What Drives Medical Overutilization?

There are many forces driving utilization in health care.  Patients come to doctors for explanations and relief. They relate symptoms that will likely lead to diagnostic testing.  For example, if you tell your physician that you have a burning sensation when you urinate, it is likely that you will be asked to surrender an aliquot of your urine for analysis.  If you enter your doctor’s office with some difficulty breathing, fever and a cough, I’ll wager that there’s a chest x-ray just around the corner.  These diagnostic tests are appropriate.

When does utilization morph into overutilization?  I don’t know where the threshold between them lies.  Moreover, doctors disagree amongst ourselves on what constitutes an unnecessary medical test. Doctors agree that there is too much testing and prescribing going on, but they tend to point their fingers toward their colleagues rather than toward themselves.  Think of politicians here.  It’s common for a congressman to criticize another congressman (usually from the other side of the aisle) for wasting money on a boondoggle.  The sponsor of the bill, however, argues that funding a research project examining if fireflies can replace street lights is a worthy endeavor!  So, in medicine and in politics, there is rampant waste and abuse, but no one admits to being a perpetrator.  Everyone else is at fault.

And, if you think doctors disagree on what constitutes necessary medical testing, consider how often doctors and insurance companies disagree if a test is medically necessary.  We all have experienced or heard about exasperating examples of this.  Although I’d rather get medical advice from a doctor than an insurance company bureaucrat, I must confess that there are times the insurance companies are right and that physicians are overreaching. 

Sir William Osler - A Giant in Medicine

Physician, Educator and Humanitarian 

The young physician starts life with 20 drugs for each disease,

and the old physician ends up with one drug for 20 diseases.

Why do physicians – even good ones – order medical testing and treatments that are not clearly indicated?  This is a complex question and I have penned dozens of Whistleblower postings on various aspects of this issue.

• Physicians are trained to take action in response to patients’ symptoms.  In general, physicians are more likely to prescribe something than to advise watchful waiting.  There is a professional bias that taking an action is preferable to inaction.
• Physicians order tests for defensive purposes in a belief that this reduces the risk of a successful medical malpractice claim.  Fortunately, this practice has ebbed in recent years. 
• Patients (and their families) expect diagnostic and therapeutic action.  Indeed, if a patient develops a medical issue and discusses it during an office or virtual visit, he expects a tangible response.  That’s the reason, of course, that the patient has come to the office.
• Patients request diagnostic tests for reassurance to relieve anxiety.  This occurs all the time.  A patient with mild heartburn, for example, asks for a scope test of the esophagus after his neighbor was just diagnosed with esophageal cancer.  While I think there is an argument to proceed, the test clearly not ‘medically necessary’.
• Medicine is a business.  Hospitals, extended care facilities and pharmaceutical companies need to encourage utilization to remain profitable.  All of these entities have marketing teams to promote use.  Drug ads are ubiquitous on television and suggest that viewers ask their doctors about the specific drugs seen.  If this practice didn’t drive utilization, then these companies wouldn’t be spending millions of dollars on advertising their products.

We will never achieve a consensus on what constitutes necessary medical care.  One doctor's essential test is another doctor's wasteful expense.  But the medical profession and our patients would be well served if we can acknowledge that overutilization is rampant and that we aim to confront it.