Overtreatment in health care
In 2017, American doctors thought that about 20% of medical care provided to patients was unnecessary. The 2,000 doctors surveyed thought that 22% of prescription drugs and almost 25% of lab tests were overtreatments.
And these are the people prescribing all the overtreatment.
The research is fairly clear: overtreatment is widespread in the U.S. medical system, and it’s it contributes to the soaring costs of health care without improving the quality of the care patients receive. It can, in some cases, endanger patients’ health.
What is to be done about it is another question.
The geography of medical practices
A lot of the issues have logical origins. Doctors are highly trained, and they tend to follow what they’re taught. Physicians who train in certain regions of the country wind up practicing in ways that are starkly different—and more costly—than other areas.
In studies involving chronic illness, some academic medical centers treat patients with 60% more intensity (measured by time patients spend in the hospital or ICU; frequency of physician visits; number of specialists involved in care; and quantity of imaging services, diagnostic testing and minor procedures) than other centers. In the first seven years following their training, for doctor in the highest intensity regions patient expenditures were 29% greater than their colleagues in the lowest intensity region.
And yet the quality of that higher intensity care, measured by health outcomes, is no better—and in fact might be worse. (as we discussed in Does more expensive care mean higher quality? Plenty of research suggests there is no relationship between health care spending and health outcomes)
Testing, testing—is it always necessary?
Another issue involves the ordering of tests. A study of residents training in some of the finest medical schools in the country found that some ordered seven times more tests than others. Too often, the ordering of test begets the ordering of more tests.
“There is a fair amount of overuse of imaging,” says Surest Chief Medical Director Dr. Tara Bishop, who studied overtreatment during her years doing academic research.
“When you order a lot of MRIs for back pain, for instance, that kicks up what we called ‘incidentalomas.” These findings of anomalies that may or may not be related to the initial back pain triggers a costly trajectory without improving care at all. “We called it the Diagnostic Misadventure of Finding Things,” Bishop says. “And it’s pretty hard to stop.”
In fact, one study demonstrated that, for people suffering from non-life threatening respiratory symptoms, CT scans will do almost nothing to improve the patient’s outcome.
Over-utilization of imaging and other lab tests at least makes some sense. Having more information would seem to lead to better decision-making. In fact, the notion that more is better informs many overtreatment decisions.
“This is a cultural idea among patients and providers,” Bishop says. “If I have pain, I want whatever information I need to help make that pain go away. Waiting a few weeks to see if it goes away is hard. I’ve experienced patients coming into my office who said, I need the MRI, and I’m not going to leave the office without it.”
Patients' role in overtreatment
Patient pressure has grown more intense as the internet provides more information. Patients more frequently come to their care provider with an idea of what they think is wrong and what they think will fix it. That’s hard to resist.
“One of my biggest pet peeves is the overuse of antibiotics. People come in with a viral infection, against which antibiotics are not effective. I can’t tell you the number of times I’ve had to educate patients—and other doctors—about prescribing antibiotics for things that are not bacterial,” Bishop says.
“You can say, ‘Well just don’t give them the antibiotics.’ But I don’t want my patient to be dissatisfied with their experience in my office. And saying no sounds simple, but it’s a 20-minute conversation about why that won’t work for them. Sometimes it’s just easier to write the prescription.”
Doctors, it should not be surprising to learn, have a bias to treat. Research strongly indicates that a doctor visit tends to trigger some sort of health care event—a test, a procedure, a prescription.
We tend to intervene when, in fact, a more gentle, supportive therapeutic regimen might lead to an outcome that’s as good or better. - Dr. Marcus Thygeson, Surest Chief Health Officer
Unnecessary surgeries vs. other treatments
That bias toward treatment is heightened when it comes to specialists. When you’re highly trained to be a hammer, a lot of problems start to look like nails. If you go to see a surgeon about knee pain, the surgeon is going to come into the room with a certain bias about whether surgery is the solution to your problem. That’s not to say surgeons will always over-prescribe surgery, or that all surgeons will, but they do have a bias.
Thygeson points toward knee arthroscopy, a fairly common surgical procedure. In 2017, about 750,000 arthroscopic knee surgeries were performed in the U.S., at a cost of $3 billion. Worldwide that number is over 2 million surgeries annually. And yet, according to an international panel of experts published in the British Journal of Medicine, arthroscopic surgery for torn meniscus or degenerative knee disease is no better for patients than physical therapy.
Other surgeries are coming under scrutiny as well, Thygeson says. Research indicates that antibiotics may be as effective as appendectomies in many appendicitis cases. A major study found that managing stable coronary artery disease is as effective as surgery to introduce stents, one of the most commonly performed heart surgeries in the U.S.
“With most decisions in health care, there are actually options and trade-offs,” Thygeson says. “There isn’t just one way to do it.”
Medical malpractice and too much information
Other doctors report practicing “defensive” medicine. About 85% of physicians in one study indicated they may overtreat because they fear medical malpractice suits. In the same survey, a large majority of doctors suspected other doctors of overtreating when there was a potential profit motive—and there’s some evidence to back that hunch. For instance, an examination of urologists found that urology practice groups that self-referred patients to radiation treatment were almost 30% more likely to prescribe radiation than non-self-referring centers.
Part of overtreating is information overload. Physicians must juggle a tremendous amount of information, and care guidelines are constantly evolving. Doctors are often told in medical school that much of what they’re being taught will be obsolete by the time they finish their residency. It’s critical for them to stay current with the ever-changing state of knowledge. To the extent they’re able to keep up, that helps reduce overtreatment.
But so does a re-alignment of benefits and value in health insurance plans. If people can see what the costs of certain procedures and treatments might be and compare that to the long-term benefits, they’ll make better choices about which treatments to move forward with.
That’s where Surest is hoping to influence overtreatment. By designing health insurance benefits that align value and cost, and by letting patients see that information before they make decisions, Surest hopes to curb overtreatment and trim health care spending for its members.