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Dr. Meredith Niess saw that her patient was scared. He had come to the veterans clinic in Denver with a painful hernia near his stomach. Niess, a primary care resident, knew he needed surgery immediately. But another doctor had already ordered a chest X-ray instead.
Test results revealed a mass in the man’s lung.
“This guy is sweating in his seat, [and] he doesn’t think about his hernia,” Niess said. “He thinks he has cancer.”
It was 2012 and Niess was upset. Although ordering a chest x-ray in a case like this is considered standard medical practice, Niess understood something his patient didn’t. Decades of evidence showed that the chest x-ray was unnecessary and that the “mass” was likely a shadow or a cluster of blood vessels. These not found findings are so common that doctors have dubbed them “incidentalomas.”
Niess also knew that the initial X-ray would trigger more tests and further delay the man’s operation.
In fact, a follow-up CT showed a clean lung but detected another suspicious “something” in the patient’s adrenal gland.
“My heart just sank,” Niess said. “It doesn’t look like medicine.”
A second CT scan finally cleared his patient for surgery – six months after he came for help.
Niess wrote about the case in JAMA internal medicine as an example of what the researchers call a “cascade of care” – a seemingly unstoppable series of tests or medical procedures.
Cascades can begin when a test done for a good reason reveals something unexpected. After all, good medicine often requires research.
“Low value care”
The most disturbing stunts, however, begin like that of Niess’ patient, with an unnecessary test – something Ishani Ganguli, a primary care physician who is an assistant professor of medicine at Harvard University, and other researchers , call “low-value services” or “low-value care.”
“A low-value service is one for which there is little or no benefit in this clinical scenario, and potential for harm,” Ganguli said.
Over the past 30 years, doctors and researchers like Ganguli have reported more than 600 procedures, treatments and services unlikely to help patients: tests like MRIs done early for uncomplicated low back pain, cancer screenings for prostate in men over 80 and routine vitamin D. trials.
Research suggests that low-value care is expensive, with one study estimating that the US healthcare system spends between $75 billion and $100 billion a year on these services. Ganguli published an article in 2019 that found the federal government was spending $35 million a year specifically on care after doctors performed ECG heart tests before cataract surgery — an example of low-value care.
“Medicare was spending 10 times more on the stunts after those EKGs than on the EKGs themselves. This is just one example of a service,” Ganguli said.
Healing cascades are common. Ninety-nine percent of doctors said they had experienced one after an incidental discovery, according to a survey conducted by Ganguli. Nearly 9 in 10 physicians said they had seen a stunt harm a patient, for example, physically or financially.
And yet, in that same survey, Ganguli reported that 41% of doctors said they continued with a cascade even though they thought the next test was not medically important.
“It’s really driven by the desire to avoid the slightest risk of missing something potentially deadly,” Ganguli said. Critics of low-value care say there is a mindset that comes from medical training that seeks all the answers, as well as compassion for patients, some of whom may have requested the test.
As health care prices rise, efforts to eradicate low-value care continue to emerge. In 2012, the American Board of Internal Medicine Foundation began urging physicians to reduce low-value care through a communications campaign called Choosing Wisely.
An electronic warning to doctors
During this time, a dozen companies have developed software that health systems can integrate into their electronic health records to notify physicians.
“We display an alert to let them know what care they were about to provide,” explained Scott Weingarten.
Weingarten worked as a doctor at Cedars-Sinai Medical Center in Los Angeles for three decades and spent years lobbying hospitals across the United States to fix the problem.
Weingarten realized that even the most sophisticated and well-resourced hospitals and doctors needed help developing new routines and breaking old habits, like ordering a chest X-ray.
Less than 10% of health systems have purchased software tools called “clinical decision aids”. But Weingarten, who co-founded Stanson Health and has since left the company, said internal analysis found electronic warnings only canceled unnecessary testing 10-13% of the time.
“Glass half full is that you paste an application into the EHR [electronic health record] and you eliminate 10-13% of low-value care, just like that,” Weingarten said. “That could mean, if deployed across the country, [we could eliminate] billions and billions of dollars of waste.”
But that 10-13% also eats into Weingarten. “Why do doctors reject this advice 87-90% of the time? ” He asked.
Even with software that warns physicians of unnecessary care, major barriers to change persist: a medical culture of more is better, physicians fear they’re missing out, patients demand more.
Perhaps the biggest challenge: Hospitals still make most of their money based on the number of services provided.
Cheryl Damberg, senior economist at Rand Corp., said what might get hospitals’ attention is money. “If payers stop paying for some low-value care services, that will definitely change the math on whether the juice is worth it,” she said.
Damberg said some commercial insurers and Medicare have started paying doctors premiums to reduce specific low-value services and to hold providers accountable for the full cost of a patient’s care. But these contracts are rare.
No one wants to give or receive low value care. But in American medicine, the pressure to “do just one more test” remains strong.
This story was produced by Compromisea podcast exploring our confusing, expensive, and often counter-intuitive healthcare system.