For people who had been awaiting the rollout of the Affordable Care Act in order to obtain health insurance for the first time, the major problem associated with American healthcare has been a lack of access to it. But for a surprising number of Americans, the greater problem may be exactly the opposite: They are receiving too much healthcare. And that’s not good news for either their wallets or their physical well-being.
The most recent estimate from the Institute of Medicine is that about 30 percent of total healthcare expenditures in America go toward unneeded care. Doctors, too, have acknowledged the problem: In a 2011 survey published in the Archives of Internal Medicine, 42 percent of American primary care physicians said that patients in their own practice were getting more care than necessary.
Excessive care typically takes the form of overabundant referrals to specialists, more diagnostic tests than would be medically necessary, or too many prescriptions—but in some cases, it can extend to actual treatments or surgeries that are not clinically indicated. Richard Baron, president of the American Board of Internal Medicine, is candid about the problem. “There were and are lots of things being done in healthcare that don’t reliably benefit patients,” he says.
From a patient perspective, it can be hard to see at first glance how too much care could be a problem. What’s wrong with an extra test, just to be safe? That almost sounds like a good thing.
But unneeded healthcare can be physically damaging. “Anything we do in medicine and healthcare has expected benefits and harms,” says Brenda Sirovich, a research associate at the VA Medical Center in White River Junction, Vermont, and the lead researcher behind the physician survey mentioned earlier. “Any time you have an intervention for a patient, no matter how small […] there is also the chance that it’s going to do some harm.” She points to the example of CT scans: for patients who are genuinely sick, they’re an important diagnostic tool. But they also expose patients to radiation, and when used too liberally, their harms outweigh their benefits.
Even for initial screening tests that pose no risk in themselves, there’s the problem of the “downstream effect;” if the first test produces an ambiguous result or a false positive, it can lead to more invasive testing that does carry substantial risk. “As you intervene on patients who have less and less reason to intervene and less and less chance of benefiting, you still retain that probability of harming them,” says Sirovich. “In a word, that is the biggest problem with doing too much—the risk of harm.”
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In some cases, the roots of the excess care are noble: Doctors just want to provide the best possible care for their patients. The operating assumption for many both inside and outside the medical field tends to be that if a little care does a little good, a lot of care will do a lot of good. Given the time constraints that many physicians are under, it can seem safest to default to over-ordering.
But there are several other major drivers of overutilization, as well. Experts debate exactly how much the threat of lawsuits influences physicians in their practice of medicine, but physicians themselves say that fear of legal challenges is a substantial factor in motivating them to provide too much care. (In Sirovich’s physician survey, malpractice was cited far more frequently than any other factor as incentivizing physicians to do more than they felt was clinically necessary.)
Skeptics challenge that physicians might not be in the best position to know exactly what motivates their own behavior. But a study published in Health Affairs this summer suggests that the malpractice effect is real. According to the report, doctors who acknowledge having a strong fear of malpractice are more likely to show a pattern of ordering aggressive diagnostic tests, and they’re also more likely to refer patients to the ER for treatment. This makes intuitive sense: Doctors are rarely asked if they did too much, but they are constantly questioned as to whether or not they did enough—and they know they can wind up in legal trouble if patients don’t think their care was sufficient.
Perhaps more troubling than medical liability issues are the financial incentives inherent in the American healthcare system. Most American healthcare currently operates on a fee-for-service model, where physicians receive payment for every service performed, regardless of whether that service actually benefits the patient or not. In some cases, especially where physicians self-refer their patients for expensive diagnostic tests and treatments, there can be substantial financial incentives for ordering interventions that might not be medically necessary.