The fact that the United States spends more of its gross domestic product on health care (18%) than any other nation is old and depressing news (JAMA. 2012 Apr 11;307:1513-6). There may be some debate about whether the quality of the product we are getting is worth this outsized investment. But it is safe to assume that there must be some wastage in the system. Exactly how much of our health care dollar is going down the drain is unknown. And the thorny question of who is responsible for the leaks has escaped close scrutiny, probably because the answer is guaranteed to result in an uncomfortable and ugly circle of finger pointing. Is it the insurance companies, hospitals, the superspecialists, the drug companies, impatient patients, or those dastardly lawyers? Pediatricians are such small players on the health care stage that our contribution to the wastage must be minimal. Our patients are little people who are generally healthy. Most of us drive midsized cars and live in modest homes. We try to be careful users of the expensive diagnostic and therapeutic tools at our disposal. We don’t deserve a place on the list of likely suspects, do we?
Using a claims-based measure of 20 services that according to evidenced-based guidelines do not improve health, the authors discovered that among the nearly four and half million commercially insured children they studied, 9.6% received at least one of these 20 “low-value” services in 1 year. The ticket for these worthless services was $27 million,of which more than $9 million was out of pocket expenses for families. If extrapolated to all of the commercially insured children in the United States, the total cost of low-value services would be $227 million for 1 year. Regardless of how wasteful cardiologists or plastic surgeons may be, this contribution to the national cost of health care for low-value services by pediatricians cannot be considered chump change.
I urge you to check out the online version of Dr. Chua’s article and then click on Table 1 so you can look at the 20 services that the authors have chosen to label low value. Although I am always leery of accepting a guideline simply because it is has been labeled “evidence-based,” I think you will find that it hard to argue with their choices, such as blood tests in children with a simple febrile seizure, oral antibiotics after tonsillectomy, or neuroimaging in children with headache. How does your practice’s behavior stack up against their list?
The list could be much longer. For example, the authors chose to exclude head imaging ordered for minor head trauma because their claims-based method didn’t provide enough clinical information. I suspect that with an expanded list of clearly low-value services, the annual cost for low-value pediatric services would be a half a billion dollars.
As concerning as the findings in this study may be, it doesn’t answer the question of what we should do to correct the problem. We can dance around the issue by saying that patients and parents are pressuring us to do something even if it’s a low-value service. We can complain that for decades we have been practicing under the dark cloud of a malpractice suit, and that if we don’t turn over every stone in our evaluation of a patient we’re going to trip on one of them and end up in court.
But the bottom line is that we are the ones who are making the choice to order a study or prescribe a medication that is not only of low value, but more than likely worthless and possibly damaging to the patient. With the help of the American Academy of Pediatrics, we need to swallow hard and begin cleaning house, throwing out those low-value services we have gotten in the habit of ordering and prescribing. Education helps, but sometimes we have to do some finger pointing even if the finger points to us.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at.