For now and the foreseeable future, close to half of U.S. health spending is conducted by public programs. To accommodate ever rising expenditures forces some unpleasant trade-offs: potential massive increases in taxation; huge increases in debt; dramatically lower spending on other goods and services (such as education and defense); or some combination thereof. In a 2010 Health Affairs article, Joseph Newhouse, faced with these choices, explained why the trajectory of total U.S. healthcare spending must be bent downward. Key to his argument, however, was the observation that it is not enough to simply address healthcare spending in federal programs, notably Medicare. The healthcare spending problem must be solved nationally, for both public and private payers.
The real question, therefore, is not whether to spend less on health care (relative to the economy or projections of current trend) but how. Either less can be spent on everything, or spending cuts can be targeted. The former approach risks reducing spending on necessary, efficient, and life-extending or life-enhancing care. The latter approach offers an opportunity to reduce waste and improve quality as spending is controlled. Increasing quality and reducing waste, as spending is tamed, sounds hard, and it is. But we already know where to begin and have an idea of how to do it.
Well-designed studies have shown that, often, treatments are offered, and paid for, that do not improve outcomes. Let’s consider just a few. About three quarters of a million new vertebral fractures occur in the U.S. each year, and people aged >50 years have a nearly 25% chance to have at least one such fracture over their lifetimes. Most such fractures heal, but a substantial number cause chronic pain. Although surgery for these fractures has been controversial, the number of vertebroplasties paid for by Medicare nearly doubled from 2001 to 2005. A 2009 study showed that vertebroplasty for vertebral fractures was no better than sham (fake) surgery in reducing pain. In spite of this study, Medicare still pays for 100,000 such procedures each year, at a cost of $1 billion annually.
In addition, studies show that more than 5 percent of people in the U.S. aged >30 years and more than 10 percent of those aged >65 years have frequent knee pain from osteoarthritis. In 2009, more than 500,000 of them underwent arthroscopic surgery, at a cost of $3 billion.10 Yet a 2002 study showed that arthroscopic surgery for knee pain was no better than sham surgery.
An enormous list could be amassed of treatments that have been proven to be ineffective, let alone cost ineffective. These could include routinely using estrogen in menopause for chronic disease prevention, suppressing arrhythmias post–myocardial infarction, doing internal carotid artery bypasses, using alpha-blockers as first-line therapy to prevent stroke, giving estrogen to men with coronary artery disease, giving high-dose glucose infusions in the critical care unit, using beta-blockers perioperatively, and inappropriately using implantable cardioverter-defibrillators. Recently, the Choosing Wisely campaign, in partnership with medical provider organizations, identified five tests or procedures that are of questionable value, in each of nine medical specialties. Adam Elshaug and colleagues identified over 150 health practices that are potentially of low value, at least to a subset of the patients who routinely receive them.
The exact amount spent on these procedures every year is not known, yet it is known that they are common, expensive, and inappropriately applied. They provide a ready, if politically challenging, means to reduce spending without decreasing quality. In fact, eliminating some of them and focusing use of others would increase quality because doing so would avoid needless health care, which itself carries risk. The key is to reform institutions and payment systems within the broader healthcare system that would provide incentives to eliminate them. This is not a simple task; knowing what to do is not the same thing as getting everyone to agree to do it.
The foregoing is a lightly edited version of a passage in my recent paper in the American Journal of Preventative Medicine with Aaron Carroll. It’s ungated and titled “The Quality Imperative: A Commentary on the U.S. Healthcare System.” You can read the rest here.