Dr. Meredith Niess noticed that her patient was afraid. The patient had a painful hernia in his stomach and was brought to the Veterans Affairs clinic Denver. Niess, a primary-care resident, knew that he needed immediate surgery. However, a different doctor had ordered a chest radiograph instead.
Test results showed that there was a mass in the man’s lung.
Niess stated, “This guy is sweating in the seat, [and] not thinking about hernia.” Niess said, “He thinks he has cancer.”
Niess was angry. It was 2012. Niess was able to see what her patient wasn’t even though she ordered a chest Xray in this case. The evidence has been there for decades. It was clear that the chest Xray was unnecessary. Niess also knew something her patient didn’t. These “incidentalomas” are common non-finding findings that doctors call “incidentalomas”.
Niess knew that the initial Xray would cause additional tests and prolong the man’s recovery.
A CT scan of the patient’s follow-up showed a healthy lung, but it also revealed another “something” suspicious in his adrenal gland.
Niess stated, “My heart just sank.” This doesn’t feel like medicine.
Six months after he had first sought help, a second CT scan cleared him for surgery.
Niess reported on the case in JAMA Internal Medicine, as an example of what researchers refer to as a “cascade” of care aEUR. This is a seemingly endless series of medical tests and procedures.
When a test is done for a valid reason and uncovers something unexpected, cascades can occur. Good medicine is often based on sleuthing.
However, the most worrying cascades start as Niess’ patient’s. This is because Niess’ patient was given an unnecessary test “aEUR”, which Ishani Ganguli (a primary care physician) calls “low-value services” and “low-value care.”
Ganguli stated that a low-value service is one for which there is no clinical benefit and the potential for harm.
Ganguli and other researchers have identified more than 600 procedures and treatments that are not likely to benefit patients over the past 30 years. These include MRIs performed early for low back pain, routine vitamin D testing, and prostate cancer screenings for older men.
Low-value care can be costly. One study estimates that the U.S. healthcare system spends between $75 billion and $100 billion per year on such services. Ganguli published a 2019 paper that showed that the federal government spends $35 million annually on care after doctors perform EKG heart tests prior to cataract surgery. This is an example of low-value healthcare.
“Medicare spent 10 times as much on cascades after those EKGs than they did for the EKGs.” Ganguli said that this is just one example of a service.
Common are cascades of care. Ganguli’s survey found that ninety-nine per cent of doctors had experienced one as a result of an accident. A staggering 99% of doctors reported that they had witnessed a cascade of harm to patients, such as financially or physically.
Ganguli also reported that 41% doctors continued to follow a cascade despite believing that the next test is not necessary for their medical care.
Ganguli said, “It’s really driven to avoid even the slightest chance of missing something potentially dangerous.” Critics of low-value healthcare claim that there is a mentality that stems from medical training and compassion for patients who may have requested the test.
Low-value care is becoming more common as health care costs rise. The American Board of Internal Medicine Foundation launched a campaign in 2012 to encourage doctors to cut low-value care. It called it Choosing Wisely.
A dozen companies have since developed software that can be embedded in electronic health records by health systems to alert doctors.
Scott Weingarten explained, “We pop up an alarm just to make them aware of how much care they were about deliver.”
Three decades ago, Weingarten was a doctor at Cedars-Sinai Medical Center Los Angeles. He spent many years lobbying hospitals throughout the United States to address the issue.
Weingarten recognized that even the most well-resourced and sophisticated hospitals and physicians required assistance in developing new routines, as well as breaking old habits, aEUR” such as knee-jerking ordering a chest radiograph.
Only 10% of health systems have used software known as “clinical decisions supports” to make clinical decisions. Weingarten, co-founder of Stanson Health, has since left the company. An internal analysis revealed that electronic warnings could cancel unnecessary tests only 10%-13% of the times.
Weingarten stated, “The glass is half full”: If you put an app in your EHR [electronic medical record], you can eliminate 10 to 13% of low-value healthcare. It could be that, if the technology is rolled out throughout the country, it could lead to the elimination of billions or billions of dollars in waste.
Weingarten is also affected by the 10%-13% ratio. “Why is it that doctors refuse to give this advice 87-90 percent of the times?” He asked.
Even though software warns doctors about unnecessary care, there are still major obstacles to change: A medical culture that believes more is better, doctors afraid of missing something, and patients who want more.
The biggest problem is that hospitals still get most of their revenue based on how many services they provide.
Cheryl Damberg is a senior economist at Rand Corp. She said money may be what gets hospitals’ attention. She said that if payers decide not to pay for low-value services, it will change the calculation as to whether the juice is worthwhile.
Damberg stated that some Medicare and commercial insurers have begun paying bonuses to doctors to help reduce the cost of low-value services, and hold providers responsible for the entire cost of a patient’s care. These contracts are very rare.
Nobody wants to provide low-value care. American medicine is awash with the desire to pass “just one more test.”
Tradeoffs produced this story. They are a podcast that explores our complicated, expensive, and often contradictory health care system.
