Unnecessary health care

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Unnecessary health care (overutilization or overtreatment) is when medical services are 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, overutilization is the predominant factor in its expense. Factors that drive overutilization include paying health care providers more to do more (fee-for-service) and covering patients' costs by a third-party (public or private insurance) payer.[2] These factors leave both doctors and patients with no incentive to restrain health care prices or use.[1][3]

Similarly, overtreatments are unnecessary medical interventions (therapies). They could be medical services for a condition that causes no symptoms and will go away on its own, or intensive treatments for a condition that could be remedied with very limited treatment. Overdiagnosis, when patients are given a diagnosis that will cause no symptoms or harm, can lead to overtreatment.

Background[edit]

In the 1970s and 1980s, Jack Wennberg's pioneering studies documented unwarranted variation,[4] different rates of treatments based upon where people lived, not clinical rationale.

When care is overused, patients are put at risk of complications unnecessarily,[5] while health care providers (such as doctors and hospitals) receive revenue from the over-treatment when coupled to a fee-for-service (FFS) payment model; FFS is a large incentive for overutilization.[1] In the United States, the country which spends the most on health care per person globally, overutilization is the most important contributor to the high cost.[1] The New York Times reports that a "chronic overuse of medical care" exists in the United States.[6] Unnecessary care, defined as services which show no demonstratable benefit to paitents, may represent 30% of U.S. medical care.[7]

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".[8]

Defining inappropriate services[edit]

Cost, quality and policy implications[edit]

In the United States, overutilization is a costly expense that lowers the quality of health care.

Between $.30 and $.40 of every dollar spent on health care is spent on the costs of poor quality. This extraordinary number represents slightly more than a half-trillion dollars a year [in 2005]. A vast amount of money is wasted on overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency.[9]

Fisher et al.[10][11] demonstrated 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".[12] Up to 30% of Medicare spending may be cut without harming patients.[11] Overuse of medical care in the United States is costing Americans billions of dollars every year.[13] Gibson and Singh have documented harm to patients from overuse of surgeries and other treatments. .[14]

Contributing factors and examples[edit]

Factors that contribute to overutilization include "self-referral, patient wishes, inappropriate financially motivated factors, health system factors, industry, media, lack of awareness" and defensive medicine.[15]

Third-party payers and fee-for-service[edit]

When patients have their expenses covered by public or private insurance, and doctors are paid under a fee-for-service (FFS) model, neither have an incentive to consider the cost of treatment, a combination which contributes to waste.[3]

Atul Gawande investigated U.S. Medicare FFS reimbursements in the town of McAllen, Texas for a 2009 article in the New Yorker.[16][17] McAllen, in 2006, was the second most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average.[18] In 1992, however, McAllen was almost exactly in line with the Medicare spending average.[18] After looking at other potential explanations such as relatively poorer health or medical malpractice, Gawande concluded that the town was a chief example of the overuse of medical services.[19] Gawande concluded that it appeared a business culture (where 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.[18][19] Gawande advised that

As America struggles to extend health-care coverage while curbing health-care 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.[18]

Imaging[edit]

The Canadian Association of Radiologists estimates that 30% of imaging is unnecessary in the Canadian health care system.[20]

Overutilization of diagnostic imaging, such as X-rays and CT scans, is defined as any application that is unlikely to improve patient care.[15] Respected organizations—such as the American College of Radiology (ACR), Royal College of Radiology (RCR) and the World Health Organization (WHO)—have developed "appropriateness criteria".[15]

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis).[21]

Physician self-referral[edit]

One type of overutilization can be physician self-referral.[22] Multiple studies have replicated the finding that when non-radiologists have an ownership interest in the fees generated by radiology equipment—and can self-refer—their utilization of imaging is unnecessarily higher.[22] The majority of U.S. growth in imaging utilization (the fastest growing physician service) comes from self-referring non-radiologists.[22] In 2004, this overutilization was estimated to contribute to $16 billion of annual U.S. health care costs.[22]

Politics[edit]

The 2010 U.S. health care reform, the Patient Protection and Affordable Care Act, did not contain serious strategies to reduce overutilization; "the public has made it clear that it does not want to be told what medical care it can and cannot have".[6] Uwe Reinhardt, a health economist at Princeton, said "the minute you attack overutilization you will be called a Nazi before the day is out".[6]

Others[edit]

Medical malpractice laws and defensive medicine[edit]

Physicians are incentivized to order clinically unnecessary, or of little potential value, tests in order to protect themselves from prosecution.[1] While defensive medicine is a favored explanation for high medical costs by physicians, it was estimated to only contribute to 2.4% of the total $2.3 trillion of U.S. health care spending in 2008.[12][43]

Efforts to reduce overuse[edit]

As overuse has become a more widely-recognized problem within medicine, professional societies and other groups have begun to push for policy changes that would encourage clinicians to avoid providing unnecessary care.

Avoiding Avoidable Care[edit]

In April 2012, the Lown Institute and the New America Foundation Health Policy Program convened the Avoiding Avoidable Care conference.[44] It was the first major medical conference to focus entirely on overuse, and included presentations from speakers including Bernard Lown, Don Berwick, Christine Cassel, Amitabh Chandra, JudyAnn Bigby, and Julio Frenk.[45] A second meeting is planned for December 2013.[46]

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[edit]

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[edit]

See also[edit]

References[edit]

  1. ^ a b c d e f g Ezekiel J. Emanuel & Victor R. Fuchs (June 2008). "The perfect storm of overutilization". JAMA : The Journal of the American Medical Association 299 (23): 2789–2791. doi:10.1001/jama.299.23.2789. PMID 18560006. 
  2. ^ Ezekiel J. Emanuel & Victor R. Fuchs. "Health Care Overutilization in the United States—Reply". JAMA : The Journal of the American Medical Association 300 (19): 2251. doi:10.1001/jama.2008.605. 
  3. ^ a b 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. 
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  45. ^ "Featured Speakers | Avoiding Avoidable Care". Retrieved 21 August 2013. 
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