Unnecessary health care

Unnecessary health care (overutilization, overuse, or overtreatment) is healthcare provided with a higher volume or cost than is appropriate.[1] In the United States, where health care costs are the highest as a percentage of GDP, overuse is the predominant factor in its expense, accounting for about a third of healthcare spending in the US ($750 billion out of $2.6 trillion).[2]

Factors that drive overuse include paying healthcare providers more to do more and covering patients' costs by a third-party (public or private insurance) payer.[3] Such factors leave both doctors and patients with no incentive to restrain health care prices or use.[1][4]

Overtreatment, in the strict sense, may refer to unnecessary medical interventions, including treatment of a self-limited condition (overdiagnosis) or to extensive treatment for a condition that requires only limited treatment.

Definition

A forerunner of the term was what Jack Wennberg called unwarranted variation,[5] different rates of treatments based upon where people lived, not clinical rationale. He had discovered that in studies that began in 1967 and were published in the 1970s and the 1980s: "The basic premise-that medicine was driven by science and by physicians capable of making clinical decisions based on well-established fact and theory-was simply incompatible with the data we saw. It was immediately apparent that suppliers were more important in driving demand than had been previously realized."[6]

In 2008, bioethicist Ezekiel J. Emanuel and health economist Victor R. Fuchs defined unnecessary healthcare as "overutilization," healthcare provided with a higher volume or cost than is appropriate.[1]

In 2009 two physicians wrote in an editorial, that unnecessary care was "defined as services which show no demonstrable benefit to patients" and might represent 30% of U.S. medical care.[7]

They referred to a 2003 study on regional variations in Medicare spending, which found, "Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions, but do not have better health outcomes or satisfaction with care."[8]

In January 2012, the American College of Physicians Ethics, Professionalism, and Human Rights Committee suggested that overtreatment can also be understood in contrast to 'parsimonious care', defined as "care that utilizes the most efficient means to effectively diagnose a condition and treat a patient."[9]

In April 2012, Berwick, from the Institute for Healthcare Improvement, and Andrew Hackbarth from the RAND Corporation defined overtreatment as "subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help them — care rooted in outmoded habits, supply-driven behaviors, and ignoring science." They wrote that trying to do something (treatment or testing) for all patients who might need it inevitably entails doing that same thing for some patients who might not need it."

In uncertain situations, "some nonbeneficial care was the necessary byproduct of optimal clinical decision making."[10]

In October 2015, two pediatricians said that looking at "overtreatment as an ethical violation" could help see the conflicting incentives of healthcare workers for treatment or nontreatment.[11]

Cost

In the US, the country that spends the most on healthcare per person globally, overuse is the most important contributor to the high cost.[1] The New York Times reported "chronic overuse of medical care" exists in the United States.[12]

Overuse of medical care costs billions of dollars every year.[13] and lowers the quality of health care. The United States National Academy of Sciences estimated in 2005 that "between $.30 and $.40 of every dollar spent on healthcare is spent on the costs of poor quality," amounting to" slightly more than a half-trillion dollars a year... wasted on overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency.[14]

When care is overused, patients are put at risk of complications unnecessarily,[15] with documented harm to patients from overuse of surgeries and other treatments.[16]

In 2003 Fisher et al.[17][18] found that "there is no apparent regional health benefit for Medicare recipients from doing more, whether 'more' is expressed as hospitalizations, surgical procedures, or consultations within the hospital."[19] Up to 30% of Medicare spending may be cut without harming patients.[18]

Causes

Physicians' decisions are the proximate cause of unnecessary care. Therefore, only the medical profession can solve this problem.[7]

Third-party payers and fee-for-service

See also: Fee-for-service

When public or private insurance cover expenses and doctors are paid under a fee-for-service (FFS) model, neither has an incentive to consider the cost of treatment, a combination that contributes to waste.[4] Fee-for-service is a large incentive for overuse because health care providers (such as doctors and hospitals) receive revenue from the overtreatment.[1]

Atul Gawande investigated Medicare FFS reimbursements in McAllen, Texas, for a 2009 article in the New Yorker.[20][21] McAllen, in 2006, was the second-most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average.[22]

In 1992, however, McAllen was almost exactly in line with the Medicare spending average.[22] After looking at other potential explanations such as relatively poorer health or medical malpractice, Gawande concluded the town was a chief example of the overuse of medical services.[23] Gawande concluded that it appeared a business culture (physicians view their practices as a revenue stream) had established itself there, in contrast to a culture of low-cost high-quality medicine at the Mayo Clinic and in the Grand Junction, Colorado, market.[22][23] Gawande advised:

As America struggles to extend healthcare coverage while curbing healthcare costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don't, McAllen won't be an outlier. It will be our future.[22]

Medical malpractice laws and defensive medicine

To protect themselves from legal prosecution physicians have an incentive to order clinically unnecessary tests, or tests of little potential value.[1] While defensive medicine is a favored explanation for high medical costs by physicians, Gawande estimated it only contributed to 2.4% of the total $2.3 trillion of U.S. health care spending in 2008.[19][24]

Examples

Imaging

Overuse of diagnostic imaging, such as X-rays and CT scans, is defined as any application unlikely to improve patient care.[25] Factors that contribute to overuse include "self-referral, patient wishes, inappropriate financially motivated factors, health system factors, industry, media, lack of awareness" and defensive medicine.[25] Respected organizations—such as the American College of Radiology (ACR), Royal College of Radiologists (RCR) and the World Health Organization (WHO)—have developed "appropriateness criteria".[25] The Canadian Association of Radiologists estimated in 2009 that 30% of imaging was unnecessary in the Canadian health care system.[26] 2008 Medicare claims showed overuse with chest CT's.[27]

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis).[28]

Physician self-referral

One type of overuse can be physician self-referral.[29] Multiple studies have replicated the finding that when nonradiologists have an ownership interest in the fees generated by radiology equipment—and can self-refer—their use of imaging is unnecessarily higher.[29] The majority of U.S. growth in imaging use (the fastest-growing physician service) comes from self-referring nonradiologists.[29] In 2004, this overuse was estimated to contribute to $16 billion of annual U.S. health care costs.[29]

Others

Reduction efforts

The 2010 U.S. health care reform, the Patient Protection and Affordable Care Act, did not contain serious strategies to reduce overuse; "the public has made it clear that it does not want to be told what medical care it can and cannot have."[12] Uwe Reinhardt, a health economist at Princeton, said "the minute you attack overutilization, you will be called a Nazi before the day is out".[12]

Professional societies and other groups have begun to push for policy changes that would encourage clinicians to avoid providing unnecessary care. Most physicians accept that laboratory tests are overused, but "it remains difficult to persuade them to consider the possibility that they, too, might be overutilizing laboratory tests."[49]

Avoiding Avoidable Care

In April 2012, the Lown Institute and the New America Foundation Health Policy Program convened the 'Avoiding Avoidable Care'[50] conference. It was the first major medical conference to focus entirely on overuse, and it included presentations from speakers including Bernard Lown, Don Berwick, Christine Cassel, Amitabh Chandra,[51] JudyAnn Bigby, and Julio Frenk.[52] A second meeting was planned for December 2013.[53]

Since the meeting, the Lown Institute has focused its work on deepening the understanding of overuse and generating public discussion of the ethical and cultural drivers of overuse, especially on the role of the hidden curriculum in medical school and residency.

Choosing Wisely

Main article: Choosing Wisely

In November 2011, the American Board of Internal Medicine Foundation began the Choosing Wisely campaign, which aims to raise awareness of overtreatment and change physician behavior by publicizing lists of tests and treatments that are often overused, and which doctors and patients should try to avoid.

Consumer cost sharing

Main article: Cost sharing

See also

References

  1. 1 2 3 4 5 6 7 8 Ezekiel J. Emanuel, Victor R. Fuchs (2008). "The perfect storm of overutilization" (PDF). The Journal of the American Medical Association. 299 (23): 2789–91. doi:10.1001/jama.299.23.2789. PMID 18560006.
  2. ↑ Kliff, Sarah (September 7, 2012). "We spend $750 billion on unnecessary health care. Two charts explain why.". The Washington Post. Retrieved 31 March 2016.
  3. ↑ Ezekiel J. Emanuel & Victor R. Fuchs. "Health Care Overutilization in the United States—Reply". The Journal of the American Medical Association. 300 (19): 2251. doi:10.1001/jama.2008.605.
  4. 1 2 Victor R. Fuchs (December 2009). "Eliminating 'waste' in health care". JAMA : The Journal of the American Medical Association. 302 (22): 2481–2482. doi:10.1001/jama.2009.1821. PMID 19996406.
  5. ↑ Alix Spiegel (November 10, 2009). "More is Less". This American Life.
  6. ↑ Michael T. McCue Clamping down on variation - Managed Healthcare Executive, February 01, 2003
  7. 1 2 Reilly BM, Evans AT (2009). "Much ado about (doing) nothing.". Ann Intern Med. 150 (4): 270–1. doi:10.7326/0003-4819-150-4-200902170-00008. PMID 19221379. (subscription required)
  8. ↑ Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003; 138:288-98.PMID 12585826
  9. ↑ Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156(1, pt 2):73-104.PMID 22213573, doi: 10.7326/0003-4819-156-1-201201031-00001.
  10. ↑ Berwick DM, Hackbarth AD. Eliminating waste in US health care.JAMA. 2012 Apr 11;307(14):1513-6. doi: 10.1001/jama.2012.362. (subscription required)
  11. ↑ Shawn L. Ralston, Alan R. Schroeder. Doing More vs Doing Good: Aligning Our Ethical Principles From the Personal to the Societal. JAMAPediatrics October 19, 2015 doi:10.1001/jamapediatrics.2015.2702 (subscription required)
  12. 1 2 3 Gina Colata (March 29, 2010). "Law May Do Little to Help Curb Unnecessary Care". The New York Times.
  13. ↑ Gibson; Singh, Rosemary (2010). The Treatment Trap: How the Overuse of Medical Care is Wrecking Your Health. Chicago: Ivan R. Dee. p. 30. ISBN 9781566638425.
  14. ↑ Lawrence, David (2005). Building a Better Delivery System: A New Engineering/Health Care Partnership – Bridging the Quality Chasm. Washington, DC: National Academy of Sciences. p. 99. ISBN 0-309-65406-8.
  15. ↑ "Medicare Options In Biden Budget Talks Get Boost". NPR. The Associated Press. June 15, 2011. Retrieved June 26, 2011.
  16. ↑ Gibson; Singh, Rosemary (2010). The Treatment Trap: How the Overuse of Medical Care is Wrecking Your Health. Chicago: Ivan R. Dee. pp. 63–83. ISBN 9781566638425.
  17. ↑ Elliott S. Fisher, David E. Wennberg, Therese A. Stukel, Daniel J. Gottlieb, F. L. Lucas & Etoile L. Pinder (February 2003). "The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care". Annals of Internal Medicine. 138 (4): 273–287. doi:10.7326/0003-4819-138-4-200302180-00006. PMID 12585825.
  18. 1 2 Elliott S. Fisher, David E. Wennberg, Therese A. Stukel, Daniel J. Gottlieb, F. L. Lucas & Etoile L. Pinder (February 2003). "The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care". Annals of Internal Medicine. 138 (4): 288–298. doi:10.7326/0003-4819-138-4-200302180-00007. PMID 12585826.
  19. 1 2 Steven A. Schroeder (April 2011). "Personal reflections on the high cost of American medical care: Many causes but few politically sustainable solutions". Archives of Internal Medicine. 171 (8): 722–727. doi:10.1001/archinternmed.2011.149. PMID 21518938.
  20. ↑ Katty Kay (July 7, 2009). "Texas town's healthcare puzzle". BBC News. Retrieved June 19, 2011.
  21. ↑ Bryant Furlow (October 2009). "US reimbursement systems encourage fraud and overutilisation". The Lancet Oncology. 10 (10): 937–938. doi:10.1016/S1470-2045(09)70297-9. PMID 19810157.
  22. 1 2 3 4 Atul Gawande (June 1, 2009). "The Cost Conundrum – What a Texas town can teach us about health care". The New Yorker. Retrieved June 29, 2011.
  23. 1 2 "Spend More, Get Less? The Health Care 'Conundrum'". Fresh Air. NPR. June 17, 2009. Retrieved June 29, 2011.
  24. ↑ Michelle M. Mello, Amitabh Chandra, Atul A. Gawande & David M. Studdert (September 2010). "National costs of the medical liability system". Health Affairs (Project Hope). 29 (9): 1569–1577. doi:10.1377/hlthaff.2009.0807. PMC 3048809Freely accessible. PMID 20820010.
  25. 1 2 3 B. Rehani (January 2011). "Imaging overutilisation: Is enough being done globally?". Biomedical Imaging and Intervention Journal. 7 (1): e6. doi:10.2349/biij.7.1.e6. PMC 3107688Freely accessible. PMID 21655115.
  26. ↑ "Do you need that scan?" (PDF). Canadian Association of Radiologists. 2009. Retrieved June 27, 2011.
  27. ↑ Walt Bogdanich; Jo Craven McGinty (June 17, 2011). "Medicare Claims Show Overuse for CT Scanning". The New York Times. Archived from the original on June 22, 2011. Retrieved June 22, 2011.
  28. ↑ Elm Ho (July 2010). "Overuse, overdose, overdiagnosis... overreaction?". Biomedical Imaging and Intervention Journal. 6 (3): e8. doi:10.2349/biij.6.3.e8. PMC 3097773Freely accessible. PMID 21611049.
  29. 1 2 3 4 David C. Levin & Vijay M. Rao (March 2004). "Turf wars in radiology: the overutilization of imaging resulting from self-referral". Journal of the American College of Radiology : JACR. 1 (3): 169–172. doi:10.1016/j.jacr.2003.12.009. PMID 17411553.
  30. ↑ James CD, Hanson K, Solon O, Whitty CJ, Peabody J (June 2011). "Do doctors under-provide, over-provide or do both? Exploring the quality of medical treatment in the Philippines". International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua. 23 (4): 445–55. doi:10.1093/intqhc/mzr029. PMID 21672923.
  31. ↑ "Effective Care – A Dartmouth Atlas Project Topic Brief" (PDF). Dartmouth Atlas Project. January 15, 2007. Retrieved June 29, 2011.
  32. ↑ Carrie Gann (October 6, 2011). "Medicare Patients Get Costly Surgery Before Death". ABC News. Retrieved October 6, 2011.
  33. ↑ Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, Jha AK (2011). "The intensity and variation of surgical care at the end of life: a retrospective cohort study". The Lancet. 378: 1408–1413. doi:10.1016/S0140-6736(11)61268-3.
  34. ↑ Malika Taufiq & Rukhsana W. Zuberi (January 2011). "Overuse of antibiotics in children for upper respiratory infections (URIs): a dilemma". Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 21 (1): 60. PMID 21276393.
  35. ↑ Markus Dietl & Dieter Korczak (2011). "Over-, under- and misuse of pain treatment in Germany". GMS health technology assessment. 7: Doc03. doi:10.3205/hta000094. PMC 3080661Freely accessible. PMID 21522485.
  36. ↑ Ryan Jaslow (June 28, 2011) Blood transfusion regulations needed to rein in overuse: Panel CBS News/Associated Press. Accessed June 28, 2011.
  37. ↑ Ron Winslow; John Carreyrou (July 6, 2011). "Heart Treatment Overused – Study Finds Doctors Often Too Quick to Try Costly Procedures to Clear Arteries". The Wall Street Journal. Retrieved July 6, 2011.
  38. ↑ Chan; et al. (2011). "Appropriateness of Percutaneous Coronary Intervention". JAMA. 306 (1): 53–61. doi:10.1001/jama.2011.916.
  39. ↑ Jay Hancock (July 18, 2011). Progress, but not enough, against needless hospital procedures The Baltimore Sun Accessed August 4, 2011.
  40. ↑ Final Decision and Order Maryland State Board of Physicians Accessed August 4, 2011.
  41. ↑ Meredith Cohn (July 29, 2011). St. Joseph Medical Center's CEO resigns The Baltimore Sun Accessed August 4, 2011.
  42. ↑ Larry Husten (July 13, 2011). Maryland Revokes Mark Midei’s Medical License Forbes Accessed August 4, 2011.
  43. ↑ Walshe K, Shortell SM (2004). "When things go wrong: how health care organizations deal with major failures.". Health Aff (Millwood). 23 (3): 103–11. doi:10.1377/hlthaff.23.3.103. PMID 15160808.
  44. ↑ Gilbert M. Gaul (July 25, 2005). "At California Hospital, Red Flags and an FBI Raid". The Washington Post. Retrieved July 5, 2011.
  45. ↑ Rosemary Gibson (August 25, 2010). "Can Funders Quell a 'Perfect Storm of Overutilization'?". Health Affairs. Retrieved July 5, 2010.
  46. ↑ Camelia S. Sima; Katherine S. Panageas; Deborah Schrag (October 2010). "Cancer screening among patients with advanced cancer". JAMA. 304 (14): 1584–1591. doi:10.1001/jama.2010.1449. PMID 20940384.
  47. ↑ Roland KB, Soman A, Bernard VB, et al. (2011). "Human papillomavirus and Papanicolaou tests screening interval recommendations in the United States". American Journal of Obstetrics and Gynecology. 205 (5): 447.e1. doi:10.1016/j.ajog.2011.06.001.
  48. ↑ Kathleen Doheny (August 20, 2011). "Annual Pap tests often ordered but unneeded" HealthDay (USA Today). Accessed August 22, 2011.
  49. ↑ Jamie A. Weydert, Newell D. Nobbs, Ronald Feld & John D. Kemp (September 2005). "A simple, focused, computerized query to detect overutilization of laboratory tests". Archives of Pathology & Laboratory Medicine. 129 (9): 1141–1143. doi:10.1043/1543-2165(2005)129[1141:ASFCQT]2.0.CO;2. PMID 16119987.
  50. ↑ "Avoiding Avoidable Care". avoidablecare.org. Retrieved January 19, 2015.
  51. ↑ Harvard Kennedy School. "Harvard Kennedy School - Amitabh Chandra". harvard.edu. Retrieved January 19, 2015.
  52. ↑ "Featured Speakers | Avoiding Avoidable Care". Retrieved 21 August 2013.
  53. ↑ "2013 Lown Conference: From Avoidable Care to Right Care". Lown Institute. Retrieved 21 August 2013.

Sources

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