July 16th, 2019
Clinicians recognize that low-value care is a serious problem in medicine, because they see it happen every day. According to a survey of physicians in 2017, a majority (64.7%) of respondents estimated that at least 15-30% of care in their specialty is unnecessary. On average, doctors said that 20.5% of care in their specialty is unnecessary. Doctors may be aware of overuse–but does that mean they are better at avoiding overuse in their own health care?
Not necessarily, according to a recent National Bureau of Economic Research (NBER) working paper by Duke University professor of law and economics Michael Frakes, MIT economics professor Jonathan Gruber, and Harvard Medical School professor of public policy and physician Anupam Jena. They used data from the military health system to evaluate how often physicians as patients elect to receive both high-value and low-value care. Measures of low-value care included cesarean section and preoperative diagnostic testing for cataract surgery and hernia surgery. Measures of high-value care included comprehensive diabetes care, medication adherence, and immunization.
They found that, compared to non-physician officers, physicians were slightly less likely to have low-value care procedures, although these procedures still happened more often than recommended. “Even the best informed patients do not make any less use of low-value health services,” the authors write. For high-value care, there was virtually no difference between the physician and non-physician groups, except for slightly higher rates of child vaccinations and comprehensive diabetes care.
“Physicians do only slightly better in adhering to both low- and high-value care guidelines than non-physicians – but not by much and not always.”
Why are doctors not much better than patients at getting the most value out of their health care? The authors conclude that “informational deficiencies” must play a much smaller role than previously thought, when it comes to over- and under-utilization of low- and high-value services.
One limitation is that their conclusion is based on the assumption that doctors are more well-informed than patients when it comes to health care value. While clinicians see overuse happen regularly in their specialty, they might be less aware of it in other specialties. For example, an endocrinologist may understand the importance of comprehensive diabetes care, but may not know that having a cardiac stress test before a low-risk surgery is more likely to cause harm than good.
However, overall the authors make a strong argument that behavioral and systemic factors may have more to do with rates of overuse and underuse than patient information. For patients who recognize low-value care, it is still difficult as an individual to go against systemic practices of care embedded in an organization’s or doctor’s habits. It would make sense that even doctors would find it difficult to contradict their own doctor’s advice.
Rates of providing health care services varies widely between hospitals and within hospitals, demonstrating that institutional culture and individual behavior have a lot to do with practice patterns. We should stop pretending that giving patients more “skin in the game” and providing more information will fix the complex problems of medical overuse and underuse.