Overuse, Underuse and Misuse

Shannon Brownlee is coming to Connecticut on March 18 to be the keynote speaker at Universal Health Care Foundation’s Reform to Transform forum, Healing Health Care:  Curing the System of Overuse, Underuse and Misuse.  What do these three terms mean?

Overuse, sometimes called overtreatment, is when we receive diagnostic tests that don’t contribute to making a diagnosis.  Or when we undergo surgery for back pain that, evidence shows, is not effective in most people for getting rid of the pain.  Or when we are prescribed an antibiotic for a sore throat that is caused by a virus, not by a bacterial infection.  The Institute of Medicine (IOM) in their report, Best Care at Lower Cost, found over $750 billion in waste in the U.S. health care system.  At least $210 billion of this waste is specifically due to unnecessary care.

As Brownlee points out in her book, Overtreated:  Why Too Much Medicine is Making Us Sicker and Poorer, more unnecessary care means more misuse:  more medical errors and more unnecessary harm to patients.  Misuse is about the many patient safety issues found throughout the health care system.  Another IOM report, To Err is Human, estimates that at least 44,000, or as many as 98,000 people die in U.S. hospitals due to preventable medical errors.  Patients receive the wrong medication or contract hospital-borne infections.   Our care is not nearly as safe as it should be or can be, or as Brownlee states bluntly in her book, “It leads to unnecessary suffering.  And it is killing people.”

Another related problem is underuse:  the failure to deliver needed care. In Overtreated, Brownlee cites one study that found, “…on average, patients were given recommended care a little less than 55 percent of the time.”  She attributes undertreatment at least in part, to poor coordination and lack of good primary care:  “What is known is that regions that have fewer specialists in relation to the population—and more primary care physicians—have better overall health.”

Another form of underuse occurs when necessary care is denied or is not reimbursed by insurance companies.  Connecticut’s Office of the Healthcare Advocate (OHA), led by Victoria Veltri, a panelist in the upcoming March 18 forum, advocates for patients and families when insurance denials of care occur.  The OHA 2013 annual report shows that mental health and substance use care is one of the most active areas where undertreatment concerns arise.

There are many answers to the problem of overuse, underuse and misuse.  Strong advocacy to protect consumers and patients is certainly key.  Another approach is to educate and empower clinicians and patients to make change.  One example is the National Physicians Alliance (NPA) project, Promoting Good Stewardship in Medicine. Led by Dr. Stephen Smith, a panelist at the upcoming forum, teams of NPA physicians from the primary care specialties of Internal Medicine, Family Medicine and Pediatrics, worked to develop three “Top 5” lists, recommendations for changes in practice that would lead to “significant health benefits and reduce risks, harms, and costs.”  This project has now evolved into the Choosing Wisely project, an effort, “focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm.  Over 50 specialties have now developed their lists of “Five Things Physicians and Patients Should Question”.

Incremental approaches to change abound. However, many people feel that nothing short of transformative change in how care is delivered and paid for will truly address the problems of overuse, underuse and misuse.

To learn more, and to participate in this important conversation, attend the next Reform to Transform forum on March 18 at Quinnipiac University’s North Haven campus.  Doors open at 6 pm for light refreshments and networking.  The program begins at 7 pm.   Tickets start at $20 and can be purchased at www.universalhealthct.org/whatwedo/events.

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