We’ve become accustomed of late to stories telling us we get too much healthcare. We get too much of the Three Ts—treatments, tests, and technology—which has become the dominant narrative in the ongoing tale of US healthcare spending. So it’s refreshing when a story comes along like the one last week from Remapping Debate that reported on those who get too little care. It’s been as if the media forgot about the great paradox of US healthcare: overtreatment and undertreatment exist side by side.
This story shows that the goals of the Affordable Care Act and the Obama administration might be a tad more complicated than the policy wonks and the press led the public to believe. Reporter Mike Alberti points out that “some of President Obama’s advisers have framed the goals of healthcare reform exclusively from the perspective of the need to cut costs, as opposed to the need to increase access of quality of care.” For an example, he quotes one member of the healthcare cognoscenti, Harvard professor David Cutler, who has written that “the ‘true measure of healthcare reform’s success is whether it drives down medical costs over the long term.’”
Alberti’s piece revolves around a study reported recently in the policy journal Health Affairs, which the administration hotly contests. That study measured the use of digitized imaging results from such tests as CT scans and MRIs and found that doctors who had access to the results of digital imaging through electronic health records were significantly more likely to order imaging tests than those who did not. Electronic records, one of the cornerstones of health reform, are supposed to reduce unnecessary tests and reduce costs—or so goes the conventional wisdom.
Alberti interviewed the author of the study, Danny McCormick, an assistant professor at the Harvard Medical School, who pointed out what the media have been missing:
There is a tremendous amount of overutilization, and that’s where the conversation has been, but there is also a tremendous amount of underutilization. If we are serious about improving the quality of care, in some settings that will imply fewer tests. In other settings, some people are going to be getting care that they are not getting now. That makes the question of overall costs a lot more complicated.
An example of what McCormick means—a medical zone where more tests are required—showed up on page one of The New York Times the other day. The US ranks poorly among developed nations when it comes to the number of premature births. A study from the World Health Organization showed that the US is similar to developing countries when it comes to the percentage of women giving birth prematurely. The reason? There are many, but one is that women don’t get prenatal care that could head off problems. The importance of prenatal care has been known for a long time. But it costs money, and those without insurance often don’t get it. With healthcare reform, they may.
Dr. Mark Chassin, who now heads the Joint Commission, a private group that accredits hospitals, used the terms “underuse” and “overuse” of medical care more than a decade ago in a seminal work on the quality of care in America. He often warned journalists that solving the underuse problem would actually cost more money—a point that has been lost in the current reportage and policy discussions.
Alberti explored the potential for electronic medical records to detect underuse of medical services. He reported that electronic health records had reduced the number of expensive imaging tests at Massachusetts General Hospital without hurting patients. If we see “that individual physicians have ordered many tests that were not rated as highly appropriate, we have an intervention with them,” the hospital’s radiologist in chief, James Thrall, told Alberti, who asked important follow-up questions. Could an electronic medical record be created to detect underutilization, for example, by suggesting that an appropriate test was not ordered and should have been? “That’s not the conversation we’re having,” Thrall replied. “The fundamental policy question is not how much healthcare we need, it’s how much healthcare we can afford.”