing work of the USPSTF, one of the most prominent recent efforts to identify LVC is the Choosing Wisely initiative, launched in 2012 by the ABIM¹⁹⁾, which began with 45 low-value tests and procedures from nine specialty societies’ “top five” lists and expanded to over 600 recommendations by 2021^19),35,)36). Similar lists have been developed for several countries, including Australia, Canada, the United Kingdom (UK), Germany, Italy, Japan, and the Netherlands³⁷⁾. These efforts also produced tools like the MedInsight Waste Calculator, which estimates the prevalence and cost of LVC using claims data^38–40).

LNVC is typically determined using lists of services deemed unnecessary in specific clinical contexts. Most studies rely solely on administrative claims data^{25),39),41–46)}, though others consider survey data^47–49). Because claims data often lack clinical details, researchers often construct both broader (more sensitive, less specific) and narrower (less sensitive, more specific) definitions of LNVC to estimate the degree of misclassification²⁵⁾. For example, all antibiotic prescriptions for patients diagnosed with acute respiratory infections may be classified as no-value under the broader definition; conversely, under the narrower definition, they would only be considered no-value if not accompanied by a diagnosis (e.g., bacterial infection) that would justify antibiotic use. Some services remain unmeasurable due to missing clinical context (e.g., symptoms needed to judge the appropriateness of urine cultures). To overcome such limitations, recent studies have explored the use of data from electronic health records, which provide more detailed clinical information and may allow for more accurate identification of overuse^50–53).

Measurement helps identify which forms of LNVC should be prioritized for intervention. In practice, it narrows the initial list to focus on services that merit greater attention. Targeting high-frequency and high-cost LNVC is a practical strategy under resource constraints. For example, Virginia’s All-Payer Claims Database proposed a “top five” list based on total costs⁵⁴⁾. Because LNVC use varies across regions and countries, priorities for mitigation should be locally determined^41),44),55).

 MAGNITUDE OF ISSUES RELATED TO LOW-VALUE CARE AND NO-VALUE CARE

A growing body of research across high-income countries shows that LNVC is common and costly. In the U.S., a study using 26 measures found that 25–42% of Medicare beneficiaries received at least one LVC annually, accounting for 0.6–2.7% of overall Medicare spending²⁵⁾. Another pooled estimate placed the national cost of LNVC at 75.7–101.1 billion U.S. dollars, or 2.0–2.7% of total healthcare spending³⁾. However, this estimate accounts for costs such as brand-name drug use instead of generics and end-of-life care measured indirectly. For example, a recent study examining 47 LNVC services among Medicare fee-for-service beneficiaries found that five USPSTF grade D services accounted for 59% of total LNVC spending⁵⁶⁾.

Internationally, the measurement of LNVC is growing, although estimates vary by methodology, considered LNVC services, and setting. In Canada, for example, 4% of adults received LNVC over three years based on ten measures⁴⁶⁾. In Japan, 4.9–7.5% of patients in acute-care hospitals received at least one LNVC annually based on 33 measures, costing 0.2–0.5% of hospital spending⁴⁴⁾. In Australia, a study considering 21 measures reported that 2.2–3.3% of admitted patients received LNVC⁴²⁾, while another study considering 27 measures found costs per capita of 6.6–13.1 Australian dollars⁴³⁾. Similar economic burdens have been reported in Germany⁵⁷⁾, Spain⁵⁸⁾, UK⁵⁹⁾, Austria⁶⁰⁾, China⁶¹⁾, and the Netherlands⁶²⁾.

Most prior research has focused on LVC, as the concept of NVC only emerged recently, meaning that few studies have explicitly defined or systematically measured it^63),64). However, as such services offer no clinical benefit and may even cause harm, they are arguably more relevant from a policy standpoint, underscoring the importance of clearly identifying and quantifying them in future research.

Existing cost estimates likely understate the full economic impact of LNVC, as they generally fail to account for downstream costs stemming from complications, adverse events, or care cascades triggered by initial low-value interventions^65–68). Low-value tests, such as preoperative electrocardiograms prior to cataract surgery⁶⁶⁾, unnecessary PSA screening⁶⁹⁾, or early magnetic resonance imaging for lower back pain^67),70), can trigger care cascades that greatly increase costs—up to tenfold in some cases.

 DRIVERS OF LOW-VALUE CARE AND NO-VALUE CARE

 System Level

Several system-level factors influence providers’ provision of LNVC (Table 1). Fee-for-service reimbursement rewards volume and type of services rather than the quality or appropriateness of care, potentially promoting overuse of tests and procedures^71),72). The ambiguity or absence of clearly defined clinical scenarios in guidelines can give way to the proliferation of a significant “gray zone,”⁷³⁾ thereby increasing LNVC. For example, PSA screening among asymptomatic men is higher in Australia than the UK, likely due to the lack of clear and unified national guidelines on PSA screening in Australia⁷²⁾. Professional societies, as well as pharmaceutical and medical device industries, can also contribute. Promotional activities targeting physicians have been linked to increased prescriptions, potentially driving overuse—for instance, U.S. pharmaceutical marketing contributed to higher opioid prescriptions and subsequent overdose deaths^74–76).

Table 1 Drivers of low-value and no-value care and potential approaches to mitigating them

Category	Drivers	Potential approach to mitigation
System level	- Provider and patient incentives - Professional societies - Industry - Practice environments - Organizational structures - Resource constraints	- Recommendations from professional societies - Payment reforms, such as implementing global budgets and value-based payment models instead of fee-for-service payment - Service coverage policy - Prior authorization - Limiting conflict of interests and industry influence among physicians and professional societies - Introducing quality metrics for low-value and no-value care
Individual-provider level	- Gaps in physician knowledge and skills - Time pressure, high workload, and reliance on habitual practices - Individual-level financial incentives - Defensive medicine - Physician attitudes, including desire to meet patient expectations, self-efficacy, skepticism, and cost-consciousness - A prevailing “more is better” culture	- Medical education (medical school, postgraduate training, and recurrent education) - Promotion of evidence-based guidelines - Quality-improvement initiatives, including monitoring, feedback, and peer comparison - Decision-support tools - Targeted approach focused on physicians with high-volume users
Consumer-demand level	- Patient expectations - Socioeconomic status, health literacy - Differences in perception of low-value care between patients and physicians	- Shared decision-making on the use of low-value care with support from tools and physician training - Information campaigns about low-value care - Cost-sharing adjustments designed to avoid discouraging necessary care - Communication strategies to manage patient expectations

Clinicians’ cultural context, financial incentives, and practice environment are also important. Physicians who relocate from regions with low levels of LNVC provision to regions with higher levels increase their provision of LNVC (e.g., mammography and PSA testing in older adults) during the first three years post-relocation⁷⁷⁾. High specialist-to-primary care ratios, high rates of specialists per capita^78–80), more competitive regional practice environments^78),81), and fragmented delivery systems are associated with more LNVC, suggesting primary care physicians can act as gatekeepers against LNVC. In the U.S., only a small share of LNVC spending is attributed to patients’ regular primary care physicians⁸²⁾. Some physicians may provide LNVC to enhance their organization’s financial position, an example of provider-induced demand⁸³⁾. Limited decision-support tools and insufficient time for clinician–patient communication further exacerbate overuse⁸⁴⁾.

Hospital-level variation in LNVC provision is substantial, yet associations with readily available hospital characteristics (e.g., size, ownership, procedure volume, teaching status) are minimal or inconsistent^44),85),86). Thus, targeting hospitals with high LNVC use may be more effective than focusing on specific institutional profiles⁸⁰⁾.

The drivers of LNVC also differ by service type. Overprescription of hypnotics or proton pump inhibitors, for instance, is less about physicians’ financial incentives and more about a “more is better” culture, industry promotion, or unclear guidelines. In contrast, low-value procedures often carry direct financial incentives—for example, hospitals owned by private-equity firms or those possessing computer tomography or magnetic resonance imaging scanners may promote unnecessary imaging. Tailoring interventions to the incentives and contexts specific to each service could therefore inform more effective system-level strategies⁸⁷⁾.

 Individual-provider Level

At the physician level, LNVC provision is associated with factors such as age, sex, medical specialty, professional training, patient volume, and personal traits⁸⁸⁾. While findings are mixed, research has consistently shown that older physicians tend to provide more LNVC, likely reflecting gaps in up-to-date knowledge and reliance on habitual practices, particularly in busy settings^45),89–91). Awareness of overuse guidelines is linked to lower LNVC rates, whereas time pressure and heavy workloads can discourage evidence-based restraint and collaborative decision-making^84),92–95). Financial incentives may also contribute: self-employed physicians in fee-for-service systems—common in Japan, South Korea, Canada, and the U.S.—have stronger incentives to increase patient visits, tests, and imaging^45),96),97).

Individual traits are also important determinants of physician behavior, with research pointing to certain types of physicians who tend to provide LNVC across multiple clinical scenarios^45),98), suggesting that certain consistent practice habits lead to overuse. Attitudes such as a desire to meet patient expectations⁸⁴⁾, low self-efficacy⁹⁹⁾, skepticism toward clinical evidence/guidelines⁹⁹⁾, and a lack of cost-consciousness¹⁰⁰⁾ are associated with high rates of LNVC. Defensive medicine also plays a key role, with fear of malpractice prompting unnecessary tests and treatments^{83),84),95),101)}. Despite recognizing overuse as a systemic issue, most physicians fail to recognize it as an issue in their own practice¹⁰²⁾. A “more is better” culture among professionals (including physicians and other medical professionals¹⁰³⁾) reinforces this tendency. Because many of these drivers are unobservable, caution is warranted when profiling physicians based only on observable characteristics.

 Consumer-demand Level

At the level of consumer demand, patients’ age, sex, ethnicity, socioeconomic status, and comorbidities have been found to be associated with LNVC, although no consistent patterns have emerged^{39),47),46),48),49),88)}. Higher socioeconomic status has been linked to greater use of unnecessary imaging (e.g., radiography for back pain) and screening (e.g., cervical or prostate cancer), possibly reflecting stronger care-seeking behavior and better access to resources^48),49). In contrast, underserved populations more often receive inappropriate medications (e.g., opioids and benzodiazepines) and low-value interventions such as benign prostatic hyperplasia testing, feeding tubes for dementia, and preoperative tests before cataract surgery^{48),49),104),105)}.

Patient expectations also play a key role. Physicians often perceive resistance to recommendations against LNVC and may overprovide to reassure patients, families, or themselves^71),106). Although patients increasingly recognize the need to reduce LNVC¹⁰⁷⁾, their concept of “low value” may differ from that of physicians; they may view treatments that do not match their personal preferences as low-value even if such treatments are clinically effective or in line with established guidelines¹⁰⁷⁾.

 STRATEGIES TO REDUCE LOW-VALUE CARE AND NO-VALUE CARE

 Provider-facing Supply-side Approaches

Multicomponent interventions targeting physicians are generally more effective than single-component ones in reducing LNVC from the supply side¹⁰⁸⁾. A useful framework for guiding de-implementation is the “Evidence, Eminence, and Economics” framework proposed by Powers et al.¹⁰⁹⁾. De-implementation usually begins with evidence showing that a service offers little or no clinical benefit—often because it was adopted before rigorous evaluation or because early promising results were later refuted by more robust, large-scale studies.

However, evidence alone rarely changes practice. Guidance and recommendations from professional societies (“eminence”) are crucial for persuading clinicians to abandon LNVC—illustrated by the impact of initiatives like Choosing Wisely, which helped redefine clinical norms. Incorporating the avoidance of LVC into quality metrics is also essential, as most guidelines traditionally focus on underuse of high-value care. Multipronged quality-improvement initiatives through data-driven and nonjudgmental feedback and peer comparison have been linked to reduced preoperative testing¹¹⁰⁾. Clinical decision-support tools, such as nudging strategies embedded in electronic health records^111),112), have also shown promise in reducing LNVC, though such systems entail administrative costs, underscoring the need for cost-effective strategies¹¹³⁾. Because a small subset of physicians accounts for a disproportionate share of LNVC^45),90), targeted interventions may be particularly efficient¹¹⁴⁾. Ultimately, a respectful, data-driven process anchored in nonjudgmental communication, explicit core values, and mutually respectful collaboration among medical directors and quality-improvement staff is also critical to the promotion of behavioral change among physicians⁸⁷⁾, as demonstrated by quality-improvement efforts in safety-net hospitals in California that successfully reduced preoperative testing¹¹⁰⁾. Emerging technologies such as machine learning may also enable low-cost identification of LNVC¹¹⁵⁾.

Beyond evidence and eminence, economic incentives are also necessary to discourage LNVC. Payment reforms, including global budget arrangements¹¹⁶⁾ and value-based payment models (e.g., Accountable Care Organizations [ACOs])¹¹⁶⁾, can promote provider accountability for the costs associated with LNVC and curb the incentives for overuse. These may be complemented by quality metrics and financial incentive programs specifically targeting LNVC reduction. Prior authorization policies, widely used by U.S. insurers, can also help identify and restrict LNVC based on clinical context; however, their administrative burden highlights the need for simplified and automated systems to maintain provider engagement.

The most extreme economic lever is restricting payment, which can be appropriate when services are clearly identifiable as no-value. For instance, in Ontario, Canada, eliminating reimbursement for low-value vitamin D testing reduced its use by 93%—a far greater decline than that seen after the Choosing Wisely recommendation²⁸⁾. However, coverage restrictions may produce unintended consequences such as upcoding or assigning alternative diagnoses to bypass limits (e.g., labeling a cold as pneumonia to justify antibiotic use). In some systems, denied fees may be passed on to patients, but under the Center for Medicare and Medicaid Services (CMS) new WISeR Care model—and in some countries like Japan—such costs are borne by providers instead¹¹⁷⁾, helping to protect patients from financial harm.

There has been widespread recognition among Japanese physicians that healthcare services are overutilized¹⁰²⁾, and although progress has been slow, some efforts have been made to reduce overutilization. For example, the Choosing Wisely Japan initiative was launched in 2013 by a group of volunteer physicians and health professionals, and they released a “Top 5” list of practices in general medicine that should be questioned by patients and health professionals¹¹⁸⁾. At the policy level, financial incentives to physicians for avoiding antibiotic prescriptions for common cold or diarrhea, and disincentives for long-term benzodiazepine prescriptions, were introduced in 2018. Specifically, the incentive to avoid antibiotic use was implemented as part of the national antimicrobial resistance campaign, accompanied by the publication of government-endorsed clinical guidelines. Nevertheless, there remains considerable room for improvement in efforts to reduce LNVC. Only a few professional societies have developed comprehensive lists of LNVC services, and the avoidance of LNVC is rarely incorporated into quality assessment metrics. In addition to addressing these challenges related to eminence, economic incentives—such as more stringent coverage restrictions for specific LNVC services or the introduction of the value-based payment models—should be considered to further promote the reduction of LNVC in Japan.

 Demand-side Approach

Demand-side strategies to reduce LNVC include increasing patient cost-sharing to curb post-hoc moral hazard and enhancing patients’ understanding of appropriate care²³⁾. However, uniform cost-sharing can inadvertently deter necessary care¹¹⁹⁾, as patients often cannot distinguish high- from low-value services. Such strategies must be carefully designed with safeguards to maintain access to essential care and avoid widening socioeconomic or racial/ethnic disparities^120),121).

 RECOMMENDATIONS

As recognition of LNVC grows, efforts to address it have intensified; however, but challenges remain in identification, measurement, and intervention. First, the evidence base still needs strengthening, as randomized controlled trials are often costly and ethically and practically difficult. Observational methods, including natural experiments^122),123) and target trial emulation^124),125), have the potential to enable scientifically robust evaluations while minimizing bias. Furthermore, outcome measures—the numerator in the value equation—should be assessed as comprehensively as possible. incorporating patient-reported outcomes and long-term follow-up to provide a more holistic assessment of value.

Second, measurement is often limited by a lack of clinical specificity in available data. Claims data alone may not capture the context needed to identify unnecessary services accurately. Leveraging richer sources (e.g., electronic health records) would likely improve measurement accuracy^50–53), but system design must also prioritize reducing documentation burdens and improving usability.

Third, machine learning offers promising, low-cost methods to identify LNVC^115),126). For example, the CMS’s WISeR model uses both machine learning and human review to streamline prior authorization and reduce LNVC¹¹⁷⁾. Machine learning can also improve diagnostic accuracy¹²⁷⁾: one study showed that applying it in an emergency department could halve unnecessary testing for acute coronary syndrome while increasing appropriate testing for high-risk patients, potentially saving up to one-third more lives¹²⁸⁾. However, we are still far from being able to impose a fully algorithmic approach to medical decision-making in many clinical scenarios, leaving physicians responsible for making decisions without data specific to individual clinical scenarios. Additionally, most predictive models degrade over time, posing a significant challenge for real-world application.

Fourth, identifying cost-effective strategies to address low-cost LNVC remains another challenge, as the administrative burden of intervention may exceed the potential savings¹¹³⁾. To mitigate these costs, insurers are increasingly turning to machine learning to support coverage and reimbursement decisions. However, to avoid unintentionally restricting necessary care, such technologies must be paired with safeguards—e.g., physician documentation and prior authorization—which can be burdensome and may hinder physicians’ productivity, making it important to carefully weigh these potential trade-offs.

Fifth, there is room to introduce incentives geared toward mitigating LNVC. Alternative payment models, such as episode-based payment, population-based payment (e.g., ACOs), and global budgets, typically shift the financial risk associated with LNVC to healthcare providers by offering limited or no additional reimbursement for such services. To mitigate concerns that moving away from fee-for-service models could result in under-provision of necessary care, alternative payment models are often coupled with quality metrics that aid in detecting underuse and incentives to deliver better care—hence the term “value-based payment.” Evidence suggests that such models can foster modest reductions in healthcare spending^129–133). When designed effectively, APMs can make providers—those best positioned to reduce LNVC—accountable for its costs.

Mitigating LNVC requires collaboration among healthcare professionals, patients, insurers, and policymakers. To facilitate such collaboration, an initial focus on NVC—services that consistently provide no clinical benefit across patient populations and have low patient demand—is warranted, as multistakeholder consensus is more likely to be achieved. Ongoing investment in research, education, and policy innovation is crucial to promoting high-value care, minimizing harm from unnecessary interventions, and building a high-quality, efficient, and sustainable healthcare system.

 CONFLICT OF INTEREST STATEMENT

Dr. Miyawaki received grants from the Japan Society for the Promotion of Science (24K02701) and the Top Runners in Strategy of Transborder Advanced Research (TRiSTAR) program conducted as the Strategic Professional Development Program for Young Researchers by the Ministry of Education, Culture, Sports, Science and Technology for other work not related to this study. Dr Mafi reported receipt of grants from the National Institute of Health (R01AG070017 and K76AG064392), the Commonwealth Fund, and Arnold Ventures, and providing unpaid consulting to the Agency for Healthcare Research and Quality outside the submitted work. Dr. Fendrick directs the University of Michigan Center for Value-Based Insurance Design. He reports providing consulting services to AbbVie, CareFirst Blue Cross Blue Shield, Centivo, Clover Health, Community Oncology Association, Covered California, Elektra Health, EmblemHealth, Employee Benefit Research Institute, Exact Sciences, GRAIL, Health[at]Scale Technologies, HealthCorum, MedZed Inc., Merck and Company, Mother Goose Health, Phathom Pharmaceuticals, Sempre Health, Silver Fern Healthcare, US Department of Defense, Virginia Center for Health Innovation, Wellth, Yale-New Haven Health System; holding equity interest in Health[at]Scale Technologies, HealthCorum, Mother Goose Health, Sempre Health, Wellth Inc., and Zansors; receiving research support from the Agency for Healthcare Research and Quality, West Health Policy Center, Arnold Ventures, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, Pharmaceutical Research and Manufacturers of America, the Robert Wood Johnson Foundation, the state of Michigan, and the Centers for Medicare and Medicaid Services; serving as coeditor for the American Journal of Managed Care; and maintaining a partnership at VBID Health. Dr. Tsugawa receives funding from the National Institute of Health (award number: R01AG068633, R01AG082991, and R01MD013913) and GRoW @ Annenberg for other work not related to this study, and serves on the board of directors of M3, Inc. No other disclosures were reported.

 SOURCES OF FUNDING

This study was partly supported by a grant from the Ministry of Health Labour and Welfare (Health Labour Sciences Research Grant 23AA2004).

 ROLE OF THE FUNDER OR SPONSOR

None.

 ACKNOWLEDGMENTS

None.

 AUTHOR CONTRIBUTIONS

Study concept and design: All authors

Acquisition, analysis, or interpretation of data: All authors

Drafting of the manuscript: Miyawaki

Critical revision of the manuscript for important intellectual content: All authors

Administrative, technical, or material support: All authors

Supervision: Tsugawa

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