Both conscientious medical practitioners and consumer health-care watchdogs were gratified last month when a professional group deemed nearly 100 medical procedures, tests and therapies overused and frequently unnecessary.
Medical care in the U.S. has long functioned under a more-is-more principle that is not only expensive and wasteful of resources, but often causes patient harm from false positives (when a test indicates disease when there is none), uncomfortable additional procedures, possible infection and unnecessary worry. Things are changing, however because of the pressures of health-care reform, a growing population of older patients and the awareness that practicing defensive medicine (doctors over-prescribing tests and procedures to protect against claims of malpractice) is misguided and doesn’t work.
As widely reported, including in the Los Angeles Times, last month the American Board of Internal Medicine (ABIM) issued the list of practices that undermine health care and contribute to runaway costs. They include:
- early elective caesarean deliveries;
- CT scans for head injuries in children;
- annual Pap test for middle-aged women.
Although individual circumstances might make these practices reasonable and appropriate, for most people they should not be routine.
The ABIM has been down this path before through its foundation, whose mission is to advance medical professionalism into clinical policy and practice through collaboration with consumer organizations, patients, insurers and policy makers. Its Choosing Wisely campaign, which encourages physicians and patients to communicate in an effort to reduce overuse of tests and procedures and make effective choices about their care.
As The Times reports, the U.S. spends more than $2.5 trillion a year on health care; that’s more than $8,000 per person, and 2 1/2 times as much as the average spent by other industrialized, affluent nations.
We spend more because hospital and doctor fees are higher here than other countries. But the cost is higher also because U.S. practitioners perform far more tests and elective procedures. They order nearly twice as many CT and MRI exams, do more knee replacements and deliver more babies by caesarean section.
Yes, the U.S. has some of the highest cancer survival rates in the world, but in comparison with other countries, we fall short in other areas, including caring for children with asthma and adults with lung disorders, for example.
The fact that more isn’t necessarily more was demonstrated last year by the Institute of Medicine (IOM), which estimated that nearly one-third of annual health-care expenditures were wasteful, or $750 billion a year.
“Millions of Americans are increasingly realizing that when it comes to health care, more is not necessarily better,” Dr. Christine K. Cassel, president of the ABIM Foundation, told The Times.
Many health-care reform advocates blame the fee-for-service business model for much overuse in health care. When someone is paid for every procedure, he or she is more likely to recommend it.
The question remains: Will this rising awareness of overdoing it change the treatment default from always doing to sometimes waiting? When diseases can be fatal, when families are pressuring the doctor to everything he or she can, a conservative approach, even if wise, can seem heartless and wrong.
Never mind that the U.S. Preventive Services Task Force has been clear about the dicey value of breast and prostate cancer screenings, noting that they often do more harm than good. Many patient advocates have objected to its pronouncements, and some congressional representatives called what it promoted as a best medical practice rationing.
The broad coalition of medical societies involved in the last call to action included the American Academy of Pediatrics, the American Academy of Ophthalmology, the American College of Obstetricians and Gynecologists and the Society of Thoracic Surgeons. Other supporters include Consumer Reports, the AARP and the National Business Group on Health.