Supply of Medical Services

The Underuse of Overuse Research

Health economics, physicians and health services researchers have found that overuse, not underuse, is the major problem for many medical services.  Yet you rarely here a campaign to reduce that quantity of medical care provided.  Why is this?

An editorial in Health Services Research gives two important explanations for this.  First, measuring overuse is difficult.  “For example, a health plan cannot easily determine whether a child receiving a tympanostomy tube for treating otitis media with effusion was ‘overuse.’ To assess appropriateness, at least one year’s worth of medical records documenting the number of episodes and duration of ear infections is necessary (Keyhani et al. 2008).”  Needless to say, this creates a significant data burden.  The RAND Appropriateness Method [Brook et al. 1986, Brook et al. 1990]  may provide some guidelines for which medical services are necessary, but even these methods are imperfect.

The second problem is that reducing overuse often cuts into the income of a politically powerful groups: doctors, medical device makers, and pharmaceutical companies.  

One well-known illustration occurred when the Agency for Health Care Policy and Research (AHCPR), now known as the Agency for Healthcare Research and Quality (AHRQ), published guidelines that suggested that nonsurgical approaches were recommended in the initial management of acute back problems. The guidelines and underlying research supplying evidence led to lobbying efforts from the North American Spine Society, which felt that its scope of practice was threatened (Deyo et al. 1997). The end result was that the House of Representatives passed a resolution in 1996 for zero funding for AHCPR. The budget for the Agency was restored in the Senate after significant efforts by the research advocates. However, this experience led to the creation of a newly named Agency, with a mission that largely abandoned its role in guideline development.

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