Thursday, May 21, 2015

qotd: IMPORTANT: The harm done by the overutilization narrative

Journal of Health Politics, Policy and Law
April 2015
Overutilization, Overutilized
By Deborah Levine and Jessica Mulligan


Overutilization is commonly blamed for escalating costs, compromising
quality, and limiting access to the US health care system. Recent
estimates suggest that nearly one-third of health care spending in the
United States is a result of unnecessary care. Despite the surge of
exposés that purport to uncover this "new" problem, narratives about
overutilization have been circulating in health policy debates since the
beginnings of the health insurance industry. This article traces how the
term overutilization has spread in popularity from a relatively small
community of mid-twentieth-century insurance experts to economists,
physicians, epidemiologists, and eventually the news media of the early
twenty-first century. A quick glimpse at the history of the term reveals
that there has been constant disagreement and debate over the meaning
and impact of overutilization. Moreover, the term has been put to very
different uses, from keeping socialism at bay to preserving the fiscal
integrity of Medicare to protecting the health of patients. The
overutilization narrative, seductive in its promise of cutting costs
without sacrificing access to quality care, too often drowns out other
difficult conversations about social welfare, health equity, prices, and
universal coverage.

Conclusion: Overutilization Has Overreached

For sixty years, overutilization has been a key term in health policy
debates. The term emerged in literature about the potential demise of
voluntary insurance and then spread to new domains: first with inpatient
hospital stays and then eventually with almost every other form of care.
The audience for this narrative expanded as well: from industry insiders
to economists, physicians, public health researchers, the media, and
finally, patients.

Utilization review and other techniques for curbing overutilization like
requiring prior authorization, capitated payments, and increasing
patient cost sharing have now been employed by insurers and providers
for decades. Yet the overall impact on health care costs appears
negligible; costs continue to rise. Moreover, some analysts point out
that the United States may be underutilizing a host of important
services relative to other countries, especially primary care.

Overutilization of certain services probably is one of the many problems
in our health care system. But there are grave consequences to
considering overutilization the central problem. For one, the increased
patient cost sharing that is supposed to rein in overutilization has
contributed to a situation in which 31.7 million people with insurance
are considered underinsured because they dedicate such a high proportion
of their household income to medical bills. And as to the sizable
uninsured population, the prospect of expanding coverage has too often
been cast as a menace to the system rather than a laudable and socially
responsible achievement.

There is a need for a more critical conversation about who wins and
loses thanks to the present system setup. Some work is already happening
in this regard, but it has yet to reach the wide popular audiences and
become "common sense" in the way that overuse has. Academic researchers
have called attention to how much we pay for services and pointed out
that our high prices are largely to blame for runaway health care costs.
Others have argued that risk-pooling techniques need to be resocialized
by turning away from the highly segmented, experience-rated pools that
currently dominate insurance marketplaces. But it is too difficult for
these counternarratives to be heard above the seductive din about
overutilization and the attendant need for individual consumer restraint
that continues to dominate discussions of health care costs in the
United States.

Overutilization is a management neologism that has become an economistic
health policy fairy tale where costs can be cut, services denied, and
hospital days reduced with no harm — financial, physical, or otherwise —
 to patients, providers, or payers. Curbing overutilization alone will
not redeem our health care system. And real people stand to lose when
reducing utilization and increasing efficiency is seen as the primary
goal of health policies.


Comment by Don McCanne

Yesterday's Quote of the Day message on the prevalence of underinsurance
and its consequences, largely caused by the increased use of high
deductibles designed to decrease utilization of health care, is a prime
example of the pervasiveness of the misguided concept that
"overutilization" needs to be the primary target of reform.

Hopefully this article, "Overutilization, Overutilized," will become a
landmark paper in the chronology of health care reform. The concept of
overutilization of health care has driven much of the political and
policy decisions in our reform efforts. This is tragic because it "too
often drowns out other difficult conversations about social welfare,
health equity, prices, and universal coverage," according to the authors.

The policies designed to correct alleged overutilization have not only
been relatively ineffective in reducing spending to a meaningful degree,
often they have also been harmful, impairing access to health care and
frequently creating financial hardships for those with health care needs.

This is particularly shameful when there remains disagreement on which
particular applications of health care are clearly excessive, and
whether they are truly as pervasive as is often claimed. Further, if
this waste is as common as is often claimed, most of it is not
recoverable because of the difficulty of establishing precise guidelines
that can be applied reliably to complex clinical settings.

We have a much greater problem with health care underutilization and its
adverse consequences which are compounded by policies designed to
curtail utilization.

The Abstract and Conclusion above describe the general theme of the
article, but the details are important if we are to turn the reform
process into one that aims to provide health care for everyone, and away
from our current processes that are blunt instruments designed to reduce
utilization while ignoring harm to the patient.

For those who do not have access to the current issue of the Journal of
Health Politics, Policy and Law, this article can be downloaded at the
link above for a fee of $15. It is unfortunate that this article is
behind a paywall, because it does need to be distributed widely.

We need to do all that we can to change the dialogue on reform. Instead
of imperiling our health care system with misguided policies to
haphazardly reduce utilization, we need to advance policies that would
make health care truly universal, comprehensive, equitable, accessible,
and priced appropriately, while increasing efficiencies through policies
that would actually be effective in recovering waste - the prime example
being the replacement of our expensive, fragmented system of financing
care with an efficient single payer national health program.

Let's change the narrative.

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