Health experts often focus on the needs of a relatively small number of people who are the heaviest users of medical treatment. You know: that five percent of Medicare beneficiaries who account for half the program’s costs.
But a new study published in the October volume of the journal Health Affairs (paywall) looks at another cost-driver in our health care system. This one will be familiar to many seniors and their adult children: Needless high-volume but relatively inexpensive tests and procedures such as cardiac screenings for low-risk patients, PSA prostate cancer tests for men aged 75 and older, and imaging for common low-back pain.
And while the study focused on the immediate financial costs of these tests, patients know about the other price: added stress and a trip into the seemingly endless vortex of follow-up doctor visits and additional tests—some invasive and risky.
The researchers looked at administrative data for 5.4 million individual medical services received in Virginia in 2014 that cost less than $538. They concluded that one-third were low-value, such as being unlikely to benefit a patient. More than 90 percent of all low-value procedures were low-cost and one-in-five patients received at least one of these low-value tests or treatments.
The total cost of these low-value, low-cost services- -$381 million—was almost twice as much as high-cost, low-value services such as knee surgeries for people with osteoarthritis. In all, low-cost, low-value procedures accounted for about 2.1 percent of all of Virginia health care expenses in 2014, or almost $10 per beneficiary.
That may not sound like a lot, but squeezing medical costs has proved to be enormously challenging. And as the US engages in its endless debate over the high cost of health insurance, remember that the primary reason premiums are so expensive is because medical services are so costly. The only way we’ll significantly slow the growth of insurance premiums is to reduce the cost of health services.
Interestingly, a recent American Medical Assn survey found physicians themselves believe that about 20 percent of procedures are unnecessary, including one-quarter of all tests. The two main reasons: Fear of malpractice suits and patient pressure (which are closely related).
The unnecessary services identified by the authors of the new Health Affairs study– including John Mafi at UCLA, Kyle Russell of the Virginia office of Health Information, and Beth Bortz of the Virginia Center for Health Innovation– are low-hanging fruit. While getting physicians to shift their practice patterns and convincing patients to change their expectations when it comes to high-cost treatments for serious illnesses has proved nearly impossible, it may be easier to address these low-cost services.
Take those often-worthless knee surgeries for patients with arthritis. The alternative is exercise and pain management. But orthopedic surgeons don’t get paid for giving such advice and American patients don’t want to hear that they may have to adjust their lifestyles rather than undergo what they think (often-incorrectly) is a quick-fix surgery. Ask any doc and he’ll tell you that if he recommends the low-cost, low-risk course, his patient is likely to trundle off to another orthopedist who will do the surgery.
Who will miss the EKG?
Now think about the low-cost, low-value procedures identified in the Health Affairs paper. A common example for older adults: Your annual physical includes an EKG or similar test even though you have no symptoms or history of cardiac disease. Why? Well… because. The average cost: About $300. And if the test is positive, it may lead to an unnecessary—and even more expensive and risky—cardiac catheterization.
Unlike that needless knee surgery, few low-risk patients demand EKGs and few will notice if their doc drops it from their annual physical. Will physicians stop doing them if presented with evidence that they are not productive? Most will. And groups such as the ABIM’s Choosing Wisely campaign are gathering the data they need.
Besides, if we can’t make these relatively small changes in the way physicians practice, there is little hope we’ll make bigger changes.