Do the right thing: Let’s confront both health care underuse and overuse

Vice President of Research and Health Care Innovation Dr. Eric B. Larson writes about more opportunities to work for effective, affordable, responsible care on joining Kaiser Permanente.

Did you know that …

• More than 6 million unnecessary cesarean sections happen every year?
• About 30 percent of U.S. colonoscopies are inappropriate according to current guidelines?
• We spend about $270 billion a year on treatments that don’t help and might hurt us?

These numbers are from the Lown Institute, which commissioned a landmark series of articles in The Lancet on Right Care. According to Lown Institute President Dr. V​ikas​ Saini, Right Care is “needed, wanted, clinically effective, affordable, socially equitable, and responsible in its use of resources.” That’s a challenging goal, but the articles give us the roadmap to reaching it. I’m pleased to say that Kaiser Permanente’s acquisition of Group Health, which was finalized this month, is a great opportunity to be at the vanguard of a movement toward Right Care.

Right Care reduces overuse and underuse

Getting to affordable, equitable, responsible care for all will require correcting medical overuse and underuse. Overuse is when people who do not need a diagnostic test or treatment get it anyway. This puts patients at risk of complications from a procedure that is not likely to help their condition. Underuse is when people who would benefit from services such as prenatal care don’t receive it.

Among the reasons for underuse are cost, lack of availability, and poor access to care.

Both overuse and underuse widen health care disparities and contribute to waste. They direct money and resources away from care that improves health and toward medicine that doesn’t work or isn’t necessary. To correct this imbalance, we should look at the business model of health care.

The model for reducing overuse

I recommend all the Right Care articles to learn more about overuse, underuse, drivers of poor care, and levers for achieving high-value care. I also recommend the series’ introductory essay “Avoiding overuse — the next quality frontier,” by my friend and care-quality guru, Dr. Don Berwick. If you are in Seattle, you might have heard him give our 2012 Birnbaum Endowed Lecture.

Berwick notes that fee-for-service financial models, in which health care systems are paid for tests and treatments rather than for keeping their patients healthy, drive overuse in the United States. No wonder the Right Care series finds that overuse tends to occur for health care services that generate revenue.

Group Health and Kaiser Permanente share a different business model. We both started and have grown as enterprises with salaried physicians and prepaid rather than fee-for-service care. Since we’re not driven by the financial need to perform tests and treatments, we have traditionally favored keeping our members healthy and worked to reduce underuse of preventive services. This shared organizational philosophy was a driving force behind Group Health’s decision to become part of Kaiser Permanente.

Berwick reminds us that fighting overuse requires changing the way we train medical professionals and pay for care. With fee-for-service as the status quo, Berwick writes, this transformation “is not for the faint of heart.” Nonetheless, as he said in his Birnbaum lecture, confronting overuse is “an ethical imperative.”

Concrete steps toward Right Care

As Group Health joins Kaiser Permanente, we continue our commitment to Right Care. Our researchers are:

• Reducing unnecessary and low-value care by evaluating Group Health’s work in “Choosing Wisely,” an initiative to address the harms of overuse from Consumer Reports, the American Board of Internal Medicine Foundation, and medical specialty societies.
• Studying the best ways to manage and reduce the impact of chronic diseases. Examples are studying ways to manage chronic pain, diabetes, and dementia, as well as proving the value of exercise programs for overall health.
• Exploring powerful yet underappreciated, undervalued, and underused ways that can, over the long term, relieve common conditions. This effective approach is termed “incrementalism” by Dr. Atul Gawande in an excellent New Yorker piece. Examples are our work on mindfulness-based stress relief and yoga to relieve back pain.

Together, the Right Care articles are a call to arms to improve health care in the United States and globally. Attacking overuse and underuse will improve care quality. It could have significant economic and social implications, if resources recovered from reducing overuse can be reinvested in providing needed services where underuse hampers communities. This approach was a defining feature of Group Health and will continue as we join Kaiser Permanente. We are a movement that leads by example, doing the right thing to achieving affordable, quality care for all.

by Eric B. Larson, MD, MPH