Unnecessary health care

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Unnecessary health care (overutilization, overuse, or overtreatment) is health care 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 was the predominant factor in its expense, accounting for about a third of its health care spending ($750 billion out of $2.6 trillion) in 2012. [2]

Contents

Factors that drive overuse include paying health professionals 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.

It is economically linked with overmedicalization.

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, US bioethicist Ezekiel J. Emanuel and health economist Victor R. Fuchs defined unnecessary health care as "overutilization", health care 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 US 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 non-beneficial care was the necessary byproduct of optimal clinical decision making." [11]

In October 2015, two pediatricians said that considering "overtreatment as an ethical violation" could help see the conflicting incentives of health care workers for treatment or nontreatment. [12]

Low-value health care, for the most part, is administration of tests or treatment, which though useful initially, offer little value if given repeatedly as a part of routine care. [13]

Cost

In the US, the country which spends the most on health care per person globally, patients have fewer doctor visits and fewer days in hospitals than people in other countries do, [14] but prices are high, [15] there is more use of some procedures and new drugs than elsewhere, and doctor salaries are double the levels in other countries. [1] The New York Times reported "no one knows for sure" how much unnecessary care exists in the United States. [16] Overuse of medical care is no longer a large fraction of total health care spending, which was $3.3 trillion in 2016. [17]

Researchers in 2014 analyzed many services listed as low value by Choosing Wisely and other sources. They looked at spending in 2008–2009 and found that these services represented 0.6% or 2.7% of Medicare costs [18] and there was no significant pattern of particular types of physicians ordering these low value services. [19] The Institute of Medicine in 2010 gave two estimates of "unnecessary services," using different methodologies: 0.2% or 1% to 5% of health spending, [20] which was US$2.6 trillion. [17] The Institute of Medicine quoted that 2010 report in a 2012 report to support an estimate of 8% ($210 billion) in unnecessary services, without explaining the discrepancy. [21] This IOM 2012 report also said there were $555 billion in other wasted spending, which have an "unknown overlap" with each other and the $210 billion. [21] The United States National Academy of Sciences estimated in 2005, without giving its methods or sources, that "between $.30 and $.40 of every dollar spent on health care 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. [22] In 2003 Fisher et al. [23] [24] found that there was "no apparent regional health benefit for Medicare recipients from doing more, whether 'more' is expressed as hospitalizations, surgical procedures, or consultations within the hospital." [25] Up to 30% of Medicare spending could be cut in 2003 without harming patients. [24]

A study of low-value care in laboratory testing suggested that Medicare may have overspent at least US$1.95 billion on laboratory tests in the year 2019. [26] The study found excessively frequent ordering of Hemoglobin A1c, prostate-specific antigen, vitamin D 25-hydroxy, and lipid panels.

When care is overused, patients are put at risk of complications unnecessarily, [27] with documented harm to patients from overuse of surgeries and other treatments. [28]

Causes

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

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. [29] [30] In 2006, the town of McAllen was the second-most expensive Medicare market, behind Miami. Costs per beneficiary were almost twice the national average. [31]

In 1992, however, McAllen had been almost exactly in line with the Medicare spending average. [31] 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. [32] Gawande concluded that a business culture (physicians viewing 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. [31] [32] 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. [31]

Medical malpractice laws and defensive medicine

To protect themselves from legal prosecution U.S. 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 in 2010 it only contributed to 2.4% of the total $2.3 trillion of U.S. health care spending in 2008. [25] [33]

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 predispositions

Dartmouth Medical School professor Gilbert Welch argued 2016 that certain predispositions by physicians and the general public may lead to unnecessary health care, including: [34] [35]

Examples

Imaging

Overuse of diagnostic imaging, such as X-rays and CT scans, is defined as any application unlikely to improve patient care. [36] 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. [36] 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". [36] The Canadian Association of Radiologists estimated in 2009 that 30% of imaging was unnecessary in the Canadian health care system. [37] 2008 Medicare claims showed overuse with chest CT's. [38] Financial incentives have also been shown to have a significant impact on dental X-ray use with dentists who are paid a separate fee for each X-ray providing more X-rays. [39]

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis). [40]

Physician self-referral

One type of overuse can be physician self-referral. [41] 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. [41] The majority of U.S. growth in imaging use (the fastest-growing physician service) comes from self-referring nonradiologists. [41] In 2004, this overuse was estimated to contribute to $16 billion of annual U.S. health care costs. [41]

As of a 2018 review evidence of overtreatment overmedicalization, and overdiagnosis in Pediatrics have been use of commercial rehydration solution, antidepressants, and parenteral nutrition; overmedicalization with planned early deliveries, immobilization of ankle injuries, use of hydrolyzed infant formula; and overdiagnosis of hypoxemia among children recovering from bronchiolitis. [42]

Others

Reduction efforts

Utilization management (utilization review) has evolved over decades among both public and private payers in an attempt to reduce overuse. [62] 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. Results of a recent systematic review found that many studies focused more on reductions in utilization than in improving clinically meaningful measures. [63]

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." [16] Uwe Reinhardt, a health economist at Princeton, said "the minute you attack overutilization, you will be called a Nazi before the day is out". [16]

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." [64] 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. [65]

The Clinical and Laboratory Standards Institute (CLSI) issued a 2017 guideline, "Developing and Managing a Medical Laboratory (Test) Utilization Program (GP49)", to help laboratories establish stewardship programs. [66]

Clinical decision support tools can help decrease unnecessary laboratory testing. [67] The PLUGS initiative (Patient-Centered Laboratory Utilization Guidance Services) aims to formalize laboratory stewardship practices. [68] The TRUU-Lab (Test Renaming for Understanding and Utilization in the Laboratory) initiative is a cooperative effort of CDC, CMS, FDA, and CAP. The project aims to standardize the names of laboratory tests to limit errant test ordering. [69] [70] Genetic testing stewardship programs have been established to streamline molecular diagnostic ordering patterns. [71]

The Joint Commission offers accreditation in patient blood management in conjunction with AABB. To become accredited, participating hospitals may distribute guidelines for appropriateness of blood transfusion, form a committee to audit blood utilization, identify areas for improvement, and monitor compliance. [72]

In the UK, 2011, online platform AskMyGP was launched to decrease the amount of unnecessary medical appointments. In the app patients are given a questionnaire about their symptoms, which then assesses the patient's need for medical care. The program was a success, and as of January 2018 has managed over 29,000 patient episodes.

The Royal College of Pathologists issued 2021 guidelines for the minimum time that should elapse before a given laboratory test is repeated in a specific clinical scenario. [73]

In April 2012, the Lown Institute and the New America Foundation Health Policy Program convened the 'Avoiding Avoidable Care' [74] 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, JudyAnn Bigby, and Julio Frenk. [75] A second meeting was planned for December 2013. [76]

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.[ citation needed ]

Patient safety committees, which are charged with reviewing the quality of care, can view overutilization as adverse event. [77]

Consumer cost sharing

See also

Related Research Articles

<span class="mw-page-title-main">Emergency medicine</span> Medical specialty concerned with care for patients who require immediate medical attention

Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency medicine physicians specialize in providing care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with emergency medical services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency medical physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.

<span class="mw-page-title-main">Physical examination</span> Process by which a medical professional investigates a patients body for signs of disease

In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patient's medical history followed by an examination based on the reported symptoms. Together, the medical history and the physical examination help to determine a diagnosis and devise the treatment plan. These data then become part of the medical record.

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailments.

Overdiagnosis is the diagnosis of disease that will never cause symptoms or death during a patient's ordinarily expected lifetime and thus presents no practical threat regardless of being pathologic. Overdiagnosis is a side effect of screening for early forms of disease. Although screening saves lives in some cases, in others it may turn people into patients unnecessarily and may lead to treatments that do no good and perhaps do harm. Given the tremendous variability that is normal in biology, it is inherent that the more one screens, the more incidental findings will generally be found. For a large percentage of them, the most appropriate medical response is to recognize them as something that does not require intervention; but determining which action a particular finding warrants can be very difficult, whether because the differential diagnosis is uncertain or because the risk ratio is uncertain.

Defensive medicine, also called defensive medical decision making, refers to the practice of recommending a diagnostic test or medical treatment that is not necessarily the best option for the patient, but mainly serves to protect the physician against the patient as potential plaintiff. Defensive medicine is a reaction to the rising costs of malpractice insurance premiums and patients’ biases on suing for missed or delayed diagnosis or treatment but not for being overdiagnosed.

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

John E. "Jack" Wennberg was an American healthcare researcher who was a pioneer of unwarranted variation in the healthcare industry. In four decades of work, Wennberg has documented the geographic variation in the healthcare that patients receive in the United States. In 1988, he founded the Center for the Evaluative Clinical Sciences at Dartmouth Medical School to address that unwarranted variation in healthcare.

Unwarranted variation in health care service delivery refers to medical practice pattern variation that cannot be explained by illness, medical need, or the dictates of evidence-based medicine. It is one of the causes of low value care often ignored by health systems.

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<span class="mw-page-title-main">Cancer screening</span> Method to detect cancer

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<span class="mw-page-title-main">Choosing Wisely</span> U.S.-based educational campaign

Choosing Wisely is a United States–based health educational campaign, led by the ABIM Foundation, about unnecessary health care.

<span class="mw-page-title-main">Peter Bach</span> Medical researcher

Peter B. Bach is a physician and writer in New York City. He is the Chief Medical Officer of DELFI Diagnostics and was previously an attending and researcher at Memorial Sloan-Kettering Cancer Center where he was the Director of the Center for Health Policy and Outcomes. His research focuses on healthcare policy, particularly as it relates to Medicare, racial disparities in cancer care quality, and lung cancer. Along with his scientific writings he is a frequent contributor to The New York Times and other newspapers.

Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.

The Physician Payments Sunshine Act is a 2010 United States healthcare law to increase transparency of financial relationships between health care providers and pharmaceutical or medical device manufacturers.

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Elliott S. Fisher is a health policy researcher and advocate for improving health system performance in the United States. He helped develop the concept of accountable care organizations and championed their adoption by Medicare. The development of the Affordable Care Act was influenced by his research on disparities in healthcare spending and utilization across the United States. He has strongly supported a rapid transition from fee-for-service to pay-for-performance models in the U.S. healthcare industry. He is a tenured faculty member at Dartmouth College, where he teaches in the Masters in Public Health program.

References

Citations

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