Keeping the “best care” option out of the health spending equation

Putting the squeeze on

In interviews with Remapping Debate, many physicians said that they have already felt a change in the environment within which they attempt to provide patients with quality care, and gave examples of certain beneficial procedures that have become especially discouraged.

McGinty of the American College of Radiology said that she has noticed that it is more difficult than it used to be to order magnetic resonance images (MRIs) because insurance companies are less likely to approve them. “There is an entire infrastructure set up by the insurance companies to manage imaging,” she said. “I’m a believer that a lot of unnecessary imaging gets done, but by making it harder to get any imaging done, we’re putting a lot of patients [who legitimately need those MRIs] through additional pain and anguish.”

Linda Cox, president of the American Academy of Allergy, Asthma & Immunology, said that insurance plans have become less willing to pay for pulmonary-function testing, which help physicians assess the severity of lung conditions such as asthma and cystic fibrosis. “Some plans say you can only get one test a year,” Cox said. “But typically you’re going to want to do one test, prescribe a treatment, and do another one some time later to determine if the treatment is working. That’s textbook. We can’t even follow our own guidelines.”

Many physicians were also quick to bring up medical services that they fear will become more difficult to perform because of the cut-cut-cut tenor of the discussion. John Fildes, a chief of the Division Trauma and Critical Care at the University of Nevada School of Medicine, said that many patients benefit greatly from rehabilitative services after a traumatic accident.

“If you’ve had a brain injury or a spinal injury, you’re going to benefit almost as much from intensive rehab as from the initial surgery,” he said. “I worry that in our conversations about cutting waste we forget how important those kinds of services are.”

Bruce Sigsbee, the president of the American Academy of Neurology, said that for certain neurological conditions like multiple sclerosis and epilepsy, there is often only one effective drug that the patient can tolerate. “Do we really want to make it harder for people the get that drug just because it happens to be the most expensive?”

What about underutilization?

According to many experts, the discussions about the overutilization of medical services have often failed to take into account a much more well-documented problem: the underutilization of medical services.

The most comprehensive studies from the last decade have found widespread underutilization. The first study to attempt to measure the amount of medical care that is utilized in the general population, in 2003, found that American adults received barely more than half of the recommended care. In 2007, another study found that American children receive less than half of recommended care.

“You can name any disease or condition that you want, and I can guarantee that there’s underutilization of an effective treatment happening,” said Patrick Alguire, the senior vice president for medical education at the American College of Physicians. “The literature is replete with studies that show people not getting things they should be getting.”

While underutilization is most acute among people that have no insurance and therefore extremely limited access to medical care of any type, Alguire said that it is also a serious problem in the insured population, especially as high cost-sharing provisions deter people from receiving beneficial care. A 2008 study published in Health Affairs found that more than 25 million adults in America were underinsured in 2007. More recent research has demonstrated that people with low-quality health insurance frequently forgo beneficial care.

Experts often point to examples of underutilization, such as underutilization of primary care services, that, if made more widely available, may actually save money in the long run. Still, Steven Asch, a professor of medicine at the Stanford University School of Medicine who has long studied both over- and underutilization said that “the costs of bringing people who aren’t getting enough care up to the appropriate level is certainly a very large number.”

When asked whether those costs could be balanced by the savings from reducing overutilization, Asch said that that was “far from clear.”

Eve Kerr, a professor of internal medicine at the University of Michigan who has also studied both over- and underutilization, explained that many of the policies that have been proposed to reduce overutilization not only ignore the problems posed by underutilization, but actually risk exacerbating those problems.

“If we use too blunt an instrument to try to cut out costs, we are going to decrease overutilization but also increase underutilization,” Kerr said. “In our rush to cut costs, we aren’t focusing on the right person getting the right care. We’re focusing on decreasing the amount of care, full stop.”

Indeed, according to Daniel Barocas, a urologic oncologist and assistant professor of medicine at Vanderbilt University Medical Center, recent research suggests that blunt attempts at decreasing inappropriate care can have the effect of reducing access to appropriate care, a phenomenon that has been dubbed the “thermostat effect.”

“If people are just being urged to hold back on something, they’re likely to do less of the good kind of imaging and less of the bad kind,” Barocas said. “You squeeze out the good with the bad.”

Cutting waste or cutting cost?

Remapping Debate interviewed several proponents of putting policies in place that are aimed at curbing overutilization, and asked them to identify the specific procedures for which they would like see reduced utilization.

Henry Aaron, a senior fellow at the Brookings Institution, listed some commonly cited procedures such as electrocardiograms and spinal surgery. Vivian Ho, a health economist at the Baker Institute at Rice University and an associate professor at the Baylor College of Medicine, also mentioned back surgery and added antibiotics that are prescribed for upper respiratory diseases, and knee replacements — all of which are well documented as being overused.