Low-Value Medical Care Persists Even After Awareness

Oct 31, 2017

Thirty cents of every health care dollar is wasted, according to speakers at a recent “Cost of Health Care in Arkansas” symposium at the UA Little Rock Bowen School of Law.  What accounts for some of the waste? Unnecessary procedures with substantial costs that usually offer little or no health benefit to the patient.  

Examples of low-value care include unnecessary diagnostic imaging, vitamin D screenings, annual electrocardiograms (EKG) for patients without symptoms or risk factors, antibiotics for a simple respiratory infection and aggressive treatment for lower back pain before it has a chance to improve through rest and gentler therapies.

Patients themselves may have to put a stop to low-value care, says Dr. Joe Thompson with the Arkansas Center for Health Improvement.

“They have the most skin in the game, so to speak,” he said.

Thompson is particularly concerned about a recent analysis that found that when patients undergo imaging for lower back pain, they are twice as likely to end up having back surgery. He suggested that with some physical therapy, rest and non-opioid medications, patients might be better off avoiding surgery that is both expensive and inherently risky. 

Michael Chernew of the Harvard Medical School spoke to a Health Care Policy and the Law symposium at the UALR Bowen School of Law about the financial and medical implications of low-value health care.
Credit Ann Kenda / ARKANSAS PUBLIC MEDIA

Michael Chernew, a health economist with Harvard Medical School in Massachusetts, said he tends to focus on the financial downside of low-value care, but agreed that the health consequences may be equally as bad.

“I think there is virtually nothing you can say in favor of getting care that’s not going to improve your health. It’s a financial drain on the system and a clinical burden on the patients,” he said.  

Analysts said many factors go into low-value care, such as “defensive medicine,” when doctors order unnecessary tests out of fear of opening themselves up for lawsuits.  

“What you hear from doctors all the time is that the reason health care costs so much is that I have to do all these things I wouldn’t do if I wasn’t going to be sued,” said UAMS Professor John Tilford. 

One in three antibiotic prescriptions in the U.S. is unnecessary, according to the Centers for Disease Control and Prevention.

But he said other factors, such as a doctor’s beliefs, training or just habit, also play into low-value care and may be larger factors than even defensive medicine.  He recalled the days when tonsillectomies used to be performed routinely on kids out of the belief that it would spare them from strep throat and tonsillitis in the future. Today, a preventative tonsillectomy would be considered low-value care.

Some analysts believe that health insurance protocols may also set the stage for low-value health care by providing financial incentives for unnecessary tests or procedures.  Dr. Adam Gaffney, a pulmonologist in Boston who advocates for a single-payer system, said a switch away from a health insurance-based system to a national program might be one way to help reduce low-value care, although he said there are many factors involved.

“In getting one lump sum from the single-payer system, you don’t really have an incentive to provide very expensive, relatively low-value sorts of interventions just to increase the bottom line,” he said.

Andrew Wilson, a research team leader with the Washington-based nonprofit Altarum, said there’s an additional problem with low-value care being hard to define. He said the Choosing Wisely campaign, which aimed to identify low-value care, spurred some debate about which tests and procedures deserve the designation of low-value.  He said it sometimes depends on the particular patient and the particular circumstances.

“It really comes down in a lot of cases to a patient-by-patient thing,” Wilson said.

To be clear, if low-value medical services were free, you still wouldn't want them. - Michael Chernew, health economist with Harvard Medical School

Chernew said progress in identifying and reducing low-value care has been very slow.  While there may be some examples of institutions that have made changes in response to information about what is wasteful, most low-value care remains unchecked. Recent studies indicated the five-year-old Choosing Wisely campaign yielded disappointing results in reducing needless care, though others have praised it. 

“On a national level, just saying that something is wasteful has not reduced its use,” said Chernew.

Patients should be on the lookout for low-value care and should feel empowered to ask questions, according to Dr. Thompson.

“I would encourage all patients to ask, is this the best thing for me or what are the alternatives I should consider?” he said.

This story is produced by Arkansas Public Media, a statewide journalism collaboration among public media organizations. Arkansas Public Media reporting is funded in part through a grant from the Corporation for Public Broadcasting, with the support of partner stations KUAR, KUAF, KASU and KTXK and from members of the public. You can learn more and support Arkansas Public Media’s reporting at arkansaspublicmedia.org. Arkansas Public Media is Natural State news with context.