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Editorial: The war on waste


“It’s still the prices, stupid.” That’s the updated conclusion about the cause of America’s healthcare cost problem.

Offered by the same authors who made the original analysis in 2003, the article in the latest Health Affairs was offered as a tribute to the late Princeton economist Uwe Reinhardt, who was an original co-author. Reinhardt, in numerous talks and writings over the years, liked to remind Americans that they paid far more than other countries for everything—from physician salaries to drugs to hospital stays.

True enough, but let’s acknowledge that there’s also a tremendous amount of waste in the system. Unnecessary tests and procedures are performed every day in America’s hospitals and physician offices.

We also have underserved populations who aren’t receiving the routine and preventive care they need. Greater use of these services might ameliorate the chronic disease epidemic that is ravaging many low- and moderate-income communities.

Couple too much waste with too few preventive measures, which could reduce use of higher-cost interventions down the road, and what you get is an America that consumes the same amount of healthcare services as other countries. But it comes at a much higher cost with inferior results.

These days, government officials from both political parties are focusing most of their attention on the price problem. Hospitals must now publish their chargemaster rates. It’s hard to see how most patients will get actionable information out of that data.

The drug industry’s price-gouging is on the congressional hot seat. But meaningful action, even with White House backing, will be difficult to achieve given the industry’s influence on Capitol Hill.

Crusading attorneys general like Xavier Becerra in California are using antitrust laws to go after the alleged price-fixing tactics of dominant systems like Sutter Health. Yet there’s scant evidence that promoting competition will bring down prices.

Indeed, there’s historical precedent to suggest that encouraging new entrants for healthcare services will only promote excessive use. Supply-driven demand thrives under fee-for-service reimbursement, which is still the dominant mode of payment.

That’s why it’s so important to continue focusing attention on the overutilization problem. The ABIM Foundation’s “Choosing Wisely” campaign, which began in 2010, has now been adopted by over 80 specialty societies. Their preferred approach is shared decision-making and they’ve identified more than 500 medical recommendations that physicians and patients should discuss.

Yet a 2017 survey by the group found 75% of physicians believe unnecessary care is still a serious problem; 69% said the average physician ordered useless tests and procedures at least once a week. Apparently, discussion between doctors and patients will only get you so far.

That’s why the time has come to focus directly on the physician workforce and their practice patterns. Dr. Marty Makary of Johns Hopkins University points out that in 2007, U.S. physicians wrote 2.4 billion prescriptions. Last year, it was 4.6 billion. “Did disease double in the last 10 years?” he asks.

It doesn’t stop there. “Ninety percent of C-sections are unnecessary; 80% of stents are inappropriate; 30% of people with cancer get the wrong treatment,” he says.

The best way to convince physicians to adopt high-value practice patterns is through sharing what their peers say are best practices. Guidelines in most cases are already developed. Professional societies, chief medical officers and clinical leaders need to develop mechanisms for letting their practicing physicians know where they stand in relationship to the standards of care in their specialties.

The challenge is getting the word out. Most clinicians are scientists at heart. If shown where they vary from value-based care, most will quickly adopt best practices.