System Overuse

Many people believe that the design of a health system influences the quality of care. Data suggest otherwise.

With rising health care costs, more attention has been placed on productive models of care and systems to cut waste. Limited studies have demonstrated patterns of overuse and waste in health care across various hospital and payer settings. This recent study conducted a systemic review to highlight the effect of managed care and other health care systems on the overuse of health care services.

Seven articles were identified that examined the rates of overuse of 5 health care services. These services included: coronary angiography, carotid endarterectomy, endoscopy for gastric ulcer management, radionuclide myocardial perfusion imaging, and antibiotic treatment and diagnostic services for upper respiratory infection (URI).  These services were analyzed across multiple different health care settings.

There were similar rates of inappropriate coronary angiography for fee-for-service (FFS) hospitals in New York and managed care hospitals in Massachusetts (4% vs. 6%). Medicare HMOs and Medicare FFS fared similarly for overuse of coronary angiography (13% vs. 13%) and for carotid endarterectomy (8.4% vs. 8.6%).

Significant differences were reported in the diagnosis and treatment of URIs between managed care organizations and FFS. Antibiotics were inappropriately given more often in managed care (31% vs. 21%; p=0.02) compared to a FFS plan. On the contrary, overuse of diagnostic tests for URIs was more common for FFS than managed care (21% vs. 4%; p=0.001).

Within the Veterans Affairs (VA) medical system, an all-American example of socialized health care, there were higher rates of inappropriate antibiotic use for URIs in some, but not all, VA systems compared community hospitals. Some VA settings inappropriately used surveillance upper endoscopy compared to community settings (37% vs. 20%). Yet, for inappropriate myocardial perfusion imaging in VA and non-VA settings, there was no statistical difference (22% vs. 17%).

Commentary

This study brings attention to the severe overuse of health care in America. While some might try to blame overuse on health system design and subsequent incentives for the players involved (doctors, hospitals, etc.), no conclusive findings arise form this study to show that any one system (fee-for-service, managed care, government hospitals, private hospitals, etc.) is more wasteful or alternatively more cost effective than another.

This study was extremely limited, however, due to the small quantity of available literature. The evidence to support one payer system or one delivery system over another does not exist. The nation should improve its focus on producing more data investigating the overuse of health care and health system design.

Shannon Brownlee’s classic 2008 narrative “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer” still stands as a great example of the overuse of health care. Yet, based on the available research, it is difficult to argue that one type of reform  – single payer, market-based alternatives, Medicare-for-all – is the ideal solution to cure the problem of over treatment in American health care.

Keyhani, S, et al. Medical Care. 2013; 51 (6): 503-508.

by

Ellana Stinson, MD