Another perspective on health care overutilization and underutilization

March 26, 2013 — I have very mixed feelings about Mike Alberti’s article [“Keeping the ‘best care’ option out of the health spending equation”] about the focus on cost/overutilization in health care. Broadly, I agree that it is difficult to reduce inappropriate use without reducing appropriate use; and I also agree that many upcoming changes, such the “Cadillac health plan” tax, are really, really bad ideas.

On the other hand, Alberti failed to take account of the personal harm caused by overutilization. He quotes J. Sanford Schwartz of U-Penn as follows:

The vast majority of what people call overutilization is care that involves tradeoffs between costs and benefits. The conversation we should be having about those services is whether we’re prepared to pay the cost to get the benefits.

Very often, when there is overutilization, there is absolutely no benefit to the patient. An example would be a friend’s father who, because of a heart condition, was urged to have an invasive heart test before a change of IV antibiotics. Reluctant to have it, he was persuaded by a son; a complication from the test killed him.

In Otis Brawley’s excellent book, “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America,” Dr. Brawley presents a balanced account of both the harms from undertreatment (he begins his book with a vivid example of a woman whose breast fell off from advanced breast cancer) and from overtreatment. [As to the latter], he provides many examples, such as a man who realized the aggressive and foolish overtreatment he got for prostate cancer had wrecked his life before it eventually killed him. Most of us know people who have been badly damaged by overtreatment, but many of us may not be aware of that.

Shannon Brownlee’s book, “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer,” and H. Gilbert Welch’s “Overdiagnosed: Making People Sick in the Pursuit of Health,” are also full of reasons why we need to avoid overuse of medical care, not primarily for financial reasons, but primarily for our own welfare.

I agree that most of the policy tools designed to reduce overuse in the Affordable Care Act (ACA) have real problems, and I am really worried about that. But I absolutely do not agree that we can assume there are benefits, even if small ones, for most all medical tests and treatments. It just isn’t so!

— Anne Peticolas, Austin, Texas