Overutilization
Encyclopedia
Overutilization refers to medical services that are provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overutilization is the predominant factor in its expense. Factors that drive overutilization include paying health care provider
s more to do more (fee-for-service
) and covering patients' costs by a third-party (public or private insurance) payer. These factors leave both doctors and patients with no incentive
to restrain health care prices
or use.
Similarly, overtreatments are unnecessary medical interventions (therapies). They could be medical services for a condition that causes no symptoms and will go away on its own, or intensive treatments for a condition that could be remedied with very limited treatment. Overdiagnosis
, when patients are given a diagnosis that will cause no symptoms or harm, can lead to overtreatment.
, different rates of treatments based upon where people lived, not clinical rationale.
When care is overused, patients are put at risk of complications unnecessarily, while health care provider
s (such as doctors and hospitals) receive revenue from the over-treatment when coupled to a fee-for-service
(FFS) payment model; FFS is a large incentive
for overutilization. In the United States, the country which spends the most on health care per person globally, overutilization is the most important contributor to the high cost. The New York Times
reports that a "chronic overuse of medical care" exists in the United States. Unnecessary care, defined as services which show no demonstratable benefit to paitents, may represent 30% of U.S. medical care.
Most physicians accept that laboratory tests are overused, but "it remains difficult to persuade them to consider the possibility that they, too, might be overutilizing laboratory tests".
Fisher et al. demonstrated that "there is no apparent regional health benefit for Medicare
recipients from doing more, whether 'more' is expressed as hospitalizations, surgical procedures, or consultations within the hospital". Up to 30% of Medicare spending may be cut without harming patients.
, patient wishes, inappropriate financially motivated factors, health system factors, industry, media, lack of awareness" and defensive medicine
.
to consider the cost of treatment, a combination which contributes to waste.
Atul Gawande
investigated U.S. Medicare FFS reimbursements in the town of McAllen, Texas
for a 2009 article in the New Yorker. McAllen, in 2006, was the second most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average. In 1992, however, McAllen was almost exactly in line with the Medicare spending average. After looking at other potential explanations such as relatively poorer health or medical malpractice, Gawande concluded that the town was a chief example of the overuse of medical services. Gawande concluded that it appeared a business culture (where physicans view their practices as a revenue stream) had established itself there, in contrast to a culture of low-cost high-quality medicine at the Mayo Clinic
and in the Grand Junction, Colorado
market. Gawande advised that
.
Overutilization of diagnostic imaging, such as X-rays and CT scans, is defined as any application that is unlikely to improve patient care. Respected organizations—such as the American College of Radiology
(ACR), Royal College of Radiology (RCR) and the World Health Organization
(WHO)—have developed "appropriateness criteria".
Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis
).
, did not contain serious strategies to reduce overutilization; "the public has made it clear that it does not want to be told what medical care it can and cannot have". Uwe Reinhardt
, a health economist at Princeton, said "the minute you attack overutilization you will be called a Nazi before the day is out".
is a favored explanation for high medical costs by physicians, it was estimated to only contribute to 2.4% of the total $2.3 trillion of U.S. health care spending in 2008.
Health care provider
A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....
s more to do more (fee-for-service
Fee-for-service
Fee-for-service is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care...
) and covering patients' costs by a third-party (public or private insurance) payer. These factors leave both doctors and patients with no incentive
Incentive
In economics and sociology, an incentive is any factor that enables or motivates a particular course of action, or counts as a reason for preferring one choice to the alternatives. It is an expectation that encourages people to behave in a certain way...
to restrain health care prices
Health care prices
Unlike most markets for consumer services in the United States, the health care market generally lacks transparent market-based pricing. Patients are typically not able to comparison shop for medical services based on price, as medical service providers do not typically disclose prices prior to...
or use.
Similarly, overtreatments are unnecessary medical interventions (therapies). They could be medical services for a condition that causes no symptoms and will go away on its own, or intensive treatments for a condition that could be remedied with very limited treatment. Overdiagnosis
Overdiagnosis
Overdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. Overdiagnosis is the least familiar side effect of testing for early forms of disease – and, arguably, the most important...
, when patients are given a diagnosis that will cause no symptoms or harm, can lead to overtreatment.
Background
In the 1970s and 1980s, Jack Wennberg's pioneering studies documented unwarranted variationUnwarranted variation
Unwarranted variation in healthcare service delivery, first so termed by Dr. John Wennberg, refers to differences that cannot be explained by illness, medical need, or the dictates of evidence-based medicine...
, different rates of treatments based upon where people lived, not clinical rationale.
When care is overused, patients are put at risk of complications unnecessarily, while health care provider
Health care provider
A health care provider is an individual or an institution that provides preventive, curative, promotional or rehabilitative health care services in a systematic way to individuals, families or communities....
s (such as doctors and hospitals) receive revenue from the over-treatment when coupled to a fee-for-service
Fee-for-service
Fee-for-service is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care...
(FFS) payment model; FFS is a large incentive
Incentive
In economics and sociology, an incentive is any factor that enables or motivates a particular course of action, or counts as a reason for preferring one choice to the alternatives. It is an expectation that encourages people to behave in a certain way...
for overutilization. In the United States, the country which spends the most on health care per person globally, overutilization is the most important contributor to the high cost. The New York Times
The New York Times
The New York Times is an American daily newspaper founded and continuously published in New York City since 1851. The New York Times has won 106 Pulitzer Prizes, the most of any news organization...
reports that a "chronic overuse of medical care" exists in the United States. Unnecessary care, defined as services which show no demonstratable benefit to paitents, may represent 30% of U.S. medical care.
Most physicians accept that laboratory tests are overused, but "it remains difficult to persuade them to consider the possibility that they, too, might be overutilizing laboratory tests".
Cost, quality and policy implications
In the United States, overutilization is a costly expense that lowers the quality of health care.Fisher et al. demonstrated that "there is no apparent regional health benefit for Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
recipients from doing more, whether 'more' is expressed as hospitalizations, surgical procedures, or consultations within the hospital". Up to 30% of Medicare spending may be cut without harming patients.
Contributing factors and examples
Factors that contribute to overutilization include "self-referralPhysician self-referral
Physician self-referral is a term describing the practice of a physician ordering tests on a patient and having them performed either by themselves or by a facility from which they receive a financial incentive for the referral....
, patient wishes, inappropriate financially motivated factors, health system factors, industry, media, lack of awareness" and defensive medicine
Defensive Medicine
Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited as the driving force behind defensive medicine...
.
Third-party payers and fee-for-service
When patients have their expenses covered by public or private insurance, and doctors are paid under a fee-for-service (FFS) model, neither have an incentiveIncentive
In economics and sociology, an incentive is any factor that enables or motivates a particular course of action, or counts as a reason for preferring one choice to the alternatives. It is an expectation that encourages people to behave in a certain way...
to consider the cost of treatment, a combination which contributes to waste.
Atul Gawande
Atul Gawande
Atul Gawande is an American physician and journalist. He serves as a general and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts and associate director of their Center for Surgery and Public Health...
investigated U.S. Medicare FFS reimbursements in the town of McAllen, Texas
McAllen, Texas
McAllen is the largest city in Hidalgo County, Texas, United States. It is located at the southern tip of Texas in an area known as the Rio Grande Valley and is part of the . Its southern boundary is located about five miles from the U.S.–Mexico border and the Mexican city of Reynosa, the Rio...
for a 2009 article in the New Yorker. McAllen, in 2006, was the second most expensive Medicare market, behind Miami. McAllen's costs, per beneficiary, were almost twice the national average. In 1992, however, McAllen was almost exactly in line with the Medicare spending average. After looking at other potential explanations such as relatively poorer health or medical malpractice, Gawande concluded that the town was a chief example of the overuse of medical services. Gawande concluded that it appeared a business culture (where physicans view their practices as a revenue stream) had established itself there, in contrast to a culture of low-cost high-quality medicine at the Mayo Clinic
Mayo Clinic
Mayo Clinic is a not-for-profit medical practice and medical research group specializing in treating difficult patients . Patients are referred to Mayo Clinic from across the U.S. and the world, and it is known for innovative and effective treatments. Mayo Clinic is known for being at the top of...
and in the Grand Junction, Colorado
Grand Junction, Colorado
The City of Grand Junction is the largest city in western Colorado. It is a city with a council–manager government form that is the county seat and the most populous city of Mesa County, Colorado, United States. Grand Junction is situated west-southwest of the Colorado State Capitol in Denver. As...
market. Gawande advised that
Imaging
The Canadian Association of Radiologists estimates that 30% of imaging is unnecessary in the Canadian health care systemHealth care in Canada
Health care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...
.
Overutilization of diagnostic imaging, such as X-rays and CT scans, is defined as any application that is unlikely to improve patient care. Respected organizations—such as the American College of Radiology
American College of Radiology
The American College of Radiology , founded in 1923, is a non-profit professional medical association composed of diagnostic radiologists, radiation oncologists, interventional radiologists, nuclear medicine physicians, and medical physicists. It is based in Reston, Virginia, with offices in...
(ACR), Royal College of Radiology (RCR) and the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(WHO)—have developed "appropriateness criteria".
Overuse of imaging can lead to a diagnosis of a condition that would have otherwise remained irrelevant (overdiagnosis
Overdiagnosis
Overdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. Overdiagnosis is the least familiar side effect of testing for early forms of disease – and, arguably, the most important...
).
Physician self-referral
One type of overutilization can be physician self-referral. Multiple studies have replicated the finding that when non-radiologists have an ownership interest in the fees generated by radiology equipment—and can self-refer—their utilization of imaging is unnecessarily higher. The majority of U.S. growth in imaging utilization (the fastest growing physician service) comes from self-referring non-radiologists. In 2004, this overutilization was estimated to contribute to $16 billion of annual U.S. health care costs.Politics
The 2010 U.S. health care reform, the Patient Protection and Affordable Care ActPatient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
, did not contain serious strategies to reduce overutilization; "the public has made it clear that it does not want to be told what medical care it can and cannot have". Uwe Reinhardt
Uwe Reinhardt
Uwe E. Reinhardt is a professor of political economy at Princeton University and holds several positions in the healthcare industry. Reinhardt is a prominent scholar in health care economics and a frequent speaker and author on subjects ranging from the war in Iraq to the future of Medicare.-...
, a health economist at Princeton, said "the minute you attack overutilization you will be called a Nazi before the day is out".
Others
- Hospitalizations, including admissions for those with chronic conditions who could be treated as outpatients
- Surgeries in Medicare patients in their last year of life, regions with high levels had higher death rates
- Antibiotic use (an overmedicationOvermedicationOvermedication is an inappropriate medical treatment that occurs when a patient takes unnecessary or excessive medications. This may happen because the prescriber is unaware of other medications the patient is already taking, because of drug interactions with another chemical or target population,...
) - Effects of direct to consumer marketing
- Opiate prescriptions
- Blood transfusions in the U.S.
- An estimated one in eight coronary stentCoronary stentA coronary stent is a tube placed in the coronary arteries that supply the heart, to keep the arteries open in the treatment of coronary heart disease. It is used in a procedure called percutaneous coronary intervention...
s (used in $20,000 procedures) with non-acute indications (U.S.)- Stents performed by the formal chair of cardiology, Mark Midei, at St. Joseph Medical Center of Towson, Maryland
- Heart bypass surgeries at Redding Medical Center which resulted in a FBI raid
- 2008 Medicare rates of double scanning with chest CTs
- Screening patients with advanced cancer for other cancers
- Annual cervical cancer screening in women with medical histories of normal pap smearPap smearThe Papanicolaou test is a screening test used in to detect pre-cancerous and cancerous processes in the endocervical canal of the female reproductive system. Changes can be treated, thus preventing cervical cancer...
and HPV test results
Medical malpractice laws and defensive medicine
Physicians are incentivized to order clinically unnecessary, or of little potential value, tests in order to protect themselves from prosecution. While defensive medicineDefensive Medicine
Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited as the driving force behind defensive medicine...
is a favored explanation for high medical costs by physicians, it was estimated to only contribute to 2.4% of the total $2.3 trillion of U.S. health care spending in 2008.