Unnecessary health care
Unnecessary health care (overutilization or overtreatment) is when medical services are provided with a higher volume or cost than is appropriate. 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. These factors leave both doctors and patients with no incentive to restrain health care prices or use.
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.
- 1 Background
- 2 Cost, quality and policy implications
- 3 Contributing factors and examples
- 4 Efforts to reduce overuse
- 5 See also
- 6 References
- 7 Further reading
- 8 External links
When care is overused, patients are put at risk of complications unnecessarily, 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. 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. The New York Times reports that a "chronic overuse of medical care" exists in the United States. Unnecessary care, defined as services which show no demonstratable benefit to paitents, may represent 30% of U.S. medical 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".
Defining inappropriate services
|This section requires expansion. (July 2011)|
Cost, quality and policy implications
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.
Fisher et al. 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". Up to 30% of Medicare spending may be cut without harming patients. Overuse of medical care in the United States is costing Americans billions of dollars every year. Gibson and Singh have documented harm to patients from overuse of surgeries and other treatments. .
Contributing factors and examples
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.
Third-party payers and fee-for-service
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.
Atul Gawande investigated U.S. Medicare FFS reimbursements in the town of McAllen, Texas for a 2009 article in the New Yorker. McAllen, in 2006, was the second most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average. In 1992, however, McAllen was almost exactly in line with the Medicare spending average. 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. 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. 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.
Overutilization of diagnostic imaging, such as X-rays and CT scans, is defined as any application that is unlikely to improve patient care. 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".
One type of overutilization can be physician self-referral. 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. The majority of U.S. growth in imaging utilization (the fastest growing physician service) comes from self-referring non-radiologists. In 2004, this overutilization was estimated to contribute to $16 billion of annual U.S. health care costs.
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". Uwe Reinhardt, a health economist at Princeton, said "the minute you attack overutilization you will be called a Nazi before the day is out".
- Hospitalizations, including admissions for those with chronic conditions who could be treated as outpatients
- Surgeries in Medicare patients in their last year of life, regions with high levels had higher death rates
- Antibiotic use (an overmedication)
- Effects of direct to consumer marketing
- Opiate prescriptions
- Blood transfusions in the U.S.
- An estimated one in eight coronary stents (used in $20,000 procedures) with non-acute indications (U.S.)
- Heart bypass surgeries at Redding Medical Center which resulted in a FBI raid
- 2008 Medicare rates of double scanning with chest CTs
- Screening patients with advanced cancer for other cancers
- Annual cervical cancer screening in women with medical histories of normal pap smear and HPV test results
Medical malpractice laws and defensive medicine
Physicians are incentivized to order clinically unnecessary, or of little potential value, tests in order to protect themselves from prosecution. 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.
Efforts to reduce overuse
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
In April 2012, the Lown Institute and the New America Foundation Health Policy Program convened the Avoiding Avoidable Care conference. 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. A second meeting is planned for December 2013.
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.
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
|This section requires expansion. (October 2011)|
- 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.
- 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.
- 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.
- Alix Spiegel (November 10, 2009). "More is Less". This American Life.
- "Medicare Options In Biden Budget Talks Get Boost". NPR (The Associated Press). JUne 15, 2011. Retrieved June 26, 2011.
- Gina Colata (March 29, 2010). "Law May Do Little to Help Curb Unnecessary Care". The New York Times.
- Reilly BM, Evans AT (2009). "Much ado about (doing) nothing.". Ann Intern Med 150 (4): 270–1. PMID 19221379.
- 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.
- 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.
- 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. PMID 12585825.
- 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. PMID 12585826.
- 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.
- 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.
- 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.
- 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 3107688. PMID 21655115.
- Katty Kay (July 7, 2009). "Texas town's healthcare puzzle". BBC News. Retrieved June 19, 2011.
- 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.
- 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.
- "Spend More, Get Less? The Health Care 'Conundrum'". Fresh Air (NPR). June 17, 2009. Retrieved June 29, 2011.
- "Do you need that scan?". Canadian Association of Radiologists. 2009. Retrieved June 27, 2011.
- Elm Ho (July 2010). "Overuse, overdose, overdiagnosis... overreaction?". Biomedical Imaging and Intervention Journal 6 (3): e8. doi:10.2349/biij.6.3.e8. PMC 3097773. PMID 21611049.
- 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.
- 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.
- "Effective Care – A Dartmouth Atlas Project Topic Brief". Dartmouth Atlas Project. January 15, 2007. Retrieved June 29, 2011.
- Carrie Gann (October 6, 2011). "Medicare Patients Get Costly Surgery Before Death". ABC News. Retrieved October 6, 2011.
- 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. doi:10.1016/S0140-6736(11)61268-3.
- 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.
- 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 3080661. PMID 21522485.
- Ryan Jaslow (June 28, 2011) Blood transfusion regulations needed to rein in overuse: Panel CBS News/Associated Press. Accessed June 28, 2011.
- Ron Winslow and 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.
- Chan et al. (2011). "Appropriateness of Percutaneous Coronary Intervention". JAMA 306 (1): 53–61. doi:10.1001/jama.2011.916.
- Jay Hancock (July 18, 2011). Progress, but not enough, against needless hospital procedures The Baltimore Sun Accessed August 4, 2011.
- Final Decision and Order Maryland State Board of Physicians Accessed August 4, 2011.
- Meredith Cohn (July 29, 2011). St. Joseph Medical Center's CEO resigns The Baltimore Sun Accessed August 4, 2011.
- Larry Husten (July 13, 2011). Maryland Revokes Mark Midei’s Medical License Forbes Accessed August 4, 2011.
- 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.
- Gilbert M. Gaul (July 25, 2005). "At California Hospital, Red Flags and an FBI Raid". The Washington Post. Retrieved July 5, 2011.
- Rosemary Gibson (August 25, 2010). "Can Funders Quell a 'Perfect Storm of Overutilization'?". Health Affairs. Retrieved July 5, 2010.
- Walt Bogdanich and 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.
- 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.
- 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.
- Kathleen Doheny (August 20, 2011). "Annual Pap tests often ordered but unneeded" HealthDay (USA Today). Accessed August 22, 2011.
- 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. PMID 20820010.
- "Avoiding Avoidable Care".
- "Featured Speakers | Avoiding Avoidable Care". Retrieved 21 August 2013.
- "2013 Lown Conference: From Avoidable Care to Right Care". Lown Institute. Retrieved 21 August 2013.
- Shannon Brownlee (2007). Overtreated: Why too much medicine is making us sicker and poorer. London: Bloomsbury. ISBN 1-58234-580-5.
- Hendee WR, Becker GJ, Borgstede JP, et al. (October 2010). "Addressing overutilization in medical imaging". Radiology 257 (1): 240–5. doi:10.1148/radiol.10100063. PMID 20736333.
- R. E. Malone (October 1998). "Whither the almshouse? Overutilization and the role of the emergency department". Journal of Health Politics, Policy and Law 23 (5): 795–832. doi:10.1215/03616878-23-5-795. PMID 9803363.
- Sana M. Al-Khatib, Anne Hellkamp, Jeptha Curtis, Daniel Mark, Eric Peterson, Gillian D. Sanders, Paul A. Heidenreich, Adrian F. Hernandez, Lesley H. Curtis & Stephen Hammill (January 2011). "Non-evidence-based ICD implantations in the United States". JAMA : The Journal of the American Medical Association 305 (1): 43–49. doi:10.1001/jama.2010.1915. PMID 21205965.
- David B. Larson, Lara W. Johnson, Beverly M. Schnell, Shelia R. Salisbury & Howard P. Forman (January 2011). "National trends in CT use in the emergency department: 1995–2007". Radiology 258 (1): 164–173. doi:10.1148/radiol.10100640. PMID 21115875. – a story on the study
- Gawande, Atul A.; Colla, Carrie H.; Halpern, Scott D.; Landon, Bruce E. (3 April 2014). "Avoiding Low-Value Care". New England Journal of Medicine 370 (14): e21. doi:10.1056/NEJMp1401245.
- Disease Creep: How we're fooled into using more medicine than we need by medical investigative journalist Jeanne Lenzer