I recently had the pleasure of disussing wasteful health care services on Sirius XM channel 111’s “The Business of Health Care” program with Perelman School of Medicine assistant professors Mitesh Patel, MD, and Kira Ryskina, MD; and John Mafi, MD, from the David Geffen School at UCLA. Wasteful care—also termed inappropriate care—is defined as the overuse or misuse of health care services that provide little to no benefit to a patient. An example of this is a physician prescribing antibiotics for acute sinusitis (sinus infection); the vast majority of sinus infections are viral in nature and antibiotics do nothing for the patient. The administration of antibiotics in these patients can also have deleterious effects if a patient is allergic to them (or has an adverse reaction) and creates increased resistance in bacteria to the antibiotics. Inappropriate care in aggregate has been estimated to cost the U.S. $500-700 billion, which is 15-20 percent of the $3.5 trillion spent annually on the health care system.
So why does this occur? There are several factors and a number of parties involved, including the patient. First there are cultural drivers such as physician training. During residency, physicians are taught that action is more appropriate than inaction and an emphasis is placed on being as thorough as possible (e.g. the extra test/diagnostic may further help).
There’s also evidence that the bad habits formed in residency can follow physicians for the rest of their career. In her recent study published in the Mayo Clinic proceedings, Dr. Ryskina found that residency training in high-intensity care settings (measured by the amount of money spent and the number of tests and treatments provided) instills inappropriate care practices in physicians and this behavior typically persists for 10-15 years. Dr. Mafi also recently published an article in JAMA Internal Medicine on the use of primary care services in high-intensity care settings versus community settings. He found that there are more inappropriate services delivered in high intensity care settings such as increased specialty referrals and unnecessary MRI/CT scans (e.g. for non-specific back pain). Conversely, those who are trained in less intensive care settings, provide less inappropriate care.
There are also financial factors that encourage wasteful care. The more a clinician does, the more they get paid (note: The ACA is focused squarely on this issue with an emphasis on value-based medicine). The marketing practices of products to physicians (e.g. drug companies detailing products to physicians in their offices) and patients (direct to consumer marketing) is also partly to blame. A recent Millbank Quarterly article found that most patient consumers of health care remain poorly informed about the costs and benefits of treatments and therefore tend to prefer expensive, and often superfluous, “high tech” care as opposed to “high touch” alternatives.
Lastly, there are legal factors that drive wasteful care. The fear of facing a malpractice suit for not doing enough has caused physicians to overcompensate. The blame for this rests with us—the patients.
So what can be done? The first step is to increase awareness. According to the Millbank Quarterly study, the public should be made aware that the health risks of diagnosis and treatment has more to do with a culture of inappropriate care than individual providers. It also found that promoting “high touch” as opposed to “high tech” treatments can improve this understanding. In other words, continuity of care and having a clinician who knows a patient’s medical history can help in delivering appropriate care.
The medical community as well is working on increasing awareness of this issue though the American Board of Internal Medicine’s “Choosing Wisely” campaign. This is a campaign promulgated by many of the specialty medical societies and it includes a list of 5 to 10 specific initiatives to minimize inappropriate care. Medical training in and around the issues of low value care has also become a focus of many of the medical schools in the U.S.
An openness to the health economics of new and emerging technologies for the diagnosis and treatment of diseases/conditions needs to continue. This likely includes government agencies such as Medicare and the FDA being more open to these types of analyses—where costs and outcomes of new technologies are weighed and evaluated against accepted practices. There is a great deal of work to be done to ensure appropriate care is delivered.
For audio of this episode of “The Business of Health Care” on Business Radio Powered by the Wharton School on Sirius XM Channel 111, click below: