Medical Overuse: More Care is Not Necessarily Better Care
Overuse of health care is moving into the policy spotlight as a critical—and addressable—cost and quality issue. Overuse—providing care that is not medically warranted or expensive services that don’t add value over less costly ones—contributes to our high national health care costs. Strategies to address overuse are critical to improving quality, reducing health care costs and eliminating “waste” in the health care system.
Recent estimates show that overuse may account for nearly one third of the $2.6 trillion spent on health care in the U.S. annually. Overuse gained new visibility at the April 2012 Avoiding Avoidable Care conference in Cambridge, Mass. Experts convened to examine overtreatment and how to reduce it, following closely on the heels of Korenstein and colleagues’ widely cited Archives of Internal Medicine study examining research on overuse in January 2012, as well as earlier efforts by the Congressional Budget Office and the Institute of Medicine drawing attention to overuse as a serious but often neglected concern.
As consumers of value-based health care, we are called on to engage as active, responsible decision makers about our health and health care. We are expected to play a critical role in improving quality and bending the health care cost curve by making informed choices about our health care, including what and how much health care we need and want. But, after decades of attention to underuse and access to health care, why should we worry about overuse of care? Can we avoid receiving too much care and the possibility of harm from overtreatment?
What is overuse?
One of the greatest challenges in tackling overuse of health care is coming to agreement about what it is. Overuse is usually defined in relation to appropriate care, often using evidence-based guidelines, when available, as standards. But we have a hard time agreeing about what constitutes appropriate use and where to look to find it.
Some of the excess health care we receive is over diagnosis that results from our push for early detection, changing definitions of health and illness and the numbers game of defining test results in the normal (and abnormal) ranges. Preventive services, including screening and diagnostic testing, are frequently subject to overuse, with studies reporting overuse ranging from 7.6 to 60.8 percent for some services. Overuse is not a problem found solely in high cost areas. One study sponsored by the Commonwealth Fund found near equal percentages of overuse in high and low cost areas.
Another type of overuse is medicalization, the process by which non-medical problems become defined and treated as medical problems. Last year researchers at RAND estimated the costs of treating 12 medicalized conditions including menopause, sleep disorders, obesity and others at $77.1 billion in annual health care spending.
Both consumers and providers are drivers of overuse. For consumers, medical solutions can assuage our anxieties about our health and promise a quick cure for what ails us. For providers, overuse of health care is often a routine part of action-oriented encounters with patients. In one recent poll of primary care physicians nearly half reported that their patients received too much medical care, and more than a quarter said they were practicing more aggressively than they’d like to. Physicians are also known to overuse innovative therapies and others that are not known to be effective in an attempt to provide all options to patients in their care.
Can we identify, measure and report overuse?
Another challenge in addressing overuse is finding standards to measure it. Overuse is typically identified and measured according to criteria for appropriateness, by comparing actual care with clinically appropriate or ideal care. Research evidence on outcomes and comparative effectiveness of treatments and services is needed as a basis for determinations of appropriateness, and as Korenstein confirms, studies and measures of overuse are limited in number and scope. We are reminded that, even among health care quality measures for the 2011 Healthcare Effectiveness Data and Information Set (HEDIS) only 4 of 39 measures explicitly address overuse.
What’s a consumer to do? How can we address and curb the tide of overuse?
Consumers are concerned about overuse, even if we aren’t clear about how best to address it. Reports on the Health Care Community Discussions initiated in December 2008 by President Barack Obama’s presidential transition team state that, while participants’ comments about most quality concerns were expressed in general terms, 36 percent of reports that mentioned quality focused on overuse of services.
Consumer advocate Jesse Gruman, president of the Center for Advancing Health, explains our reluctance as patients and families to take providers to task on issues of medical excess in her remarks at the Avoiding Avoidable Care conference. We are barraged by media messages about the importance of screenings, tests and other procedures, Gruman says, and when we are sick we are at our most vulnerable—rarely the empowered, engaged patient ready to advocate our informed choice. Most of us are not particularly engaged in our care and we are unlikely to do so until we hear loud and clear from our clinicians and other trusted groups and organizations that it is important, possible and safe for us to do so.
Well, we’re starting to hear that message.
One new voice is Choosing Wisely, launched in April 2012 by the ABIM Foundation in partnership with nine medical specialty societies, Consumer Reports and other partners. Choosing Wisely provides an online list of five tests and procedures to avoid from each medical specialty with the intent of encouraging conversations between physicians and patients about services or procedures to avoid the overuse or misuse of tests and procedures. Both medical and consumer organizations are participating, including the American Academy of Family Physicians, the American College of Physicians, the American College of Radiology, and six other specialty groups; and consumer organizations including the AARP, Alliance Health Networks, Leapfrog Group, Midwest Business Group on Health and the National Business Coalition on Health.
Growing interest in value-based insurance designs signals another opportunity to put the brakes to overuse. These designs challenge the purchasing community to design incentives and disincentives that discourage members from seeking unneeded tests and other forms of overuse without restricting access to appropriate care. Oregon’s Benefit Boards provide a case in point. The value-based insurance designs the Boards implemented in 2010 include provisions to increase copayments for overused or preference-sensitive services of low value, upping the ante for consumer engagement while reining in overuse.
Overuse: It’s a tough issue we can’t ignore
Overuse is targeted as one of six national priorities for health and health care improvements by the National Priorities Partnership, a collaboration of 51 public, private and nonprofit organizations convened by the National Quality Forum to provide input to development of a National Quality Strategy. The hard work to shift the culture of clinical practice and consumer engagement is underway. Measures are in development and consumers, providers and purchasers are stepping to the plate. It’s a slow process, but it’s a start.
More care is not necessarily better care. Often, less care is better care, better quality and better cost. Consumers and providers are both part of the problem of overuse. But as consumers, we’re the ones directly affected by the costs and harmful effects of overuse of health care. It’s time we stand up and become part of the solution.