• You're getting nickel and dimed for low-value medical tests in Washington, report says

    By: Debbie Cockrell, The News Tribune

    Updated:

    If it seems you undergo too many medical tests with each doctor’s visit, you could be on to something that’s actually a larger issue in this state.

    That’s according to a new report: “First Do No Harm: Calculating Health Care Waste in Washington State.”

    The analysis, produced by the nonprofit Washington Health Alliance, was officially released Thursday, Feb. 1. An advance copy was sent to media for review ahead of the public release. 

    The report looked at 47 common treatment approaches it said were “known by the medical community to be overused.”

    The report determined 93 percent of the overuse was attributed to 11 common tests, procedures and treatments.

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    Blame it on a “more is better” culture of health care exhibited in many cases, with reasons ranging from patients asking for specific treatments to doctors fearing the possible ramifications of under-treating patients — a fear exhibited in past studies elsewhere.

    The level of overuse examined in the report wasn’t dominated by big-ticket procedures. Think more along the lines of pre-op lab work before a surgery, or antibiotics prescribed for viruses.

    “Many of the services are individually low cost, and therefore a doctor or patient may not consider it problematic,” Susie Dade, deputy director of the alliance, told The News Tribune via email. “But when low-cost services are used over and over, they add up to tremendous waste.

    “In the alliance’s analysis, we found that about 80 percent of the low-value services examined for this report are low cost (meaning less than about $500). However, we all pay the price with increased premiums and health care costs.”

    All told, 36 percent of spending on the services reviewed by the report went to low-value treatments or procedures totaling an estimated $282 million.

    The solution? The report recommends a critical eye toward eradicating overuse: “We need to keep our collective ‘foot on the gas’ to transition from paying for volume to paying for value in health care.”

    REASONS VARY FOR OVERUSE
    More than 45 percent of the services examined were determined by the report to be of low value — likely wasteful or wasteful.

    In Washington state, out of a total study pool of approximately 2.4 million commercially insured people, about 1.3 million individuals received one of the 47 services in a period spanning July 2015 to June 2016. Among those individuals, 47.9 percent received a low-value service.

    Why do these tests, procedures, and treatments keep happening?

    “In some cases patients ask for or agree to things because they don’t realize the potential for harm, be it physical, emotional, or financial, that can happen with unnecessary tests, procedures or medications,” Dade said. “In other cases, tests are ordered by providers, with little input by or even awareness of the patient.

    “In a ‘more is better’ culture in health care, there is a belief that it’s better to have additional tests because it’s better to be safe than sorry. However, this doesn’t account for the potential for different kinds of harm.”

    Fear of under-treatment also could be a factor. Another study looking at over-treatment considered this in 2011 when MarketWatch reported more than three out of four primary-care doctors said malpractice concerns led them to order more diagnostic tests or referrals than might be necessary.

    “Physicians overwhelmingly think they could be sued for not doing something, but very few think they could be sued for doing something excessive or unnecessary,” said Dr. Brenda Sirovich of the Veterans Affairs Medical Center in White River Junction, Vt. at that time. She was the lead author of the study published in the Sept. 26, 2011 edition of the Archives of Internal Medicine.

    BEST PRACTICES OR NOT?
    There’s also the issue that best practices at some medical offices might not be “best” anymore.

    “While we have learned that many services are overused, they are so ingrained in the health care system that there isn’t much consideration given to their necessity,” Dade wrote.

    Take, for example, preoperative evaluation — EKGs, chest X-rays, pulmonary-function testing.

    “A recommendation from the American Society of Anesthesiologists in 2013 notes that preoperative cardiac-stress testing is only appropriate for identifying extremely high-risk patients, in whom the results would change management prior to surgery, change the decision of the patient to undergo surgery, or change the type of procedure that the surgeon will perform,” Dade said.

    She also noted that the American College of Cardiology and American Heart Association recommends that there is no benefit for routine preoperative cardiac testing in low-risk surgery for patients with no cardiac disease.

    And that’s just for starters.

    “Another is reducing unnecessary imaging (eye disease, low back pain, uncomplicated headache),” she wrote.

    Other studies have pointed to overuse of imaging, including a 2016 Neurology study that showed Medicare recipients were more than twice as likely to receive “potentially inappropriate” imaging for headaches than those presenting the same symptoms at VA health facilities.

    “Better understanding the reasons for the more selective use of neuro-imaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing,” the 2016 study concluded.

    Overuse of antibiotics is still an issue in this state, according to the new Washington state report, with 98 percent of individuals in the study with acute upper respiratory or ear infections receiving unnecessary antibiotics within 7 days of a diagnosis at an estimated total of $2.3 million.

    So why, after all the warnings, do prescriptions continue to flow for these cases?

    “When people are really sick with an acute upper respiratory infection or painful earache, they are seeking relief,” Dade pointed out. “Patients will often ask their provider for medication and providers too frequently prescribe antibiotics without first determining that the infection is bacterial, not viral.”

    NEXT STEPS
    Given that unnecessary health care even has its own Wikipedia entry at this point, what can be done to break the cycle?

    Questions for patients to consider include comparing options, talking to doctors about the risks and side effects and just asking if a test or procedure is necessary.

    Dade says the level of change addressed in the report “includes improving shared decision making, where patients receive objective information to help them understand their treatment choices.”

    “We also need to change the way providers are paid, focusing on quality instead of on quantity,” she said.

    THE REPORT

    “First Do No Harm: Calculating Health Care Waste in Washington State.” http://bit.ly/2DRFP4e

    Washington Health Alliance: http://wahealthalliance.org/

    MOST OVERUSED TESTS, ETC.

    The report determined 93 percent of overuse was attributed to just 11 common tests, procedures and treatments:

    ▪ Too frequent cervical cancer screening in women.

    ▪ Preoperative baseline laboratory studies before low-risk surgery.

    ▪ Unnecessary imaging for eye disease.

    ▪ Annual EKGs or cardiac screening in low-risk, asymptomatic individuals.

    ▪ Prescribing antibiotics for acute upper respiratory and ear infections.

    ▪ PSA (prostate specific antigen) screening.

    ▪ Population-based screening for OH-Vitamin D deficiency.

    ▪ Imaging for uncomplicated low back pain in the first six weeks.

    ▪ Preoperative EKG, chest x-ray and pulmonary function testing prior to low risk surgery.

    ▪ Cardiac stress testing.

    ▪ Imaging for uncomplicated headache.

    Source: Washington Health Alliance
     

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