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 (fee-for-service), defensive medicine to protect against litigiousness, and insulation from price sensitivity in instances where the consumer is not the payer—the patient receives goods and services but insurance pays for them (whether public insurance, private, or both).^[3] Such factors leave many actors in the system (doctors, patients, pharmaceutical companies, device manufacturers) with inadequate incentive to restrain health care prices or overuse.^[1][4] This drives payers, such as national health insurance systems or the U.S. Centers for Medicare and Medicaid Services, to focus on medical necessity as a condition for payment. However, the threshold between necessity and lack thereof can often be subjective.

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 health care as "overutilization," healthcare provided with a higher volume or cost than is appropriate.^[1] Recently, economists have sought to understand unnecessary health care in terms of misconsumption rather than overconsumption.^[7]

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.^[8] 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."^[9]

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."^[10]

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."^[11]

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.^[12]

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.^[13]

Overuse of medical care costs billions of dollars every year.^[14] 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.^[15]

When care is overused, patients are put at risk of complications unnecessarily,^[16] with documented harm to patients from overuse of surgeries and other treatments.^[17]

In 2003 Fisher et al.^[18][19] 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."^[20] Up to 30% of Medicare spending may be cut without harming patients.^[19]

Causes

Physicians' decisions are the proximate cause of unnecessary care, though the potential incentives and penalties they face can influence their choices.

Third-party payers and 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.^[21][22] McAllen, in 2006, was the second-most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average.^[23]

In 1992, however, McAllen was almost exactly in line with the Medicare spending average.^[23] 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.^[24] 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.^[23][24] Gawande advised:

As America struggles to extend healthcare 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.^[23]

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.^[20][25]

Direct-to-consumer advertising

Direct-to-consumer advertising can encourage patients to ask for drugs, devices, diagnostics, or procedures. Sometimes service providers will simply give these treatments or services rather than attempting the potentially more unpleasant task of convincing the patient what they have requested is not needed, or is likely to cause more harm than good.^[1]

Physician biases

Dartmouth Medical School professor Dr. Gilbert Welch argues that doctors can have certain predispositions which may lead to unnecessary health care, including:^[26][27]

• Attempting to mitigate a risk without considering how small or unlikely the potential benefit
• Attempting to fix an underlying problem instead of using a less-risky monitoring or coping strategy
• Acting too quickly when waiting for more information might be more wise
• Discounting the potential downsides of diagnostic testing
• Acting without considering the benefits of doing nothing
• Preferring newer treatments over older without considering the potential cost of new treatments or the effectiveness of older ones
• Treating patients with terminal illness to maximize life span over quality of life, without probing the preferences of the patient

Examples

Imaging

Overuse of diagnostic imaging, such as X-rays and CT scans, is defined as any application unlikely to improve patient care.^[28] 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.^[28] 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".^[28] The Canadian Association of Radiologists estimated in 2009 that 30% of imaging was unnecessary in the Canadian health care system.^[29] 2008 Medicare claims showed overuse with chest CT's.^[30]

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis).^[31]

Physician self-referral

One type of overuse can be physician self-referral.^[32] 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 use of imaging is unnecessarily higher.^[32] The majority of U.S. growth in imaging use (the fastest-growing physician service) comes from self-referring nonradiologists.^[32] In 2004, this overuse was estimated to contribute to $16 billion of annual U.S. health care costs.^[32]

Others

• Hospitalizations^[33] for those with chronic conditions who could be treated as outpatients^[34]
• Surgeries in Medicare patients in their last year of life; regions with high levels had higher death rates^[35][36]
• Antibiotic use for viral or self-limiting infections^[1][37] (an overmedication that can promote antibiotic resistance)
• Opiate prescriptions^[38] carry the risk of addiction. In some cases, the number of pills prescribed might exceed what is actually needed for pain relief from a given condition, or a different pain management technique or medication would be effective but less risky.
• Many blood transfusions in the U.S. are given without checking to see if they are needed after a previous transfusion, or are given in cases where monitoring, recovering the patient's own blood, or iron therapy would be effective and reduce the risk of complications^[39]
• An estimated one in eight coronary stents (used in $20,000 procedures) with nonacute indications (U.S.)^[40][41]
  • Stents performed by the formal chair of cardiology, Mark Midei, at St. Joseph Medical Center of Towson, Maryland^{[42][43][44][45]}
• Heart bypass surgeries at Redding Medical Center which resulted in a FBI raid^[46][47][48]
• Screening patients with advanced cancer for other cancers^[49]
• Annual cervical cancer screening in women with medical histories of normal pap smear and HPV test results^[50][51]

Reduction efforts

Utilization management (utilization review) has evolved over decades among both public and private payers in an attempt to reduce overuse. In this effort, insurers employ physicians to review the actions of other physicians and detect overuse. Utilization review has a poor reputation among most clinicians as a corrupted system in which utilization reviewers have their own perverse incentives (i.e., find ways to deny coverage no matter what) and in some cases are not practicing physicians, lacking real-world clinical insight or wisdom.

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."^[13] Uwe Reinhardt, a health economist at Princeton, said "the minute you attack overutilization, you will be called a Nazi before the day is out".^[13]

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."^[52] 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.

In April 2012, the Lown Institute and the New America Foundation Health Policy Program convened the 'Avoiding Avoidable Care'^[53] 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,^[54] JudyAnn Bigby, and Julio Frenk.^[55] A second meeting was planned for December 2013.^[56]

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.

Patient safety committees, which are charged with reviewing the quality of care, can view overutilization as adverse event.^[57]

Consumer cost sharing

See also

• Medicare fraud
• Moral hazard
• Antibiotic misuse
• Choosing Wisely

References

Sources

• Shannon Brownlee (2007). Overtreated: Why too much medicine is making us sicker and poorer. London: Bloomsbury. ISBN 1-58234-580-5. 
• Gawande, Atul (11 May 2015). "America’s Epidemic of Unnecessary Care". newyorker.com. Retrieved 4 May 2015. 
• Hendee WR, Becker GJ, Borgstede JP, et al. (October 2010). "Addressing overutilization in medical imaging". Radiology. 257 (1): 240–5. PMID 20736333. doi:10.1148/radiol.10100063. 
• 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. PMID 9803363. doi:10.1215/03616878-23-5-795. 
• 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. PMC 3432303 . PMID 21205965. doi:10.1001/jama.2010.1915. CS1 maint: Multiple names: authors list (link)
• 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. PMID 21115875. doi:10.1148/radiol.10100640. CS1 maint: Multiple names: authors list (link) – 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. PMID 24693918. doi:10.1056/NEJMp1401245. 

External links

• Disease Creep: How we're fooled into using more medicine than we need by medical investigative journalist Jeanne Lenzer