As many as 42 percent of U.S. Medicare patients were subjected to procedures providing little if any medical benefit, costing the government program up to $8.5 billion in wasteful spending, according to a study published on Monday.
The research, reported in JAMA Internal Medicine, is the first large-scale analysis of what Medicare spends on procedures widely viewed as unnecessary, from advanced imaging for simple lower back pain to pre-operative chest X-rays and putting stents in patients with stable heart disease. The study looked at the frequency at which doctors used 26 such procedures in 2009.
It builds on the growing body of work in the field of evidence-based medicine, which applies rigorous scientific scrutiny to common procedures. Using that approach, oncologists, cardiologists and other specialists have identified several hundred questionable procedures as part of the "Choosing Wisely" campaign, which began in 2012.
Although the study examines 2009 data, "there is no reason to think these patterns have not persisted (or) worsened" over time, said Dr J. Michael McWilliams of Harvard Medical School, senior author of the paper. "Imaging for back pain has actually increased."
While the study examined only a few procedures, he said, "we think this is just the tip of the iceberg."
Although many of the questionable procedures are completely useless (arthroscopic surgery for knee arthritis is no better than pretend surgery, for instance), some might benefit a very few patients.
If many of those who received such a procedure were among the rare ones who would benefit, then 2009 Medicare spending on wasteful procedures totaled $1.9 billion, or 0.6 percent, McWilliams and his colleagues calculated. If the patients were unexceptional, $8.5 billion (2.7 percent) was wasted.
The cost is more than financial. "Low-value services are not harmless," said co-author Aaron Schwartz of Harvard. "They expose patients to radiation and surgery."
At least one in four Medicare patients, and as many as 42 percent, received wasteful services in 2009, the researchers calculated.
There are several possible reasons. One is what physicians in a community consider the standard of care. Another is defensive medicine - performing a test so as not to get sued for "missing" something. Pre-op X rays and stress testing, for instance, offer little or no benefit, yet physicians order them.
It is not clear how to deter that. Strict insurance coverage policies will not work, McWilliams suspects, because physicians could argue that theirs is the exceptional patient who needs the procedure. But replacing today's fee-for-service healthcare with models that pay physicians a lump sum to care for a patient might.
Low-key reminders also might help. At Cedars-Sinai Medical Center in Los Angeles, Dr. Scott Weingarten has incorporated a large part of Choosing Wisely's guidelines into electronic medical records. Each time a physician tries to order any of 120 procedures on the lists, a screen reminds him that a medical specialty group has deemed it likely useless.
Since the system was introduced last fall, Weingarten said, use of the procedures has fallen as much as 18 percent.
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