Why it is so difficult to reduce unnecessary medical care

The United States spends enormous amounts of money on health care that does little or nothing to help patients, and may even harm them. In Colorado, a new analysis shows that the number of tests and treatments performed for which the risks and costs outweigh the benefits has barely budged despite a decade-long effort to curb such treatment.

The state — including the government, insurers and patients themselves — spent $134 million last year on what’s called low-value care, according to the report from Center for Improving Value in Healthcare, a Denver nonprofit that collects billing data from health plans across Colorado. The top low-value items in terms of spending in each of the past three years were prescriptions for opiates, prescriptions for multiple antipsychotics and screenings for vitamin D deficiency, according to the analysis.

Nationwide, these treatments increase costs, lead to health complications, and interfere with more appropriate care. But the structure of the American health care system, which rewards doctors for providing more care than the right care, has made it difficult to stop such waste. Even in places that have reduced or eliminated the financial incentive for additional testing, such as Los Angeles County, low-value care remains a problem.

Lalit Bajaj, an emergency physician at Children’s Hospital Colorado, with another emergency physician, Julia Fuzak Freeman. In an effort to reduce unnecessary X-rays and antibiotics, Bajaj and his colleagues implemented new protocols in 2015 to educate parents about bronchiolitis, how to manage symptoms until children get better, and why imaging or medication are unlikely to help.

Austin Day/Children’s Hospital Colorado

And when patients are told by doctors or health plans that tests or treatments are not necessary, they often question whether they are being denied care.

While some highly motivated clinicians have advocated for effective interventions in their own hospitals or clinics, these efforts have barely moved the needle on low-value care. Of the $3 trillion spent on health care in the United States each year, 10% to 30% of that care is low-value, according to several estimates.

“There is a culture of ‘more is better,'” said Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design. “And ‘more is better’ is very hard to overcome.”

To conduct its study, the Center for Improving Value in Health Care used a calculator developed by Fendrick and others that quantifies spending on services identified as low-value care by To choose carefully campaign, a collaboration between the American Board of Internal Medicine Foundation and now more than 80 medical specialty societies.

Fendrick said the $134 million tallied in the report represents only “a small slice of the universe of no and low-value care” in Colorado. The calculator tracks only the 58 services that the developers were most confident reflected low-value care and does not include the cost of the cascade of care that often follows. For example, every dollar spent on prostate cancer screening in men over 70 results in $6 in follow-up tests and treatments, according to an analysis published in JAMA Network Open in 2022.

In 2013, Children’s Hospital Colorado learned that it had the second-highest rate of abdominal CT scans—a low-value service—among U.S. children’s hospitals, with about 45% of children coming to the emergency room with abdominal pain and receiving the imaging. Research had shown that these scans were not helpful in most cases and exposed the children to unnecessary radiation.

Digging into the problem, clinicians there found that if emergency room doctors couldn’t find the appendix on an ultrasound, they quickly ordered a CT scan.

New protocols implemented in 2016 have surgeons come to the emergency room to evaluate the patient before a CT scan is ordered. The surgeons and emergency physicians can then decide whether the child has a high risk of appendicitis and must be hospitalized, or a low risk and can be sent home. Within two years, the hospital reduced the number of CT scans of children with abdominal pain to 10% with no increase in complications.

“One of the hardest things to do in this work is to align financial incentives,” said Lalit Bajajan emergency physician at Children’s Colorado, who is championing the effort “because in our health care system, we get paid for what we do.”

Lalit Bajaj, an emergency physician at Children's Hospital Colorado
Lalit Bajaj, an emergency physician at Children’s Hospital Colorado, led an effort to reduce CT scans in children who arrive in the emergency room with abdominal pain after research showed that these scans — considered a low-value service — were not helpful in most cases and exposed the children to unnecessary radiation.

Austin Day/Children’s Hospital Colorado

Cutting CT scans meant less revenue. But Children’s Colorado worked with an insurance plan to create an incentive program. If the hospital could keep the rate of high-cost imaging down and save the health plan money, it could earn a bonus from the insurer at the end of the year that would partially offset the lost revenue.

But Bajaj said it’s difficult for doctors to manage patient expectations about tests or treatment. “It’s not a good feeling for a parent to come in and I tell them how to support their child through the illness,” Bajaj said. “They don’t really feel like they got tested. ‘Did they really assess my child?'”

It was a major obstacle in the treatment of children with bronchiolitis. The respiratory condition, most often caused by a virus, sends thousands of children to the pediatric emergency room each winter, where unnecessary chest X-rays are often ordered.

“The data told us that they really didn’t produce any change in care,” Bajaj said. “What they did was add unnecessary expenses.”

Too often, doctors reading the X-rays mistakenly thought they were seeing a bacterial infection and prescribed antibiotics. They would also prescribe bronchodilators, like albuterol, they thought would help the children breathe easier. But studies have shown that these drugs do not relieve bronchiolitis.

Bajaj and his colleagues implemented new protocols in 2015 to educate parents about the condition, how to manage symptoms until children get better, and why imaging or medication are unlikely to help.

“These are difficult concepts for people,” Bajaj said. Parents want to feel that their child has been fully evaluated when they come to the emergency room, especially since they are often paying more of the bill.

The hospital reduced its X-ray rate from 40% in the 17 months before the new protocols to 29% in the 17 months after implementation, according to Bajaj. The use of bronchodilators decreased from 36% to 22%.

Part of the secret to children’s success is that they “brand” their interventions. The hospital’s quality improvement team brings together employees from various disciplines to brainstorm ways to reduce low-value care and assign the effort a catchy slogan: “Image gently” for appendicitis or “Rest is best” for bronchiolitis.

“And then we get T-shirts made. We get mouse pads and water bottles made,” Bajaj said. “People really enjoy T-shirts.”

In California, the Los Angeles County Department of Health Services, one of the largest safety-net health systems in the country, receives a fixed dollar amount for each person it covers, regardless of how many services it provides. But staff found that 90% of patients undergoing cataract surgery received extensive preoperative testing, a low-value service. In other health systems, it will usually reflect a do-more-to-get-more-paid scenario.

“That wasn’t the case here in LA County. Doctors weren’t making more money,” said John Mafi, associate professor of medicine at UCLA. “It suggests that there are many factors other than economics that may be at play.”

When quality improvement staff at the county health system investigated the causes, they found the system had instituted a protocol that required X-rays, electrocardiograms and a full set of lab tests before surgery. A medical record review found that the extra tests did not identify problems that would interfere with surgery, but they often led to unnecessary follow-up visits. An anomaly on an EKG could lead to a referral to a cardiologist, and since there was often a backlog of patients waiting for cardiology visits, surgery could be delayed for months.

In response, the health system developed new guidelines for preoperative screenings and relied on a nurse trained in quality improvement to advise surgeons when preoperative testing was warranted. The initiative lowered the number of chest X-rays, EKGs and laboratory tests by two-thirds without an increase in adverse events.

The initiative lost money in its first year due to high start-up costs. But over three years, it resulted in modest savings of about $60,000.

“A fee-for-service-driven health care system where they make more money, if they order more tests, they would have lost money,” Mafi said, because they make a profit on each test.

Although the savings were minimal, patients needed surgery sooner and did not face an additional cascade of unnecessary testing and treatment.

Fendrick said some hospitals make more money providing all these tests in preparation for cataract surgery than they do on the surgeries themselves.

“These are elderly people. They get EKGs, they get chest X-rays and they get blood tests,” he said. “Some people need those things, but many don’t.”

KFF Health Newsformerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism on health issues and is one of the core operating programs of KFF — the independent source of health policy research, polling and journalism.

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