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April 10, 2018
Per a recent JAMA article by Irene Papanicolas, et al entitled “Health Care Spending in the US and Other High Income Countries,” and a follow-up piece in JAMA Forum by the article’s co-author Ashish Jha, MD, MPH, overutilization hasn’t proven to be a main driver of high health care spending in the U.S. as it compares to other countries. But does that mean we should leave that out of the equation altogether?
The two papers focus on a comparative analysis, accounting for differences from countries. In their piece, Papanicolas et al conclude that the “higher spending as compared to ten high-income countries is largely due to prices of labor and goods, including pharmaceuticals and devices, and administrative costs.” In “Why Does US Health Care Spending Far Outstrip That of Other Countries,” Jha claims that previous notions of what is driving the spending, such as U.S. consumers’ “high expectation of care, the fee-for-service system… lack of social spending, focus on specialists over primary care [and] excessive defensive medicine,” are not borne out by the data.
While some may be quick to abandon the efforts to reduce low-value care after reading these pieces, I think it’s important to note that neither article says that there is not a problem with utilization in this country and abroad. In fact, the 20 countries now involved in Choosing Wisely have about the same amount of overuse—30 percent of the tests and procedures are unnecessary. This was suggested by a recent study in Canada. If countries that have embraced the campaign to reduce utilization are successful in decreasing overuse and the U.S. is not, we will likely see a difference in spending, which after all is use times price. Time will tell.
I agree with Jha that “masterful” data collection on the part of the Organization for Economic Cooperation and Development will be very helpful in determining how health systems all over the world need to change to achieve the Quadruple Aim. I am, however, concerned by how other stakeholders will interpret the findings from this study. Making health care affordable is a large problem that cannot be tackled using one strategy alone. So before we throw out the baby with the bathwater, here is my list of five reasons why it is important for us to continue our collective efforts to reduce unnecessary care:
- Harm to patients. Overuse causes harm; it’s a quality issue. NAM reports that 30,000 people die each year as a result of tests and procedures they do not need. For example, Rebecca Smith Bindman’s study found a “large increase in the rate of advanced diagnostic imaging and associated radiation exposure.”
- Physicians and other clinicians are more in control of utilization than setting prices. In addition, as stated in the Physician Charter, physicians and clinicians are professionally obligated to be good stewards of finite resources.
- There is no silver bullet. Per Don Berwick, we must work on multiple fronts (or wedges) to solve a $750 billion problem.
- Every penny counts. The potential savings by eliminating unnecessary care were estimated to be close to $200 billion and that can happen now. The Choosing Wisely campaign has identified over 500 tests and treatments that need to be questioned. Why are we waiting for prices to go down—a complicated political process that will require more time—to take action?
- Targeted incomes. I learned long ago in graduate school that when unit prices go down, utilization goes up to meet providers’ targeted incomes. If we don’t address overuse now, when prices actually do decrease, we will just have providers increasing use to meet targeted incomes.
Regardless of the why, the issue still remains that health care spending is too high in this country. Much like the behavioral change asked of individuals around the environmental movement (e.g., recycling, taking public transportation), it’s important to continue to message that every bit helps. In my opinion, saving $200 billion by eliminating unnecessary care would be a great start.
Daniel B. Wolfson
EVP & COO, ABIM Foundation