Twelve years ago, in its landmark study Crossing the Quality Chasm, the Institute of Medicine (IOM) found that “the health care industry is plagued with overutilization of services, underutilization of services, and errors in health care practice.” In simple English, the IOM reported that health care was riddled with overuse, underuse and misuse of medical services.
The IOM also defined quality health care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Simply translated, that means getting the right care, at the right time, from the right provider with no mistakes.
Looking at the stories, the speeches, and the political commentary over the last few years, you’d think that the only thing that matters in American health care is that people are getting way too much medical treatment, much of it unnecessary, and it costs the country a fortune.
Although misuse pops up every now and then when a hospital commits some egregious error, we hear very little about underuse. Yet, that 2001 IOM report found that undertreatment can have as many devastating consequences for the public as overtreatment.
Mike Alberti, an investigative reporter for the media start-up Remapping Debate, whose purpose is to ask “why and why not,” has dug into the question of underuse of health care services. Alberti’s conclusion: “Remapping Debate found only limited direct evidence of ‘overutilization.’ We also found that the claim that utilization could be reduced at no risk to patient health has been oversold.”
It’s no wonder that the notion of overtreatment has crowded out the idea of undertreatment. Well-publicized books such as Overtreated by Shannon Brownlee and Otis Browley’s How We Do Harm: A Doctor Breaks Ranks about Being Sick in America have helped propel the public discussion toward overtreatment.
So have disciples of the Dartmouth Atlas crowd, those folks up in New England, who have spread the gospel that costs of care vary around the country and high cost areas don’t necessarily deliver better care. If each high-cost region reduced its spending to that of the low-cost regions, savings of 30 percent or more would be possible, say devotees of the Dartmouth Atlas of Health Care, who include our president.
Alberti picks apart this claim, arguing that the gap between “the indirect evidence that is represented by the findings on regional variation and directly observed and measured evidence for specific procedures call into question 'the idea that utilization can be reduced with little or no risk to patients'.” He quotes Mark Pauley, a professor of health care management at the University of Pennsylvania:
“These numbers get dangled in front of policy makers to tempt them into thinking we can cut costs and not hurt anyone, but a lot of (the) push to cut overutilization is based on circumstantial evidence.”
Circumstantial evidence or not, the idea of reducing overtreatment is being used to make public policy. What’s so bad about that you might ask? After all, some people are harmed by overtreatment, and some treatments may be unnecessary and costly.
Minimizing overtreatment also fits well with the current political goal of reducing the costs of medical care. While wringing out excess care will somehow lower costs, focusing on undertreatment might end up adding to the national health care tab, a point Mark Chassin, the IOM’s Crossing the Quality Chasm expert, used to stress with reporters. Giving people what they need would cost money that Medicare, insurance companies, and employers would have to pay, and nobody wants that.
Yet, Alberti points out that comprehensive studies over the last decade have found “widespread underutilization.” In 2007, for example, American children were getting less than half of recommended care. “The literature is replete with studies that show people not getting things they should be getting,” says Patrick Alguire, a senior vice president at the American College of Physicians.
We have to look no further than Medicare to see what he means. Last year, only 12 percent of Medicare beneficiaries who were enrolled in traditional Medicare (not Medicare Advantage plans) received their annual wellness exam, a new preventive service called for by Obamacare. Although that was a 38 percent increase over 2011 when the benefit became available, that’s still a lot of underuse of a service most professionals agree is worthwhile for seniors.
So far, Remapping Debate hasn't gotten as much attention as the Dartmouth Atlas or Shannon Brownlee's Overtreated, but its message is just as important. The right care at the right time may not always mean less care. Too little care is still harming too many people and our country, too.