Doing Better by Doing Less: Approaches to Tackle Overuse of Services Timely Analysis of Immediate Health Policy Issues January 2013 Robert A. Berenson and Elizabeth Docteur This analysis presents what we fewer hospital admissions, and There is variation in the level of know about the provision of shorter lengths of stay in inappropriate use by type of service, medically inappropriate and comparison with many developed and it is evident that some services unnecessary services that drive up countries.2 According to many are subject to a great deal of health care spending without indicators of preventive service use, overprovision. A recent review of making a positive impact on U.S. performance is only average or the research literature found rates at patients’ health outcomes. It also below average.3 But there are which particular therapeutic describes approaches that have certain areas, including some procedures, tests, or medications already been used to address this relatively high-tech and high-cost were performed or prescribed when issue—with limited success. We services such as imaging and clinically inappropriate ranged from suggest that broader payment cardiac surgery, where the United a low of 1 percent to a high of 89 reforms are needed to minimize States appears among the most percent.7 For example, a 2007 study incentives to overdiagnose and prolific users.4 found that 60.8 percent of colon overtreat and to better support the cancer screenings undertaken were other approaches. Extrapolating from studies focusing medically inappropriate, while a on particular conditions or services, 2005 study found that 27 percent of Introduction some analysts have estimated that as physical therapy prescriptions for much as a third of U.S. health care low back pain did not meet The United States is an outlier in spending is unnecessary and threshold standards for appropriate terms of its per capita spending on 5 wasteful. This estimate includes service use. health care, surpassing other the provision of medical services developed countries by a and the prescription of medicines While any overuse of services considerable margin. High prices that are medically inappropriate—in drives up spending, inappropriate and fees in the U.S. health sector other words, health care from which service use is particularly important have been identified as important the patient derives no medical because it has the potential to harm drivers of these spending variations. benefit or for which the potential patients. One in every four patients The complexity and fragmentation harms exceed the potential benefits. admitted to the hospital is of our system also plays a role in More than a quarter of all wasteful prescribed an inappropriate generating higher-than-average spending in health care—an medicine, sometimes leading to administrative costs and in creating estimated $210 billion out of $765 adverse drug reactions that are an environment in which waste, billion in wasteful spending in responsible for 20 percent of 1 fraud, and abuse can thrive. 2009—is attributed to overuse of inpatient deaths.8 Other examples of services that are medically harmful overuse include radiation The volume and mix of health care inappropriate or otherwise exposure from imaging scans such services provided in the United unnecessary, which includes as CT scans, elective C-sections States also play a role in explaining services that are provided more performed for convenience, and higher health spending, although the frequently than warranted and prescribing aggressive treatment story is complicated. By many higher-cost services that are no options to those with terminal measures of service volume, the better than lower-cost alternatives.6 illnesses without disclosing the United States is not an outlier. In likely futility of such interventions. fact, we have fewer physician visits, Reducing the overuse of just seven What do we know about Based upon their findings, services known to be subject to high inappropriate service Korenstein and colleagues rates of inappropriate use could save concluded that inappropriate use is between $33 billion and $62 billion use? often a problem for the services 9 annually. Although inappropriate service use included in the published articles, has been studied by researchers although there is wide variation in The potential of achieving cost since at least the late 1970s, rates of overuse documented by the reductions while substantially measuring it is technically research. At the same time, for the improving health care quality and challenging and costly. As a result, vast majority of procedures, tests, outcomes can only tantalize policy- there is still a lot we do not know and medications in use today, no makers in this era of rapidly rising about its incidence and the reasons studies have assessed the extent to health spending and very strong for its persistence. Despite the which they are overused in practice. constraints on the financing side. limited evidence base, the evidence Because of limitations in the scope Meanwhile, current support for that we do have suggests that there of the research, there are important experimentation with new forms of is a great deal of costly overuse of gaps in our understanding that limit health service delivery and services that has defied efforts to opportunities to reduce health care concurrent changes in payment and address the problem. The problem is spending without adversely regulatory oversight make the difficult to study for reasons affecting public health. present a most opportune moment in discussed below, and those same which to consider the prospects for The review demonstrated that new reasons also make implementing ensuring that those changes help, and costly procedures were policies to tackle the problem rather than hinder, efforts to reduce particularly underrepresented in the difficult. 11 inappropriate service use. research literature. In part, this What has the research shown? dearth is explained by shortfalls in This analysis focuses on what we comparative effectiveness research know about the provision of After reviewing the research for many services, particularly new medically inappropriate and other literature on inappropriate services, ones. Filling these gaps in the unnecessary services, which drive Korenstein and colleagues evidence base would need to be up health spending without making uncovered 172 articles measuring prioritized if this research is to serve a positive impact on the health overuse that were published as a resource for targeting potential outcomes of patients. We begin by between 1978 and 2009 and met opportunities for enhancing the reviewing the literature on the minimum quality standards in terms cost-efficiency of spending on 10 extent of medically inappropriate of methodology and other criteria. health care services. overuse, continue by describing Of these, 53 articles addressed approaches used to tackle therapeutic procedures, 38 Certain services, including inappropriate service use, and then concerned diagnostic tests, and 81 antibiotic use and several coronary discuss the implications of current pertained to medications. Within procedures, have been subject to and proposed provider payment each area, a relatively small number repeated study over time. For some methods on the provision of of procedures, tests, and medicines of these services, such as carotid inappropriate services and in had been studied. For example, 59 endarterectomy, the rate of spurring excess volume of services. studies (more than one-third of the inappropriate use has declined 12 In the review of payment total) addressed antibiotics for considerably. In the case of approaches, we discuss upper respiratory tract infections, 17 inappropriate antibiotic use, there is opportunities to modify the various studies looked at coronary evidence of reductions in overuse, payment methods to address the angiography, and 7 studies but a high level of overuse persists, provision of medically inappropriate investigated use of upper despite significant outreach and services and overuse of unnecessary endoscopy. In sum, only 18 unique education efforts. This finding services, as more broadly construed. therapeutic procedures, 24 indicates that publication of diagnostic tests, and 13 medications research documenting overuse is not were evaluated in terms of the necessarily sufficient to ensure incidence of inappropriate use. changes in practice patterns. Timely Analysis of Immediate Health Policy Issues 2 Why do we know so little about this particularly ones that are relatively claims data, continue to limit its critical aspect of health care new or in use for new indications, broad application. quality? and mean that practice standards may reflect differences in expert Do geographic areas where service Korenstein and colleagues pointed opinion where the science is use is relatively high have more to a number of reasons why unresolved. These standards require inappropriate services? inappropriate use of services is updating to be consistent with the In a recently published review of relatively less studied in comparison 15 current state of knowledge. For the literature, Keyhani and with underuse of medically example, recent studies determined appropriate services.13 Measuring colleagues identified only five that the accepted practice of raising studies addressing the question of overuse via the assessment of the end-stage renal disease patients’ rate of provision of medically whether geographic