By Trudy Lieberman
We know too well the cost of American health care keeps rising as far as the eye can see. In 1995 health care accounted for 13.4 percent of GDP; in 2018 it consumed 17.7 percent. It is projected to rise even more.
Despite all the talk about how patients should become wise consumers of medical care, they can’t really do much to stop the big hospital systems, big physician groups, or powerful drug companies from charging the prices they do. In our system, those groups pretty much control what medical care costs.
There is, however, one thing patients can do that would contribute to eliminating some wasteful health care spending and at the same time get better care for themselves. They can try to avoid what health researchers call “low-value” care.
Low-value care generally means any test or procedure that, at best, has minimal value in a clinical situation. Some examples include chest X-rays or EKGs before cataract surgery; routine vitamin D testing; MRIs and other imaging for run-of-the-mill pain in the lower back; and antibiotics for viral upper respiratory infections like the common cold.
Health researchers estimate that low-value medical services add up to about $100 billion in health care spending each year. That’s waste that pushes up insurance premiums, deductibles, and other cost sharing we all have to pay.
Perhaps even more important, low-value tests can lead to what medical researchers call “cascades,” a series of tests and treatments that follow from a test. “They are incredibly common,” said primary-care doctor and health-policy researcher Dr. Ishani Ganguli, who is also an assistant professor at the Harvard Medical School. They occur when an unexpected finding leads to new tests, phone calls, ER visits, invasive procedures, or hospitalizations. “We’ve observed most cascades lead to nothing.”
Ganguli and colleagues looked at Medicare bills for cataract surgery, one of the most common and low-risk procedures for older adults. “Pre-operative testing doesn’t change outcomes or reduce your risk of complications from surgery,” she said.
Every group of 100 people who got an EKG before cataract surgery also got up to 11 extra tests, office visits, treatments, new diagnoses, or hospitalizations in the next three months. Researchers estimated the extra cost was $35 million in one year, 10 times more than the total cost of all the initial EKGs. “On average, those extra treatments offered no benefits,” Ganguli said.
Given those outcomes, why are eye surgeons still ordering the test? Some erroneously believe Medicare requires the test. Others do it out of habit or because their colleagues still order the tests. Some have experienced malpractice claims or are worried about being sued if something is missed.
Another study of some 400 physicians found more proof that cascades can cause further harm. All but two doctors surveyed had experienced cascades for their patients, and also either they or their family members had experienced them. The doctors reported that such cascades harm patients psychologically, physically, and financially.
That study also found that doctors in rural areas were more likely to say such cascades harmed patients. Such tests left many of the rural doctors feeling anxious and frustrated, and many believed they had wasted a lot of time and effort dealing with the additional tests and treatments. Ganguli said some may be frustrated by the lack of resources in rural areas and the additional burden placed on patients who may have to travel miles for some test that might be unnecessary in the first place.
So what should patients do?
If you have a medical abnormality that is in the gray area, it’s hard to leave it alone. Anxiety often drives the cascade. Still, patients in that situation need to ask a lot of questions about why further testing or medical procedures are necessary and whether more information would tell a doctor something new. Patients need to understand up front what the consequences might be.
A few years ago, the American Board of Internal Medicine and other partners launched the Choosing Wisely project, which aims to help patients select tests and treatments that are evidence-based, non-duplicative of other tests, and are truly necessary. Check its website choosingwisely.org to learn about low-value tests.
Have you experienced a cascade of tests? Tell firstname.lastname@example.org.