Harvard Heart Letter

Overuse, underuse, and valuable use

Asking "Is this really necessary?" is always appropriate.

By Thomas Lee, M.D.
Editor in Chief, Harvard Heart Letter

Among the many uncertainties in health care today is the question of whether some doctors might recommend and deliver too much care. Stories like the one about a Maryland cardiologist who implanted hundreds of unneeded stents are rare, and the vast majority of doctors put the people they treat first, far ahead of any personal financial interests.

Fragmentation of care

Based on what I see as president of Partners Community Healthcare, Inc., a network of more than 5,500 physicians, overuse is driven more by our fragmented health care system than by individual avarice. Most doctors are paid piecemeal for what they do. This is called the fee-for-service model. With advances in pharmacology and medical technology, what doctors are able to do expands almost monthly. Together, medical progress and the fee-for-service environment conspire to fuel overuse and medical cost inflation.

In many cases today, no doctor can take sole responsibility for a person's health because so many different providers and processes are involved. The reorganization of providers into groups that take collective responsibility for people's health care outcomes — and get paid accordingly — is under way. But these rearrangements, called accountable care organizations and medical homes, are disruptive and will take time to create.

In the meantime, a study identified nearly 40 clinical situations in which certain tests are inappropriate. One example is conducting routine electrocardiograms on people at low risk of coronary artery disease; another is performing angiograms on people with stable angina (chest pain during or after physical exertion) whose symptoms are well controlled with medication (Annals of Internal Medicine, Jan. 17, 2012).

You can help

Guidelines for doctors are helpful, but you can do your part as well. Be aware of the telltale signs that a doctor might be overusing health care resources, such as requests for frequent office visits without reasonable cause. Most lab results, for example, can be delivered via phone or email, with a follow-up visit necessary only if the results are complex or abnormal.

Before ordering tests, doctors should ask themselves how the results would alter their care of the person being tested. If you ask your doctor that question and he or she can't answer it to your satisfaction, consider declining the test — or finding a new doctor. It's never inappropriate to ask whether a visit, test, or procedure is really necessary. Sometimes raising such issues motivates a physician to consider alternative — perhaps even better — approaches.

Today, clamors for improved efficiency and lower costs are also rekindling worries from a couple of decades ago that doctors might do too little. We need to recognize that efficiency in health care need not be a threat to our well-being. You and I have to improve health care efficiency, lest outside forces impose careless rationing on us.

So I encourage you to seek out and stick with physicians or physician groups that understand value in health care and view efficiency as a dimension of quality.