The Overuse of Treatment Options in the U.S. Health Care Industry

Over the last several years, as the U.S. government has debated the Affordable Care Act (ACA) and health care reform, ongoing research related to the quality of care provided by the U.S. health care system as a whole has been published. U.S. spending on health care has reached astronomical proportions—per capita health care spending is approximately twice that of other industrialized nations—and its cost to the U.S. government will become crippling if nothing changes (Bentley, Effros, Palar, & Keeler, 2008, p. 631). This leaves doctors in the middle of a very volatile, shifting political situation with an increasing number of new legal and ethical issues to confront in this new environment. With such intense focus on the need to decrease overall health care costs, how can doctors maintain a high level of quality care for their patients? And isn’t maintaining that quality of care their ethical duty?

In earlier—possibly simpler—times, the doctor’s duty seemed to be very straightforward. Her duty was to her patient; she had an obligation to act in the best interests of her patient’s health. While it could be argued that even that duty is not always straightforward, as Angell contends in her forward-looking journal article on financial and political pressures being brought to bear on doctors beginning in the early 1990s, a doctor’s duty seemed to become splintered when she was suddenly required to balance a patient’s individual health care needs against the finite amount of health care resources required by society as a whole (Angell, 1993, p. 279). When those interests conflict, doctors are increasingly put in a tough spot when it comes to recommending and delivering treatment options.

This tension—if anything—is exerted even more strongly on doctors today as they are pulled between the health care needs of their patients and society’s limited pot of health care resources. Doctors are somehow expected to maintain the highest possible quality of care, while acting as a benevolent steward and reducing the overall costs of health care. “Doing so,” according to Angell, “requires doctors to practice with one eye on costs, which may mean sometimes denying beneficial care that they would surely have provided in earlier times” (1993, p. 279).

This view that doctors must choose between saving the American health care system money and providing high quality health care for their patients is the traditional—and a logical—angle at which to consider the balancing issues. More recently, however, there has been discussion of whether or not more expensive care truly does equal higher quality care. According to Schuster, McGlynn, and Brook in their 2005 review of quality of care in the U.S. health care system, good quality health care “increase[s] the likelihood of desired health outcomes and [is] consistent with current professional knowledge…” He goes on to describe poor quality care as too much, too little, or the wrong care. Examples of too much care include “providing unnecessary tests, medications, and procedures, with associated risks and side effects” (p. 844).

It would seem, then, that receiving too much care—also known as overtreatment—might be more expensive, but might actually result in a poorer quality of care for the patient. It follows therefore, that the cost of care isn’t necessarily directly correlative with the quality. Several recent reviews of studies have attempted to discover how much of the staggeringly expensive cost of U.S. health care might be directly related to patient overtreatment.

By way of explanation, Moynihan, Doust, and Henry (2012) pointed out that with current advanced levels of technology, it is now possible to detect very insignificant “abnormalities” with screening equipment. The question is, though, whether or not it’s helpful to do so. One must ask if the abnormality is likely ever to need treatment. If not—and if the patient insists on receiving treatment anyhow to remove something that never would have caused issues—what risks have been needlessly taken, what resources have been used that might have been needed elsewhere, and what are some of the potential negative consequences of a healthy person becoming classified in the health care system as an ill person with a medical issue?

In addition to better discrimination by doctors as to which are benign abnormalities and which are likely to go on to cause harm, Moynihan suggests that there should be more discussion among the public and professionals about the consequences of overdiagnosis. He goes on to say, “More deeply, mounting evidence that we’re harming healthy people may force a questioning of our faith in ever-earlier detection, a renewal of the process of disease definition, and a fundamental shift in the systemic incentives driving dangerous excess” (Moynihan et al., 2012, p. 1).

Additionally, the ethical implications of doctors recommending what could be seen by some to be excessive health care services can be seen from Bentley’s (2008) discussion of the causes of the inefficiencies of the health care system. She explains that none of the actors in the U.S. health care system have any of the economic incentives that would normally drive efficiencies in an industry. She then points out that fee-for-service providers are, in fact, paid by the service. She also alleges that physicians are not disinterested advisors when they provide advice and treatment recommendations to their patients because in addition to making the recommendations, they are also the providers of that treatment. She does, however, concede that the possibility of malpractice litigation is another driving force that might influence a physician to err on the side of overtesting, as opposed to undertesting. While doctors are still expected to make decisions in the best interests of their patients, the fact that some are questioning whether the motivation behind treatment recommendations are pecuniary would seem to indicate an ethical hot button area in the current health care climate.

A 2012 study by Schleifer and & Rothman stated unequivocally that 30 percent of U.S. health care costs could be attributed to the overuse of medical interventions, including pharmaceuticals, testing, and screening, to the tune of $210 billion in 2009. He, like Bentley, attributes this issue to several factors that encourage an increase in medical treatments, including physician fear of medical malpractice lawsuits, fee-for-payment structures, pharmaceutical and medical device marketing efforts, and physicians’ natural inclination to thoroughness.

Schleifer didn’t stop there, however. As a part of his study, he engaged in discussions with patients to see what type of expectations they had related to treatments provided by physicians. He found that patient expectations might, in fact, also be a factor in some cases of overtreatment, especially as patients have become much more proactive about their health care options over the past 20 or so years. While he did find that patients often thought that more was better in the context of health care treatment—especially when it came to testing and screening for conditions such as cancer—this point-of-view did not extend to every area of health care.

Patients tended to think that doctors overprescribed pharmaceuticals, for example. Some patients revealed that the side effect descriptions in pharmaceutical advertising contributed to this point-of-view. They distrusted pharmaceutical companies and made references to doctors getting kickbacks for prescribing certain medications.

Patients exhibited some hostility to the idea that overtesting or unnecessary screening was overtreatment and not advisable if unnecessary. They tended to think that—regardless of whether or not they were a part of a high risk population, for example—they didn’t want to be one of the ones who could have caught a disease early, but missed it by not being proactive.

The results of the study also reflected suspicion and wariness related to the government’s intentions when it communicated advice related to unnecessary screenings and tests. The patients attribute the government’s motive to be predominately cost-related, which makes them skeptical when it recommends delaying or foregoing screening or testing.

While this was a limited, qualitative study, the findings seemed indicative of widespread views related to societal perspectives of overtreatment issues. Based on his findings, Schleifer made recommendations that included educating the public about overtreatment issues such as unnecessary screening and testing in a way that might help alleviate some of patients’ wariness. (2012).

Much in the same vein, in a 2005 review of studies analyzing U.S. health care industry quality issues, Schuster and & Rothman stated: “A large part of our quality problem is the amount of inappropriate care provided in this country. Elimination of such nonbeneficial and potentially harmful care would lead to a large savings in human and financial costs” (2005, p. 888). His review indicated to him that overtreatment—which he considers to be “too much care” in the form of “providing unnecessary tests, medications, and procedures, with associated risks and side effects”—occurred often and in all of those forms. By way of specific examples, he found that antibiotics were often prescribed for viral infections, thus increasing the likelihood of antibiotic-resistant bacterial strains. He noted that in a study spanning several large U.S. urban centers and a number of hospitals, patients presenting with depression were not provided with antidepressants, which have been proven to be effective treatment options for depression, but, were instead sent home with mild tranquilizers, which have not been proven to have any efficacy for patients presenting with depression.

Interestingly, one of Schuster’s most poignant points from the review “is the surprisingly small amount of systematic knowledge available on the quality of health care delivered in the United States. Even though health care is a huge industry that affects the lives of most Americans, we have only snapshots of information about particular conditions, types of surgery, and locations of care” (2005, 846).

Korenstein shares a similar point of view in her 2012 review of studies on the overuse of health care services in the U.S. In it, she acknowledges that overtreatment hasn’t been a widely discussed issue in the past when she posits that “[p]erhaps because it is difficult to define, study, and document, overuse has not become a standard component of quality of care assessments” (p. 171). It stands to reason that a difficult-to-measure quality might not readily lend itself to becoming a popular quality metric.

Korenstein (2012) goes on to say in her review, however, that she thinks more research should be done to gain an increased understanding of the magnitude of overtreatment issues. While much study has been done on issues related to undertreatment, not nearly as much has been done on overtreatment. Her main conclusion is that more research needs to be done before reasonable conclusions can be drawn.

In conclusion, issues related to the overtreatment of patients have brought into question traditional assumptions about health care expense versus quality of care. While much research must still be done on the subject, the idea that quality health care does not automatically equal expensive health care might mean that strategic changes to the health care system can be made that will both save money and provide better quality care. Additionally, related ethical and legal implications for physicians must be kept in mind as a balance is sought between cost and quality.

References

Angell, M. (1993). The doctor as double agent. Kennedy Institute of Ethics Journal, 3(3), 279–286.

Bentley, T., Effros, R., Palar, K., & Keeler, E. (2008). Waste in the U.S. health care system: A conceptual framework. Milbank Q. 86(4), 629–659.

Korenstein, D., Falk, R., Howell, E., Bishop, T., & Keyhani, S. (2012). Overuse of health care services in the United States: An understudied problem. Arch Int Med., 172(2), 171–178.

Moynihan, R., Doust, J., & Henry, D. (2012). Preventing overdiagnosis: How to stop harming the healthy. BMJ, 344, e3502.

Schleifer, D., & Rothman, D. (2012). The ultimate decision is yours: Exploring patients’ attitudes about the overuse of medical interventions. PloS One., 7(12), e52552.

Schuster, M. A., McGlynn, E. A., & Brook, R. H. (2005). How good is the quality of health care in the United States? Milbank Q, 83, 843–895.