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Overuse of Health Care Services - Cost, Consequences and Considerations for Change

Several years ago, a family member was suffering from persistent headaches and nerve pain radiating through one side of her head, face and neck. She underwent a battery of tests, including a CT scan, which revealed no abnormalities.  Several weeks passed with no relief and a second doctor ordered another CT scan.  The family member pushed back – what was the purpose only three weeks later?  Did the benefit outweigh the risk of more radiation exposure? After much back and forth, the doctor relented. And it turned out that a second CT scan was indeed unnecessary - the cause was ultimately determined to be a pinched nerve.

There are millions of health care decisions made each day that are well informed by clinical evidence and follow best practices as well as those that are driven by habit or perverse economic incentives, which can lead to overuse of unnecessary, even harmful, services. The Institute of Medicine estimates that unnecessary services represent about 10% of all U.S. health care spending — nearly $300 billion a year. And while overuse of services drives up spending, inappropriate service is particularly troubling because it has the potential to harm patients.  For example, according to an Urban Institute study, one in every four patients admitted to the hospital is prescribed an inappropriate medicine, which can lead to adverse drug reactions.

There are many possible reasons for the provision of inappropriate or unnecessary services, such as financial incentives, legal concerns, lack of education, patient demand and professional biases. While there are no quick solutions, some possible considerations to tackle these problems include:

Understanding that more care is not always better care. As our CT scan story above demonstrates, there are certainly opportunities for reducing the quantity of care without compromising quality. Educate clinicians and patients about why an unnecessary test could wind up being bad for them so that doctors and patients can have more constructive conversations about the tests.

One size does not fit all.  We should be taking steps to move from a quality assessment system that merely tracks use of services to a quality management system that helps providers and patients make better decisions about when care is necessary or inappropriate. That may mean taking the time for more personalized assessments with each patient, as well as taking into account the preferences of patients who are well informed about their options.

Reconceiving the value of services.  As we discussed in a previous article, while clinical outcomes are a paramount measure of value for physicians, for patients, affordable out-of-pocket costs and friendly and helpful staff rank more important than health improvement. Additionally, according to an ABIM Foundation study nearly  three-quarters of doctors believe  that the average physician orders unnecessary tests at least once per week, most often stemming from fear of lawsuits and clinical uncertainty. Understanding these divergent views and behavioral drivers on is important for delivering appropriate services.

Payments and pricing.  With reforms in how we pay for medical services, doctors will need to focus carefully on which services they provide and for whom. For example, Accountable Care Organizations, episodes of care/bundled