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Why It鈥檚 So Tough to Reduce Unnecessary Medical Care

Why It鈥檚 So Tough to Reduce Unnecessary Medical Care

Lalit Bajaj, an emergency medicine doctor at Children鈥檚 Hospital Colorado, with fellow emergency physician Julia Fuzak Freeman. To reduce unnecessary X-rays and antibiotics, Bajaj and his colleagues implemented new protocols in 2015 to educate parents on bronchiolitis, how to manage symptoms until kids get better, and why imaging or medication is unlikely to help. (Austin Day/Children鈥檚 Hospital Colorado)

The U.S. spends huge amounts of money on health care that does little or nothing to help patients, and may even harm them. In Colorado, a new analysis shows that the number of tests and treatments conducted for which the risks and costs exceed the benefits has barely budged despite a decade-long attempt to tamp down on such care.

The state 鈥 including the government, insurers, and patients themselves 鈥 spent $134 million last year on what is called low-value care, according to the report by the , a Denver nonprofit that collects billing data from health plans across Colorado. The top low-value items in terms of spending in each of the past three years were prescriptions for opiates, prescriptions for multiple antipsychotics, and screenings for vitamin D deficiency, according to the analysis.

Nationwide, those treatments raise costs, lead to health complications, and interfere with more appropriate care. But the structure of the U.S. health system, which rewards doctors for providing more care rather than the right care, has made it difficult to stop such waste. Even in places that have reduced or eliminated the financial incentive for additional testing, such as Los Angeles County, low-value care remains a problem.

And when patients are told by physicians or health plans that tests or treatments aren鈥檛 needed, they often question whether they are being denied care.

While some highly motivated clinicians have championed effective interventions at their own hospitals or clinics, those efforts have barely moved the needle on low-value care. Of the $3 trillion spent each year on health care in the U.S., 10% to 30% consists of this low-value care, according to multiple estimates.

鈥淭here鈥檚 a culture of 鈥榤ore is better,鈥欌 said , director of the University of Michigan Center for Value-Based Insurance Design. 鈥淎nd 鈥榤ore is better鈥 is very hard to overcome.鈥

To conduct its study, the Center for Improving Value in Health Care used a calculator developed by Fendrick and others that quantifies spending for services identified as low-value care by the campaign, a collaborative effort of the American Board of Internal Medicine Foundation and now more than 80 medical specialty societies.

Fendrick said the $134 million tallied in the report represents just 鈥渁 small piece of the universe of no- and low-value care鈥 in Colorado. The calculator tracks only the 58 services that developers were most confident reflected low-value care and does not include the costs of the cascade of care that often follows. Every dollar spent on prostate cancer testing in men over 70, for example, results in $6 in follow-up tests and treatments, published in JAMA Network Open in 2022.

In 2013, Children鈥檚 Hospital Colorado learned it had the second-highest rate of CT abdominal scans 鈥 a low-value service 鈥 among U.S. children鈥檚 hospitals, with about 45% of kids coming to the emergency room with abdominal pain getting the imaging. Research had shown that those scans were not helpful in most cases and exposed the children to unnecessary radiation.

Digging into the problem, clinicians there found that if ER physicians could not find the appendix on an ultrasound, they swiftly ordered a CT scan.

New protocols implemented in 2016 have surgeons come to the ER to evaluate the patient before a CT scan is ordered. The surgeons and emergency doctors can then decide whether the child is at high risk of appendicitis and needs to be admitted, or at low risk and can be sent home. Within two years, the hospital cut its rate of CT scans on children with abdominal pain to 10%, with no increase in complications.

鈥淥ne of the hardest things to do in this work is to align financial incentives,鈥 said , an emergency physician at Children鈥檚 Colorado who championed the effort, 鈥渂ecause in our health care system, we get paid for what we do.鈥

Cutting CT scans meant less revenue. But Children鈥檚 Colorado worked with an insurance plan to create an incentive program. If the hospital could hold down the rate of high-cost imaging, saving the health plan money, it could earn a bonus from the insurer at the end of the year that would partly offset the lost revenue.

But Bajaj said it鈥檚 tough for doctors to deal with patient expectations for testing or treatment. 鈥淚t鈥檚 not a great feeling for a parent to come in and I tell them how to support their child through the illness,鈥 Bajaj said. 鈥淭hey don鈥檛 really feel like they got testing done. 鈥楧id they really evaluate my child?鈥欌

That was a major hurdle in treating kids with bronchiolitis. That respiratory condition, most often caused by a virus, sends thousands of kids every winter to the ER at Children鈥檚, where unneeded chest X-rays were often ordered.

鈥淭he data was telling us that they really didn鈥檛 provide any change in care,鈥 Bajaj said. 鈥淲hat they did was add unnecessary expense.鈥

Too often, doctors reading the X-rays mistakenly thought they saw a bacterial infection and prescribed antibiotics. They would also prescribe bronchodilators, like albuterol, they thought would help the kids breathe easier. But studies have shown those medicines don鈥檛 relieve bronchiolitis.

Bajaj and his colleagues implemented new protocols in 2015 to educate parents on the condition, how to manage symptoms until kids get better, and why imaging or medication is unlikely to help.

鈥淭hese are hard concepts for folks,鈥 Bajaj said. Parents want to feel their child has been fully evaluated when they come to the ER, especially since they are often footing more of the bill.

The hospital reduced its X-ray rate from 40% in the 17 months before the new protocols to 29% in the 17 months after implementation, according to Bajaj. The use of bronchodilators dropped from 36% to 22%.

Part of the secret of Children鈥檚 success is that they 鈥渂rand鈥 their interventions. The hospital鈥檚 quality improvement team gathers staff members from various disciplines to brainstorm ways to reduce low-value care and assign a catchy slogan to the effort: 鈥淚mage gently鈥 for appendicitis or 鈥淩est is best鈥 for bronchiolitis.

鈥淎nd then we get T-shirts made. We get mouse pads and water bottles made,鈥 Bajaj said. 鈥淧eople really do enjoy T-shirts.鈥

In California, the Los Angeles County Department of Health Services, one of the largest safety-net health systems in the country, typically receives a fixed dollar amount for each person it covers regardless of how many services it provides. But the staff found that 90% of patients undergoing cataract surgery were getting extensive preoperative testing, a low-value service. In other health systems, that would normally reflect a do-more-to-get-paid-more scenario.

鈥淭hat wasn鈥檛 the case here in LA County. Doctors didn鈥檛 make more money,鈥 said , an associate professor of medicine at UCLA. 鈥淚t suggests that there鈥檚 many other factors other than finances that can be in play.鈥

As quality improvement staffers at the county health system looked into the reasons, they found the system had instituted a protocol requiring an X-ray, electrocardiograms, and a full set of laboratory tests before the surgery. A records review showed those extra tests weren鈥檛 identifying problems that would interfere with an operation, but they did often lead to unnecessary follow-up visits. An anomaly on an EKG might lead to a referral to a cardiologist, and since there was often a backlog of patients waiting for cardiology visits, the surgery could be delayed for months.

In response, the health system developed new guidelines for preoperative screenings and relied on a nurse trained in quality improvement to advise surgeons when preoperative testing was warranted. The initiative drove down the rates of chest X-rays, EKGs, and lab tests by two-thirds, with no increase in adverse events.

lost money in its first year because of high startup costs. But over three years, it resulted in modest savings of about $60,000.

鈥淎 fee-for-service-driven health system where they make more money if they order more tests, they would have lost money,鈥 Mafi said, because they make a profit on each test.

Even though the savings were minimal, patients got needed surgeries faster and did not face a further cascade of unnecessary testing and treatment.

Fendrick said some hospitals make more money providing all those tests in preparation for cataract surgery than they do from the surgeries themselves.

鈥淭hese are older people. They get EKGs, they get chest X-rays, and they get bloodwork,鈥 he said. 鈥淪ome people need those things, but many don鈥檛.鈥