Keeping the “best care” option out of the health spending equation
An imaginary number?
In discussions about waste and overutilization, it is frequently claimed that 30 percent or more of U.S. spending on health care could be eliminated without any effect on patient health.
In large part, that figure is derived from the findings of researchers at the Dartmouth Institute for Health Policy and Clinical Practice, a group that produces the much-cited Dartmouth Atlas of Health Care. The Dartmouth group was highly influential in the debate over health reform in 2009. Yet material questions remain about the significance of the data on which the group relied.
Researchers at Dartmouth arrived at the figure of 30 percent by comparing Medicare spending and outcomes in different regions of the country. They found that the amount of spending on health care varies widely, often does not correlate with better outcomes, and that if each higher-cost region in the country reduced its spending to the level of the low-spending, high-quality regions, savings of 30 percent or more are possible.
Arthur MacEwan, a professor emeritus of economics at the University of Massachusetts Boston, pointed out that the common argument that insurance coverage that is “overly generous” leads patients to get more care than is good for them rests on the assumption that people enjoy receiving health care and actively seek it out.
This assumption, he said, was “not likely to hold up under scrutiny.”
“I think most people will generally do what their doctor tells them to and nothing more,” MacEwan said. “There may be some outliers in terms of people requesting MRIs and that sort of thing, but most people trust their doctor and defer to [his or her] judgment.”
Indeed, Don McCanne, senior health policy fellow at Physicians for a National Health Program, said that if anything, people are more likely to feel inhibitions about getting even a minimal amount of care than they are eager to seek out care that is not prescribed to them.
Especially if a patient is unhealthy, he said, going to the doctor can be a demoralizing experience, one that many would rather avoid unless it became absolutely necessary.“I don’t think people perceive of going to the doctor as a fun activity,” McCanne said.
“If they did, we might see more people getting their recommended colonoscopies.”
These findings have frequently been deployed as evidence that one-third or more of national spending on health care is wasted on unnecessary tests and procedures, and that it is possible to reduce the amount of utilization without worsening outcomes.
However, as Remapping Debate’s investigation found, there is a meaningful gap between the indirect evidence that is represented by the findings on regional variation and directly observed and measured evidence for specific procedures. According to several experts, this gap has profound implications for policy makers attempting to cut back on overutilization, and calls into question the idea that utilization can be reduced with little or no risk to patients.
The most comprehensive review of the direct evidence of overutilization was published last year in the Archives of Internal Medicine. The study, which was led by Deborah Korenstein, an associate professor of general internal medicine at the Icahn School of Medicine at Mount Sinai Hospital in New York, reviewed the literature on overutilization from 1979 to 2009 and found that “the robust evidence about overuse in the United States is limited to a few [medical] services.”
In her literature review, Korenstein was able to identify fewer than three dozen medical procedures for which there was evidence of inappropriate use, and for the majority of those procedures, she said, the evidence was limited to one or two studies. The majority of the studies focused on the same four procedures.
When placed up against the lack of direct evidence of overutilization, Korenstein said, the 30 percent figure, “is kind of imaginary. It’s not based on any real knowledge.”
According to Geraldine McGinty, chair of the Commission on Economics at the American College of Radiology, arguments about overutilization are also complicated by the fact that there is some degree of uncertainty about the benefits of many procedures.
“As soon as you start making clinical appropriateness guidelines, you see that there are big gaps in our knowledge about the effectiveness of different treatments,” she said. “Defining what’s appropriate is sometimes kind of an arbitrary decision.”
“These numbers get dangled in front of policy makers to tempt them into thinking we can cut costs and not hurt anyone, but a lot of [the] push to cut overutilization is based on circumstantial evidence,” said Mark Pauly, a professor of health care management at the University of Pennsylvania.
If Pauly is right, and the circumstantial evidence proves less valid than is commonly thought, then the soundness of the entire foundation underlying the argument that costs can be cut significantly without harming patient care by reducing utilization would be in serious question.
Scalpels or chainsaws?
Pauly added that overselling the idea that services are broadly overutilized creates the incentive for policymakers to attempt to realize savings by cutting utilization indiscriminately, with the result of reducing access to beneficial services in the process.
“If anyone tells you that they can get meaningful savings out of reducing waste in a way that’s guaranteed to do more good than harm, they’re trying to sell you something,” he said.
Further complications arise because even those procedures that experts agree are broadly overused are still beneficial for the majority of patients who receive them.
For example, there is a broad consensus that cardiologists implant more coronary stents, which are small metal tubes that are placed inside heart arteries to keep them open, than are medically necessary. But James Fasules, a pediatric cardiologist and the senior vice president of advocacy at the American College of Cardiology, said that about 70 percent of stents are used in emergency situations, such as when a patient is having a heart attack, and are not medically controversial. Of the remaining 30 percent, he said, many would still be considered medically necessary.
According to Robert Berenson, an internist and a fellow at the Urban Institute, the fact that many overutilized procedures are still medically necessary much more often than not makes it very difficult to reduce the unnecessary care without impacting necessary care.
“You can’t just go in and whack the payment for those areas,” he said. “The truth is that it is incredibly difficult to take out the waste without doing harm.”