Overutilization

Overutilization refers to medical services that 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.

Contents 1 Background 1.1 Defining inappropriate services 2 Cost, quality and policy implications 3 Contributing factors and examples 3.1 Third-party payers and fee-for-service 3.2 Imaging 3.2.1 Physician self-referral 3.3 Politics 3.4 Others 3.5 Medical malpractice laws and defensive medicine 4 Cost sharing 5 See also 6 References 7 Further reading

Background

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

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.^[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]

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.^[13]

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.^[3]

Atul Gawande investigated U.S. Medicare FFS reimbursements in the town of McAllen, Texas for a 2009 article in the New Yorker.^[14][15] McAllen, in 2006, was the second most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average.^[16] In 1992, however, McAllen was almost exactly in line with the Medicare spending average.^[16] 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.^[17] Gawande concluded that it appeared a business culture (where physicans 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.^[16][17] 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.^[16]

Imaging

The Canadian Association of Radiologists estimates that 30% of imaging is unnecessary in the Canadian health care system.^[18]

Overutilization of diagnostic imaging, such as X-rays and CT scans, is defined as any application that is unlikely to improve patient care.^[13] 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".^[13]

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis).^[19]

Physician self-referral

One type of overutilization can be physician self-referral.^[20] 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.^[20] The majority of U.S. growth in imaging utilization (the fastest growing physician service) comes from self-referring non-radiologists.^[20] In 2004, this overutilization was estimated to contribute to $16 billion of annual U.S. health care costs.^[20]

Politics

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

• Hospitalizations,^[21] including admissions for those with chronic conditions who could be treated as outpatients^[22]
• Surgeries in Medicare patients in their last year of life, regions with high levels had higher death rates^[23][24]
• Antibiotic use^[1][25] (an overmedication)
• Effects of direct to consumer marketing^[1]
• Opiate prescriptions^[26]
• Blood transfusions in the U.S.^[27]
• An estimated one in eight coronary stents (used in $20,000 procedures) with non-acute indications (U.S.)^[28][29]
  • Stents performed by the formal chair of cardiology, Mark Midei, at St. Joseph Medical Center of Towson, Maryland^{[30][31][32][33]}
• Heart bypass surgeries at Redding Medical Center which resulted in a FBI raid^[34][35][36]
• 2008 Medicare rates of double scanning with chest CTs^[37]
• Screening patients with advanced cancer for other cancers^[38]
• Annual cervical cancer screening in women with medical histories of normal pap smear and HPV test results^[39][40]

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.^[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][41]

Cost sharing

See also

• Medicare fraud
• Moral hazard

References

Further reading

• 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