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

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

Definition

A forerunner of the term was what

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

When care is overused, patients are put at risk of complications unnecessarily,^[26] with documented harm to patients from overuse of surgeries and other treatments.^[27]

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.^[28][29] In 2006, the town of McAllen was the second-most expensive Medicare market, behind Miami. Costs per beneficiary were almost twice the national average.^[30]

In 1992, however, McAllen had been almost exactly in line with the Medicare spending average.^[30] 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.^[31] 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.^[30][31] 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.^[30]

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][32]

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:^[33][34]

• Attempting to mitigate a risk without considering how small or unlikely the potential benefit is
• 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 wiser
• Acting without considering the benefits of doing nothing
• Discounting downsides of diagnostic testing
• Preferring newer over older treatments without considering the 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 a patient's preferences

Examples

Imaging

Overuse of diagnostic imaging, such as X-rays and CT scans, is defined as any application unlikely to improve patient care.

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis).^[39]

Physician self-referral

One type of overuse can be physician self-referral.^[40] 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.^[40] The majority of U.S. growth in imaging use (the fastest-growing physician service) comes from self-referring nonradiologists.^[40] In 2004, this overuse was estimated to contribute to $16 billion of annual U.S. health care costs.^[40]

As of a 2018 review evidence of overtreatment

• Hospitalizations[42] for those with chronic conditions who could be treated as outpatients^[43]
• Surgeries in Medicare patients in their last year of life; regions with high levels had higher death rates^[44][45]
• Antibiotic use for viral or self-limiting infections
  antibiotic resistance
  )
• Opiate prescriptions^[47] 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^[48]
• An estimated one in eight coronary stents (used in $20,000 procedures) with nonacute indications (U.S.)^[49][50]
  • Stents performed by the formal chair of cardiology, Mark Midei, at
    St. Joseph Medical Center of Towson, Maryland^{[51][52][53][54]}
• FBI raid^[55][56][57]
• Screening patients with advanced cancer for other cancers[58]
• Annual
  HPV test results^[59][60]

Utilization management (utilization review) has evolved over decades among both public and private payers in an attempt to reduce overuse.^[61] 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.^[62]

The 2010 U.S. health care reform, the

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."[63] In November 2011, the

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.

In April 2012, the Lown Institute and the

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.^[67]

Consumer cost sharing

This section needs expansion. You can help by adding to it. (October 2011)

See also

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

References

Citations