The high cost of unnecessary medical care

In Colorado, a new analysis from the Center for Improving Value in Health Care found that the state government, insurers, and patients spent $134 million on "low-value care" — care that provides little to no benefit to patients. Some of the low-value items contributing to this cost include prescriptions for opiates, prescriptions for multiple antipsychotic medications, and screenings for vitamin D deficiency.

According to Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design, the report's estimate is just "a small piece of the universe of no- and low-value care" in Colorado. The report only considered 58 services and did not include the costs of potential follow-up care.

In the United States, between 10% and 30% of the $3 trillion spent on healthcare each year is for low-value care. These unnecessary treatments can lead to higher costs, cause health complications, and hinder access to more appropriate care.

Although there have been efforts to reduce these unnecessary services, there has not been much progress over the last decade, in part because the U.S. healthcare system typically rewards doctors for providing more care rather the most appropriate care for a patient.

"One of the hardest things to do in this work [to reduce unnecessary care] is to align financial incentives because in our health care system, we get paid for what we do," said said Lalit Bajaj, an emergency physician at Children's Hospital Colorado.

"There's a culture of 'more is better,'" Fendrick said. "And 'more is better' is very hard to overcome."

Some patients may also feel like they're being denied care if physicians or health plans tell them that a certain test or treatment isn't necessary. According to Bajaj, it can be difficult for doctors to handle patient expectations when it comes to testing or treatment.

"It's not a great feeling for a parent to come in and I tell them how to support their child through the illness," Bajaj said. "They don't really feel like they got testing done. 'Did they really evaluate my child?'"

Efforts to reduce unnecessary care

Despite the difficulty of reducing unnecessary services, some organizations have been able to make progress over the years.

In 2013, Children's Hospital Colorado had the second-highest rate of CT abdominal scans among children's hospitals in the United States. Around 45% of children coming to the hospital's ED with abdominal pain received a CT scan. These scans are generally considered a low-value service, and research has shown that they are not beneficial in most cases and expose patients to unnecessary radiation.

In 2016, hospitals leaders implemented new protocols that required surgeons to come to the ER to evaluate a patient before a CT scan is ordered. The surgeons and ED doctors would then decide if a child was at high risk of appendicitis and needed to be admitted, or if they were at a low risk and could be sent home.

Within two years, the hospital reduced its rate of abdominal CT scans to 10% and did not see any increase in complications. Although fewer CT scans meant less revenue, the hospital worked with an insurer to create an incentive program that would help offset the lost revenue. If the imaging rate remained low, the hospital could earn a bonus from the insurer at the end of the year.

Similarly, the hospital implemented new protocols for treating bronchiolitis, a viral respiratory infection, after leaders found that children were getting unneeded chest X-rays and prescriptions for antibiotics and bronchodilators. The new protocols helped providers educate parents on the condition, how to manage symptoms, and why imaging or medication would be unlikely to help.

After the new protocols were implemented, the hospital reduced its X-ray rate from 40% to 29% and its use of bronchodilators from 36% to 22%.

Separately, the Los Angeles County Department of Health Services (LADHS) found that 90% of patients receiving cataract surgery had extensive preoperative testing even though it wasn't necessary. Because LADHS receives a fixed amount for each person it treats, the additional tests weren't adding to any profits.

Quality improvement staff found that the health system had implemented a protocol requiring an X-ray, electrocardiograms, and a full set of laboratory tests before cataract surgery. These extra tests often led to unnecessary follow-up visits, potentially delaying a patient's surgery for months.

The health system developed new guidelines for preoperative screenings and had a nurse trained in quality improvement advise surgeons when testing was needed. These changes decreased the rates of chest X-rays, EKGs, and lab tests by two-thirds, and helped the health system save around $60,000 over three years.

Although the overall savings were small, patients were able to get cataract surgeries more quickly and did not have to undergo unnecessary follow-up testing or treatments. (Hawryluk, KFF Health News, 11/13)

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