• Michael I Ellenbogen, Aaron A Wiegand, J Matthew Austin, Nancy L Schoenborn, Nihal Kodavarti, and Jodi B Segal.
• Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Meyer 8-134P, Baltimore, MD, 21287, USA. Mellenb6@jhmi.edu.
• J Gen Intern Med. 2023 Aug 1; 38 (11): 251925262519-2526.

BackgroundHealthcare in the USA is increasingly delivered by large healthcare systems that include one or more hospitals and associated outpatient practices. It is unclear what role healthcare systems play in driving or preventing overutilization of healthcare services in the USA.ObjectiveTo learn how high-value healthcare systems avoid overuse of services DESIGN: We identified "positive deviant" health systems using a previously constructed Overuse Index. These systems have much lower-than-average overuse of healthcare services. We confirmed that these health systems also delivered high-quality care. We conducted semi-structured interviews with executive leaders of these systems to validate a published framework for understanding drivers of overuse.ParticipantsLeaders at select healthcare systems in the USA.InterventionsNone APPROACH: We developed an interview guide and conducted semi-structured interviews. We iteratively developed a code book. Paired reviewers coded and reconciled each interview. We analyzed the interviews by applying constant comparative techniques. We mapped the emergent themes to provide the first empirical data to support a previously developed theoretical framework.Key ResultsWe interviewed 15 leaders from 10 diverse healthcare systems. Consistent with important domains from the overuse framework, themes from our study support the role of clinicians and patients in avoiding overuse. The leaders described how they create a culture of professional practice and how they modify clinicians' attitudes to facilitate high-value practices. They also described how their patients view healthcare consumption and the characteristics of their patient populations allowed them to practice high-value medicine. They described the role of quality metrics, insurance plan ownership, and alternative payment model participation as encouraging avoidance of overuse.ConclusionsOur qualitative analysis of positive deviant health systems supports the framework that is in the published literature, although health system leaders also described their financial structures as another important factor for reducing overuse and encouraging high-value care delivery.© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.

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