Overutilization

Overutilization

Overutilization refers to medical services that are 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, overutilization is the predominant factor in its expense. Factors that drive overutilization include paying health care providers more to do more (fee-for-service) and covering patients' costs by a third-party (public or private insurance) payer.[2] These factors leave both doctors and patients with no incentive to restrain health care prices or use.[1][3]

Similarly, overtreatments are unnecessary medical interventions (therapies). They could be medical services for a condition that causes no symptoms and will go away on its own, or intensive treatments for a condition that could be remedied with very limited treatment. Overdiagnosis, when patients are given a diagnosis that will cause no symptoms or harm, can lead to overtreatment.

Contents

Background

In the 1970s and 1980s, Jack Wennberg's pioneering studies documented unwarranted variation,[4] different rates of treatments based upon where people lived, not clinical rationale.

When care is overused, patients are put at risk of complications unnecessarily,[5] while health care providers (such as doctors and hospitals) receive revenue from the over-treatment when coupled to a fee-for-service (FFS) payment model; FFS is a large incentive for overutilization.[1] In the United States, the country which spends the most on health care per person globally, overutilization is the most important contributor to the high cost.[1] The New York Times reports that a "chronic overuse of medical care" exists in the United States.[6] Unnecessary care, defined as services which show no demonstratable benefit to paitents, may represent 30% of U.S. medical care.[7]

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".[8]

Defining inappropriate services

Cost, quality and policy implications

In the United States, overutilization is a costly expense that lowers the quality of health care.

Between $.30 and $.40 of every dollar spent on health care is spent on the costs of poor quality. This extraordinary number represents slightly more than a half-trillion dollars a year [in 2005]. A vast amount of money is wasted on overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency.[9]

Fisher et al.[10][11] demonstrated 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".[12] Up to 30% of Medicare spending may be cut without harming patients.[11]

Contributing factors and examples

Factors that contribute to overutilization include "self-referral, patient wishes, inappropriate financially motivated factors, health system factors, industry, media, lack of awareness" and defensive medicine.[13]

Third-party payers and fee-for-service

See also: Fee-for-service

When patients have their expenses covered by public or private insurance, and doctors are paid under a fee-for-service (FFS) model, neither have an incentive to consider the cost of treatment, a combination which contributes to waste.[3]

Atul Gawande investigated U.S. Medicare FFS reimbursements in the town of McAllen, Texas for a 2009 article in the New Yorker.[14][15] McAllen, in 2006, was the second most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average.[16] In 1992, however, McAllen was almost exactly in line with the Medicare spending average.[16] After looking at other potential explanations such as relatively poorer health or medical malpractice, Gawande concluded that the town was a chief example of the overuse of medical services.[17] Gawande concluded that it appeared a business culture (where physicans 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.[16][17] Gawande advised that

As America struggles to extend health-care 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.[16]

Imaging

The Canadian Association of Radiologists estimates that 30% of imaging is unnecessary in the Canadian health care system.[18]

Overutilization of diagnostic imaging, such as X-rays and CT scans, is defined as any application that is unlikely to improve patient care.[13] Respected organizations—such as the American College of Radiology (ACR), Royal College of Radiology (RCR) and the World Health Organization (WHO)—have developed "appropriateness criteria".[13]

Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis).[19]

Physician self-referral

Main article: Physician self-referral

One type of overutilization can be physician self-referral.[20] 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 utilization of imaging is unnecessarily higher.[20] The majority of U.S. growth in imaging utilization (the fastest growing physician service) comes from self-referring non-radiologists.[20] In 2004, this overutilization was estimated to contribute to $16 billion of annual U.S. health care costs.[20]

Politics

The 2010 U.S. health care reform, the Patient Protection and Affordable Care Act, did not contain serious strategies to reduce overutilization; "the public has made it clear that it does not want to be told what medical care it can and cannot have".[6] Uwe Reinhardt, a health economist at Princeton, said "the minute you attack overutilization you will be called a Nazi before the day is out".[6]

Others

  • Hospitalizations,[21] including admissions for those with chronic conditions who could be treated as outpatients[22]
  • Surgeries in Medicare patients in their last year of life, regions with high levels had higher death rates[23][24]
  • Antibiotic use[1][25] (an overmedication)
  • Effects of direct to consumer marketing[1]
  • Opiate prescriptions[26]
  • Blood transfusions in the U.S.[27]
  • An estimated one in eight coronary stents (used in $20,000 procedures) with non-acute indications (U.S.)[28][29]
  • Heart bypass surgeries at Redding Medical Center which resulted in a FBI raid[34][35][36]
  • 2008 Medicare rates of double scanning with chest CTs[37]
  • Screening patients with advanced cancer for other cancers[38]
  • Annual cervical cancer screening in women with medical histories of normal pap smear and HPV test results[39][40]

Medical malpractice laws and defensive medicine

See also: Medical malpractice

Physicians are incentivized to order clinically unnecessary, or of little potential value, tests in order to protect themselves from prosecution.[1] While defensive medicine is a favored explanation for high medical costs by physicians, it was estimated to only contribute to 2.4% of the total $2.3 trillion of U.S. health care spending in 2008.[12][41]

Cost sharing

Main article: Cost sharing

See also

References

  1. ^ a b c d e f g Ezekiel J. Emanuel & Victor R. Fuchs (June 2008). "The perfect storm of overutilization". JAMA : The Journal of the American Medical Association 299 (23): 2789–2791. doi:10.1001/jama.299.23.2789. PMID 18560006. http://www.ipalc.org/Healthcare_Policy/The%20Perfect%20Storm%20of%20Overutilization%20%28JAMA%202008%29.pdf. 
  2. ^ Ezekiel J. Emanuel & Victor R. Fuchs. "Health Care Overutilization in the United States—Reply". JAMA : The Journal of the American Medical Association 300 (19): 2251. doi:10.1001/jama.2008.605. 
  3. ^ a b Victor R. Fuchs (December 2009). "Eliminating 'waste' in health care". JAMA : The Journal of the American Medical Association 302 (22): 2481–2482. doi:10.1001/jama.2009.1821. PMID 19996406. 
  4. ^ Alix Spiegel (November 10, 2009). "More is Less". This American Life. http://www.thisamericanlife.org/radio-archives/episode/391/more-is-less. 
  5. ^ "Medicare Options In Biden Budget Talks Get Boost". NPR (The Associated Press). JUne 15, 2011. http://www.npr.org/templates/story/story.php?storyId=137200637. Retrieved June 26, 2011. 
  6. ^ a b c Gina Colata (March 29, 2010). "Law May Do Little to Help Curb Unnecessary Care". The New York Times. http://www.nytimes.com/2010/03/30/health/30use.html. 
  7. ^ Reilly BM, Evans AT (2009). "Much ado about (doing) nothing.". Ann Intern Med 150 (4): 270–1. PMID 19221379. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19221379. 
  8. ^ Jamie A. Weydert, Newell D. Nobbs, Ronald Feld & John D. Kemp (September 2005). "A simple, focused, computerized query to detect overutilization of laboratory tests". Archives of Pathology & Laboratory Medicine 129 (9): 1141–1143. doi:10.1043/1543-2165(2005)129[1141:ASFCQT]2.0.CO;2. PMID 16119987. 
  9. ^ Lawrence, David (2005). Building a Better Delivery System: A New Engineering/Health Care Partnership – Bridging the Quality Chasm. Washington, DC: National Academy of Sciences. p. 99. ISBN 0-309-65406-8. http://www.nap.edu/catalog/11378.html. 
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  13. ^ a b c B. Rehani (January 2011). "Imaging overutilisation: Is enough being done globally?". Biomedical Imaging and Intervention Journal 7 (1): e6. doi:10.2349/biij.7.1.e6. PMC 3107688. PMID 21655115. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3107688. 
  14. ^ Katty Kay (July 7, 2009). "Texas town's healthcare puzzle". BBC News. http://news.bbc.co.uk/2/hi/americas/8137085.stm. Retrieved June 19, 2011. 
  15. ^ Bryant Furlow (October 2009). "US reimbursement systems encourage fraud and overutilisation". The Lancet Oncology 10 (10): 937–938. doi:10.1016/S1470-2045(09)70297-9. PMID 19810157. 
  16. ^ a b c d Atul Gawande (June 1, 2009). "The Cost Conundrum – What a Texas town can teach us about health care". The New Yorker. http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?currentPage=all. Retrieved June 29, 2011. 
  17. ^ a b "Spend More, Get Less? The Health Care 'Conundrum'". Fresh Air (NPR). June 17, 2009. http://www.npr.org/templates/transcript/transcript.php?storyId=105483669. Retrieved June 29, 2011. 
  18. ^ "Do you need that scan?". Canadian Association of Radiologists. 2009. http://www.car.ca/uploads/patient%20info/car_cat_scan_eng.pdf. Retrieved June 27, 2011. 
  19. ^ Elm Ho (July 2010). "Overuse, overdose, overdiagnosis... overreaction?". Biomedical Imaging and Intervention Journal 6 (3): e8. doi:10.2349/biij.6.3.e8. PMC 3097773. PMID 21611049. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=3097773. 
  20. ^ a b c d David C. Levin & Vijay M. Rao (March 2004). "Turf wars in radiology: the overutilization of imaging resulting from self-referral". Journal of the American College of Radiology : JACR 1 (3): 169–172. doi:10.1016/j.jacr.2003.12.009. PMID 17411553. 
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  33. ^ Larry Husten (July 13, 2011). Maryland Revokes Mark Midei’s Medical License Forbes Accessed August 4, 2011.
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  35. ^ Gilbert M. Gaul (July 25, 2005). "At California Hospital, Red Flags and an FBI Raid". The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2005/07/24/AR2005072400969.html. Retrieved July 5, 2011. 
  36. ^ Rosemary Gibson (August 25, 2010). "Can Funders Quell a 'Perfect Storm of Overutilization'?". Health Affairs. http://healthaffairs.org/blog/2010/08/25/can-funders-quell-a-perfect-storm-of-overutilization/?cat=grantwatch. Retrieved July 5, 2010. 
  37. ^ Walt Bogdanich and Jo Craven McGinty (June 17, 2011). "Medicare Claims Show Overuse for CT Scanning". The New York Times. Archived from the original on June 22, 2011. http://www.webcitation.org/5zcfYCb5l. Retrieved June 22, 2011. 
  38. ^ Camelia S. Sima, Katherine S. Panageas & Deborah Schrag (October 2010). "Cancer screening among patients with advanced cancer". JAMA 304 (14): 1584–1591. doi:10.1001/jama.2010.1449. PMID 20940384. 
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Further reading

  • Hendee WR, Becker GJ, Borgstede JP, et al. (October 2010). "Addressing overutilization in medical imaging". Radiology 257 (1): 240–5. doi:10.1148/radiol.10100063. PMID 20736333. 
  • 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. doi:10.1215/03616878-23-5-795. PMID 9803363. 
  • 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. doi:10.1001/jama.2010.1915. PMID 21205965. 
  • 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. doi:10.1148/radiol.10100640. PMID 21115875.  – a story on the study

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