An Unlikely Prescription From Doctors: Less Is More

Photograph by PM Images

A few years ago, preparing to run a half-marathon, I got a physical. Though the exam showed I was healthy, the doctor referred me to a cardiologist he knew for an exercise stress test. He didn’t give me a medical reason but scribbled something like “running half marathon” on the note. My insurance would have paid for it, but the test felt unnecessary, and I skipped it.

America’s health system paid for $210 billion of unnecessary medical care in 2009, according to the Institute of Medicine, more than 8 percent of the nation’s health spending. It’s a big part of the reason Americans pay more for medicine than other rich nations but we aren’t any healthier (PDF). Shrinking that number is essential to containing health care’s growing share of our household, business, and government budgets.

That’s why a group of medical societies have identified 90 procedures that are “commonly ordered, but which are not always necessary” and are sometimes harmful, according to the announcement from the ABIM Foundation. Among their suggestions: Kids under age 4 shouldn’t get cough or cold medicine, doctors shouldn’t induce labor for pregnant women before 39 weeks, and patients with advanced dementia should get oral assistance eating rather than feeding tubes. The new guidelines follow 45 other procedures already highlighted last year. (In the last round, they said stress tests aren’t warranted in patients without symptoms.)

The guidelines draw on research about what kind of screening and treatment actually makes people better. The medical societies have a clear message for doctors and patients: More treatment isn’t always better. Tests can produce false positives that cause distress and lead to more costly, invasive procedures. Too many CT scans can increase cancer risks, especially in children. “Many times it’s not just the cost of unnecessary treatment, but harm that happens to patients,” says Dr. Christine Cassel, president and chief executive officer of the ABIM Foundation, which is associated with the American Board of Internal Medicine.

The problem is a lot of this information is baffling for consumers, and most doctors still have financial incentives to do more, not less. “They haven’t had a lot of incentive to ask that question: ‘Do I really need to order this now in this patient?’” says Cassel. In addition, the fear of malpractice lawsuits prompts some doctors to order tests they might otherwise skip.

Some doctors’ incentives are starting to change. While hospitals and medical practices still for the most part make more money by providing more care, elements of the Affordable Care Act and programs from private insurers reward doctors for keeping patients healthy rather than for how many tests and procedures they do. “Most doctors really want to do the right thing and aren’t just churning the system to make more money,” Cassel says.

As patients, too, we’re paying more health costs on our own, so we’re more likely to question whether a test or procedure is needed. Though the guidelines can be confusing to laypeople, ABIM Foundation has joined with Consumer Reports, Wikipedia, and the AARP to publish plain-language explanations for people searching for medical information.

Cassel says professional medical societies are the right authorities to tell patients when a test or treatment is better left undone. When that message comes from the government or the insurance industry, it’s met with cries of rationing or death panels. But the backlash to the guidelines—and they’re guidelines, not hard rules—has been less than Cassel expected. Many people she talked to had their own encounters with procedures that were unnecessary or inappropriate. “People understand that more is not better,” she says.

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