Doctor with hospital patient

Reducing wasteful health care spending begs the question, what is waste?

August 11, 2014 — The U.S. spends more than $2.8 trillion on health care each year, and some estimate that 30% of that price tag may be waste. To promote more effective use of health care resources, a group of national organizations representing medical specialists is working to identify procedures and tests that may be overused. The Choosing Wisely initiative, sponsored by the American Board of Internal Medicine, has over the past few years received more than 300 recommendations from specialists ranging from allergists to thoracic surgeons. These lists are being disseminated to physicians and consumers with the aim of sparking discussion between doctors and patients about appropriate and necessary care.

But will this effort actually help reduce health care spending? Probably not, said Meredith Rosenthal, professor of health economics and policy and associate dean for diversity, at an August 5, 2014 Hot Topics lecture at Harvard School of Public Health (HSPH). While the recommendations are a good start to a much-needed conversation about what constitutes waste, in their current form they are merely helpful suggestions, she said. In order to affect the bottom line, she added, they would need to be translated into concrete guidelines and billing codes.

Taking that next step would likely be “headache-inducing,” Rosenthal said. “Until we can agree on what services should be avoided, it’s pretty impossible to address [waste].”

While Choosing Wisely may recommend against a particular test for patients who are at low risk of developing a disease, doctors may disagree about the definition of risk. And attempts to start a conversation around the appropriateness of care can be politically unpopular. She cited the controversy over the recommendation in the Affordable Care Act that physicians speak to patients about end-of-life care—dubbed “death panels.”

The recommendations could help reduce some unnecessary spending if they were embedded into clinicians’ daily routines, Rosenthal said. For example, a prompt could pop up when a certain test or procedure is ordered, encouraging the clinician to think twice about whether what they are ordering is appropriate.

But first, more information is needed on what health care services are actually being overused, Rosenthal said. Few services are always wasteful. For example, a treatment may do little for most patients with heart disease, but could save the lives of a small population. Any effort to reduce costs must not deprive patients of care that is truly necessary, she said.

Read New England Journal of Medicine article Choosing Wisely — The Politics and Economics of Labeling Low-Value Services

Amy Roeder

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