Research on how much inappropriate or unnecessary care occurs in the United States is a fertile area. The most recent contribution is a paper with survey results carried at the Public Library of Science website. (PLOS Study) The doctors surveyed appear to have been pretty honest. The survey was conducted among 2100 physicians drawn from the American Medical Association membership and representing a mix of primary care and specialists. The physicians were asked about how much care they thought was unnecessary, why that care was delivered and what steps could be taken to limit unnecessary testing and treatment. Overall, the physicians thought 20.6% of medical care was unnecessary; 22% of prescriptions fit that category, 25% of testing and 11% of procedures. Respondents tended to see procedures as more likely to be necessary and testing least likely to be appropriate. The range of responses was pretty significant. 27% thought 30% to 45% of medical care was unnecessary and 4.6% thought none of it was unneeded. These are high numbers and since doctors are ordering the services, they ought to know. If the 20% number is accurate, you are talking about hundreds of billions of dollars a year in spending that could be avoided. But a lot of doctors, other clinicians and staff would be out of business.
So why do they order this unnecessary testing and treatment? 85% said fear of malpractice actions was a primary cause; 59% cited patient pressure and 38% difficulty in accessing patient records, which might give information that would avoid duplicate testing in particular. 71% acknowledged that physicians were more likely to go ahead and order unnecessary services when the doctor makes money from doing so. How to address this issue? 55% said train residents better on appropriateness criteria; 52% said make it easier to get access to all records on a patient, wherever those records are located; and 52% said create more practice guidelines. 76% said that de-emphasizing fee-for-service payment and productivity bonuses would reduce delivery of inappropriate care. It is interesting that physicians think fee-for-service payment is partly to blame for unnecessary care. Given the rapid acquisition of physician practices by health systems, not sure this is likely to change and that trend may increase production pressures. But a general movement to try to use other payment systems might help. A big immediate step would clearly be to limit malpractice actions and find another way to compensate victims of bad care for their actual economic losses, and only those losses. There may not be a lot of these suits, but the fear is what motivates doctor behavior. This is an important piece of research, although like any study it may have methodological limitations, and it points the way to actions that could be taken to reduce physician delivery or ordering of unnecessary care.