When less health care is more

Many patients believe more health care is better health care. However, in most cases, it is simply more. Less-expensive interventions are often more effective. For example:

  • One study found that a greater percentage of strokes have been prevented in the last decade by making sure patients took aspirin than by developing more potent anti-platelet medication.
  • Older men diagnosed with low-risk prostate cancer can choose active surveillance rather than invasive treatment without losing quality of life.
  • Recovery from small heart attacks was as successful on drug therapy as with invasive vessel-clearing procedures.
  • Similarly, 22 percent of elderly Americans had coronary bypass surgery or balloon angioplasty in 1990, compared with 2 percent of Canadians. However, the 30-day death rate after a heart attack was the same for each nation.

There are other examples of expensive care that does not do much good:

  • One out of 5 heart defibrillators are implanted without solid evidence that the devices will be helpful. They are implanted to shock an irregularly beating heart back into a normal rhythm. They work well in patients with advanced heart failure, but they have been ineffective in other patients. The procedure costs $35,000 and may cause unnecessary harm.
  • Americans spent nearly $86 billion in 2005 on imaging, physician visits and medication for back and neck pain – most of which did not improve the patients’ conditions.
  • Medical imaging – which includes CT, PET and MRI scans – has become a $100 billion business. However, studies show 20 to 50 percent of the procedures should not have been done because they neither helped diagnose patients nor helped determine their treatment.

The apparent heart-defibrillator overuse is an example of what is often called “technology creep.” After a device is approved for use in a high-risk population, its use expands to a larger, lower-risk population, for whom risks outweigh the benefits. This, in a nutshell, is a major contributor to runaway medical costs and clinical waste. It is not the technology itself. It is technology utilized beyond its original intent – often to recoup its original cost and to bolster profits.

Imaging costs have grown at twice the rate of other health-care technologies, including laboratory procedures and pharmaceuticals. A contributing factor is the financial incentives of self-referral. Federal regulations prohibit physicians from referring Medicare or Medicaid patients to services in which they have a financial interest. However, an exception is allowed if physicians have equipment in their offices – presumably for patient convenience.

Patients of doctors who own or lease MRI equipment are more likely to be scanned for lower back pain. A 2011 study showed an increase of nearly one-third for primary-care physicians and 13 percent for orthopedists. Orthopedic patients who were scanned were 34 percent more likely to have back surgery – meaning the scans induced more surgery. The study’s authors point out there is no definitive evidence that either MRIs or surgery improve outcomes for lower back pain.