Reducing Unneeded Health Care Saves Lives and Money

Every day, some version of runaway U.S. health care costs is in the news. A person with cancer racks up huge uninsured bills. A patient gets hit with surprise medical bills, even though new rules make them illegal. Health insurers post enormous profits even as hospitals and the health care work force are being pummeled by the pandemic.

Despite the enormous toll inflicted by COVID viruses, the soaring costs and unaffordability of medical care can make a case as the nation’s most serious long-term health crisis. Health care is twice as expensive per capita in this country as in other developed economies, but Americans are hardly twice as healthy. In fact, they fare substantially worse on longevity and health measures than do people in these other countries.

The direct damages to consumers are only part of the story. Federal and state budgets are being overwhelmed by spending on Medicaid, Medicare, and, to a lesser extent, the Affordable Care Act. This weakens our economy and starves other deserving sectors such as infrastructure from needed investments. It also blinds people to the real costs of care and of the financial consequences of the decisions we make about the care we want.

After paying their health insurance premiums, consumers generally do not know much about the rest of their health care costs. High deductible health plans have helped a bit to inform people who have them. But in many cases, paying insurance premiums seems like a ticket to an all-you-can-eat health care buffet.

Many people cannot afford to get health care but most of us have the opposite problem and spend too much on care, either by paying for the most expensive versions of available care or seeking care that provides no or little health value. Keep in mind here that your trusted primary care physician may be one of the worst offenders.

Doctors are under lots of pressure to prescribe unneeded care. Doing so can protect them from malpractice suits. It also can satisfy patients who demand such care because they think it will help them. With such procedures usually covered by insurance, ordering that extra test or procedure can seem like a no-brainer.

Ten years ago, an effort was launched by health care providers to reduce the use of unneeded and low-value care. Called Choosing Wisely, it harnessed a growing body of clinical research to identify health procedures that consumers don’t need. Beyond saving money, foregoing such care can in many cases make us healthier. Getting unneeded tests, it turns out, can entail health risks.

A recent assessment of the Choosing Wisely campaign noted, that at its launch it had partnered with “9 physician societies to announce 45 clinical recommendations that discouraged unnecessary care. The campaign now includes more than 80 clinical partners and more than 600 recommendations.”

Progress is slow and spotty. A detailed look at the use of unneeded or low-value care in the VA health system found that military veterans were getting lots of care they didn’t need. “The most frequently delivered low-value service was prostate-specific antigen testing for men aged 75 years or older,” the study found. “The costliest low-value services were spinal injections for low back pain ($43.9 million; 21.4 percent of low-value care spending) and percutaneous coronary intervention for stable coronary disease ($36.8 million; 17.9 percent of spending).”

Odds are you’ve heard of nearly none of Choosing Wisely’s recommendations or even of the group itself. That’s a shame, because the best and cheapest health care often is the care you don’t need in the first place.

In my 2021 book, Get What's Yours for Health Care: How to Get the Best Care at the Right Price, I provided an abbreviated look at some of the most over-prescribed and least-needed care as identified by Choosing Wisely.

I hope you find it useful.

THE ABCs OF “DON’T”

These entries are in “medspeak.” Google them as needed for more information.

Common Treatments

·         Don’t order antibiotics for adenoviral conjunctivitis (pink eye).

·         Don’t prescribe oral antibiotics for uncomplicated acute tympanostomy tube otorrhea.

·         Don't prescribe or recommend cough and cold medicines for respiratory illnesses in children under four years of age.

·         Don't prescribe oral antibiotics for upper URI or ear infection (acute sinusitis, URI, viral respiratory illness or acute otitis externa).

Diagnostic Testing

·         Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

·         Don’t do imaging for uncomplicated headache.

·         Don’t obtain brain imaging studies (CT or MRI) in the evaluation of simple syncope and a normal neurological examination.

·         Don’t order computed tomography (CT) scan of the head/brain for sudden hearing loss.

·         Don’t perform a postcoital test (PCT) for the evaluation of infertility.

·         Don’t perform advanced sperm function testing, such as sperm penetration or hemizona assays, in the initial evaluation of the infertile couple.

·         Don’t perform electroencephalography (EEG) for headaches.

·         Don’t perform imaging of the carotid arteries for simple syncope without other neurologic symptoms.

·         Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.

·         Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.

·         Don’t perform voiding cystourethrogram (VCUG) routinely in first febrile urinary tract infection (UTI) in children aged 2–24 months.

·         Don’t routinely do diagnostic testing in patients with chronic urticaria.

·         Don’t routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

·         Don’t routinely order imaging tests for patients without symptoms or signs of significant eye disease.

·         Don’t use coronary artery calcium scoring for patients with known coronary artery disease (including stents and bypass grafts).

·         Don't order computed tomography (CT) head imaging in children 1 month to 17 years of age unless indicated.

·         Don't order CT scans of the abdomen and pelvis in young otherwise healthy emergency department patients (age <50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic.

·         Don't perform routine head CT scans for emergency room visits for severe dizziness.

Disease Approach

·         Don’t place peripherally inserted central catheters (PICC) in stage III–V CKD patients without consulting nephrology.

·         Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.

·         Don’t schedule elective, non-medically indicated inductions of labor or Cesarean deliveries before 39 weeks, 0 days gestational age.

·         Don't perform an arthroscopic knee surgery for knee osteoarthritis.

·         Don't perform computed tomography (CT) scans in the routine evaluation of abdominal pain.

·         Don't perform revascularization without  prior medical management for renal artery stenosis.

·         Don't perform vertebrolplasty for osteoporotic vertebral fractures.

·         Don't prescribe antidepressants as monotherapy in patients with bipolar I disorder.

·         Don't prescribe nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.

Preoperative evaluation

·         Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.

·         Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.

·         Don’t obtain EKG, chest X rays or Pulmonary function test in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery.

Routine Joint MRIs

·         Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

Screening Tests

·         Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

·         Don’t perform population based screening for 25-OH-Vitamin D deficiency.

·         Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.

·         Don't order unnecessary cervical cancer screening (Pap smear and HPV test) in all women who have had adequate prior screening and are not otherwise at high risk for cervical cancer.

·         Don't order unnecessary screening for colorectal cancer in adults older than age 50 years.

·         Don't perform coronary angiography in patients without cardiac symptoms unless high-risk markers present.

·         Don't perform PSA-based screening for prostate cancer in all men regardless of age.

Philip Moeller is the principal author of the Get What’s Yours series of books about Social Security, Medicare, and health care. @PhilMoeller