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Harvard: Overused Medical Services Cost Medicare Billions

By Jordan Rau

May 12th, 2014, 4:05 PM

Medical overtreatment is the inverse of former Supreme Court Justice Potter Stewart’s definition of pornography: while easy to define in concept, it can be hard to know it when you see it.

A treatment that is appropriate for one patient can also be unnecessary or even counterproductive for another, depending on the patient’s condition. This has been a major obstacle for studies seeking to pinpoint overused services, which by the most expansive estimates may account for as much as a third of the nation’s health spending.

Using a novel method, a study released Monday by researchers from the Harvard Medical School Department of Health Care Policy evaluated the prevalence in Medicare of 26 tests and procedures that have been found to offer little or no clinical benefit. The services were mostly culled from mainstream lists, including studies in medical journals, the Choosing Wisely campaign and the U.S. Preventive Services Task Force. The procedures included a form of back surgery in which collapsed spinal disks are filled with cement, as well as CT scans or MRIs on people with headaches.

The study in the journal JAMA Internal Medicine concluded that at least one in four Medicare beneficiaries received one of these 26 “low-value” services during 2009, and possibly significantly more. Two of the researchers, Aaron Schwartz and Dr. J. Michael McWilliams, said in an interview the total number of unnecessary treatments was surely higher, since their study encompassed just 26 tests and procedures.

“There are hundreds of other low-value services,” said McWilliams, a Harvard professor.

The researchers took a two-step approach. First, they analyzed Medicare billing records to isolate services provided to patients where they might not be warranted. For example, when tallying the number of surgeries to remove plaque from a carotid artery in the neck, they focused on patients who did not have any history of symptoms of mini-strokes.

The researchers calculated that there were 21.9 million instances of the 26 low-value treatments during 2009. Forty-two percent of beneficiaries received at least one such service, costing Medicare $8.5 billion, or 2.7 percent of spending.

To err on the side of caution, the researchers then analyzed the records a second time, using the most restrictive definitions they could devise. In re-examining the frequency of the carotid surgeries, for instance, they excluded operations that were associated with an emergency department visit, because that might indicate the patient was having a stroke. They also looked at only female patients, because there is evidence this procedure, known as a carotid endarterectomy, is less beneficial for women. With the more selective filter, the amount Medicare spent on that surgery dropped from $263 million to $110 million.

The frequency of other procedures dropped by an even greater degree. The researchers initially found that out of every 100 patients with general back pain, 12.4 received an imaging test. When the researchers limited their search to back scans of patients with no diagnoses in the billing records that might possibly justify the scan, such as a fever, cancer or drug use, they identified 2.5 instances for every 100 beneficiaries. The dollar figure those back scans cost Medicare shrank from $226 million to $82 million.

But even with the more specific definitions, the researchers calculated that 9.1 million low-value services were provided in 2009, with 25 percent of Medicare beneficiaries receiving at least one. Those services cost Medicare $1.9 billion, or 0.6 percent of overall spending.

The study found significant amounts of spending on low value-services even in parts of the country where they were least frequent. They wrote that “overuse may be substantial even among more efficient providers.” However, it is not clear how often those services were being provided in the four years since the time examined by the study, when overtreatment received more attention within the medical profession. The Choosing Wisely campaign, for instance, did not begin until 2012.

The researchers said that the wide gap between how many inappropriate services were detected using the broader versus the limited method illustrated how difficult it may be to try to police the appropriateness of specific treatments. Instead, they recommended that reforms focus on moving away from paying doctors and hospitals for each service they provide. Instead, they wrote, giving caregivers set sums to treat a patient’s overall health—known as global payments—or “bundled” payments to treat one particular episode, such as replacement of a knee and the subsequent rehabilitation, “could allow greater provider discretion in defining and identifying low-value services while incentivizing their elimination.”

There are several such efforts being tried out. Massachusetts is experimenting with global payments. The federal Center for Medicare & Medicaid Innovation has approved several hundred bundled payment experiments around the country.

7 Responses to “Harvard: Overused Medical Services Cost Medicare Billions”

  1. Matt says:

    I wonder about the true meaning of “low-value services.” I have seen plenty of doctors who inadequately document an adequate history and physical, simply due to time constraints, but still treat appropriately. Is is possible that some of these “low-value services” are actually just issues of inadequate documentation of say Amaurosis fugax in a patient who then receives the appropriate treatment of a carotid endarterectomy, and looking at the 30,000 foot view gives a skewed picture.

  2. The resurgence of capitation as a way to effect containment in the cost of health care in this country is a solution that is still barking up the wrong tree. It appears to me that the unintended consequence of this approach will be to further diminish the number of physicians available in the future. In recent postings I have read in the newspapers and blogs, it has been noted that insurance carriers have resorted to restricting the number of internists and specialists in their medicare advantage plans due to the expense of the care they provide, sometimes without even notifying the patients that their physicians are no longer included. Furthermore, physicians who now work for hospitals are subject to the same pressures: produce more and cost less or you will be fired. With reference to the above article, what was not able to be captured in the data were the reasons why these so-called nonproductive tests were performed in the first place: the possibility that the physicians who ordered these tests were trying to protect themselves from medical malpractice suits.This is a spirit that is still alive and well in this country due to the failure to reach any meaningful sort of tort reform. This ethic likely may have played a role in the data that was mined for the study reviewed,especially data that is already five years out of date. Who in his right mind these days would opt to select medicine as their career of choice?

  3. Ted says:

    I have had a completely blocked right coronary artery for 17 years. I have not had a bypass and my health is good. For many years, my cardiologist ordered an annual nuclear stress test and echocardiogram. Then two years ago, his practice was acquired by a large hospital corporation. When I arrived for my scheduled stress test, a technician tried to talk me out of proceeding with the test, impugning the judgment of my cardiologist in ordering one. Subsequently, my cardiologist has been extremely reluctant to order tests, even when I report what I believe to be symptoms. He mentioned “revised protocols.” With my medical condition, I cannot have required a high level of monitoring for 15 years then suddenly be deemed an example of “over-use” of testing. The quality of my care has been downgraded simply due to a financial profit motive. My relationship is no longer with a medical professional who only has my best interests at heart, it includes a silent partner: a practice manager who is incentivized by a profit motive. I highly resent this. I have a private “Cadillac” health insurance plan. I do not care about controlling costs in the system of medical financing, I care only about my outcome. I have a right to the best care and that right is being denied.

  4. Carol Tucker says:

    Medicare could save billions if it would stop paying for vacuum pumps for erectile dysfunction, plus the obvious fact that it’s sexist. If Medicare continues to cover vacuum pumps for ED, then it should cover vibrators for female sexual dysfunction, as well. Additionally, prescriptions for Viagra and Cialis are dispensed like candy, whether patients really need them or not. If a man asks for the Rx, providers are only happy to comply, as they receive kickbacks from pharmaceutical corporation pimps.

    Medicare would be better serve an aging population of citizenry by covering hearing aids and dental care than being so concerned about whether or not old farts can get it up.

    And if you want to study something REALLY useful, how about all the NECESSARY tests and treatments, these ACO’s (Accountable Care Organizations, a/k/a death panels) CMS (Center for Medicare and Medicaid) created, which do nothing more than BRIBE providers to not order expensive tests and treatments, even when MEDICALLY NECESSARY. They encourage providers to “find” reasons not to order these, which in the end, will cost lives and will cause lawsuits against not only provides for negligence, but against CMS, as well.

    Why can’t you all see what is right in front of your faces? Stop covering stupid crap like sex toys and dick drugs for old farts (which are advertised by vendors profusely in the back of the AARP Newsletter), stop bribing providers to essentially allow patients who need expensive tests and procedures to die, and start making saving lives a priority instead of saving money.

  5. My Medicare Advantage plan does not pay for ED drugs!!!

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  7. Carol Tucker says:

    Original Medicare does pay for ED drugs, as well as vacuum pumps. Medicare Advantage plans have no “advantage” to patients. They’re a joke!