Understanding the Physician’s Role in Reducing Medical Waste

The concept of medical waste in the health care system has contributed to significant changes that we’ve all had to adapt to in the last 20 years. “Quality” assessments have been introduced to our electronic medical records (EMRs) and linked to our reimbursement by insurance companies in an attempt to encourage more efficient use of resources. Despite these quality assessments, the proportion of gross domestic product (GDP) spent on health care continues to rise; therefore, the struggle to lower costs continues.¹  

There are many different definitions of medical waste. Some definitions and examples of medical waste include clinical inefficiencies, missed prevention opportunities, overuse of treatment, administrative waste, medical errors, and billing fraud. However, my favorite definition is “spending on interventions that do not actually benefit the patient.” This is also referred to as low-value care.²

Low-value care should be of particular interest to the physician because it directly identifies the health care team as the main source of the waste. John “Jack” Wennberg, MD, MPH, has been pioneering the idea of low-value care for decades. One of his hallmark articles, published in Science in 1973, demonstrated the first signs of unwarranted variation in health care practice.³ Unwarranted variation can be defined as the overuse, underuse, and misuse of medical care. We all understand that perhaps a small variation in how health care is delivered should be expected, but Wennberg demonstrated variation that was unwarranted and not based on medical evidence, chance, patient preferences, or health status/illness. The variation in how health care was delivered was wide. Health care teams were overutilizing health care services in certain regions of the United States without demonstrating better health outcomes and their patients also were not sicker, which would have justified an increase in resources used.

What You Should Know About Unwarranted Variation

Wennberg found 3 types of unwarranted variation: effective care, preference-sensitive care, and supply-sensitive care.³

Effective care is rooted in medical evidence and is care that all patients should be getting. Lack of effective care would demonstrate underuse of medical care. An example of this would be prescribing a beta-blocker after a heart attack—this should be expected.

Preference-sensitive care is when more than one reasonable treatment option exists. Ideally, the patient’s preference would be solicited and considered in the decision making, but oftentimes, the provider makes the decision based solely on his/her preference without patient input. This produces wide variation in the care received based on the medical opinion of the provider or region a patient lives in, instead of medical evidence.

Supply-sensitive care is medical care that is administered based on what is available, that is, the “more is better” approach. Hospital beds should be filled, magnetic resonance imaging (MRI) machines should be busy, and the operating room should be booming. This type of care is not based on medical evidence, but rather, on available resources. Regions of the US with more physicians per capita will use more diagnostic tests and consultations, yet will not receive better outcomes for this increased care. Regions with more hospital beds available will have higher hospitalization rates for the same diseases that are not routinely treated in the inpatient setting in other regions.

Wennberg was able to demonstrate all three types of unwarranted variation in the US, including underuse of effective care, overutilization of procedures based on physician preference, and overutilization of medical care based only on the fact that it was available for use despite offering no additional benefit to the patient.³ His early research fell mostly on deaf ears, with physicians refusing to admit their wrongdoing and placing blame on other entities.

How the United States Compares to Other Nations With Medical Waste

Over time, the facts have been difficult to ignore. The financial impact of medical waste is substantial. Medical waste is estimated to cost between $760 and $935 billion in the United States. This accounts for almost 25% of the total health care spending in the US. Overtreatment alone accounts for upwards of $101 billion and administrative failures contribute over $200 billion in waste.^4,5 This leads to a troubling future that will directly impact physicians and the way we practice. However, we can control our future if we act now. In commentary in the New England Journal of Medicine,⁶ Brook suggests that physicians have two options for dealing with overspending in health care: do nothing and allow the government to decide how to deal with medical waste, or identify the waste ourselves and educate each other.

When we look at other countries, we see a distinctly different picture of how medical waste is handled/monitored. In the United Kingdom, the National Institute for Health and Care Excellence (NICE) is responsible for providing guidance and advice to improve health care in the country. One major role they play is to determine if new technology will enter the health care market, including medications, techniques, surgical procedures, etc. Some of the criteria NICE uses to determine if new technology will enter the health care market are the efficacy of new technology and the cost of the new technology. For the technology to be approved, both clinical and economic evidence must be demonstrated. Clinical evidence should show how well the treatment works and economic evidence should show how well the treatment works in relation to how much it costs to the National Health System. This criterion helps the National Health System determine if new technology represents value for the money. Additionally, new technology that is being brought to the health care market needs to prove cost effectiveness with a formal analysis.

This is drastically different from what we do in the United States where costs are oftentimes an afterthought, and new technology can be brought on board without considering its efficacy against competitors. This is surely one of the reasons why the US health care system has such high spending on medical care—because we don’t do a very good job, in my opinion, of weeding out medications, treatments, and technology, that are not valuable to the consumer.

This is also one of the reasons why my interest in economic analyses has grown. An economic analysis looks at the outcomes that a treatment produces in relation to what it costs and then directly compares that treatment with its closest competitor. Despite the value this type of analysis has, there is a still a fair amount of pushback received in the US with this type of comparison.

The Top 5 Ways You Can Control Costs

Brody wrote an interesting editorial in the New England Journal of Medicine in 2010 that outlined ethical responsibilities that he believed health care providers needed to address.² In the article, he calls for physicians and medical organizations to create a “top 5 list” of ways they can control costs within their specialty. It has always been believed that physicians hold a great deal of responsibility when it comes to cost spending in the health care system. No longer does the public believe that physicians are innocent bystanders, but they instead understand the role that physicians play in cost spending, including the suggestion of treatments that may or may not add value. Brody encourages each specialty to write a prescription on how the most money could be saved most quickly without depriving any patient of meaningful medical benefits.

This “top five list” used what is now known as the Choosing Wisely campaign.⁷ Adopted as an initiative by the American Board of Internal Medicine, Choosing Wisely’s mission is to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, free from harm, truly necessary, and not duplicative of other tests or procedures that patients have already received. In addition, the campaign directly encourages patients to seek second opinions if certain tests or procedures are recommended by a doctor that have been deemed possible sources of medical waste by the campaign.

Overall, this campaign is aimed at reducing unnecessary health care and identifying areas of medical waste. So far over 70 medical societies have contributed to the campaign and over 500 tests and procedures have been identified as warranting further discussion before patients undergo them.⁷

The podiatric profession has contributed 10 statements so far to the campaign. I would encourage all podiatrists to be familiar with what our own profession deems medical waste and re-examine our own practices if we are currently participating in these practices.⁸

Final Thoughts

Overall, what can physicians do to try to minimize their contribution toward medical waste? Start with familiarizing yourself with the medical literature and employ practices that are rooted in medical evidence. This may involve changing your current practice and learning new techniques that boast better outcomes than historic practices.

If you’re looking for a “cheat sheet,” then turn to clinical practice guidelines. These guidelines are often developed by the professional organizations that represent each specialty and are supported by research and agreed upon by experts. There is often an algorithm that is presented in these guidelines to aid in how and when to deliver medical care. Another recommendation is to engage with the patient in shared decision making. Wennberg demonstrated in his work on unwarranted variation that if patients were truly educated on all their treatment options, they likely would have chosen a different treatment than what was actually rendered.³

There are details that may not be important to the physician, but may be important to the patient. For example, a patient may not appreciate the idea of retained hardware following hammertoe surgery and, if given the option, would prefer hardware that is only temporary. Although the hardware option most likely will not change the outcome, the patient should still be educated on the choices. Treatment that is delivered based solely on physician preference and without the input of the patient will surely result in medical waste. The decision regarding which treatment should be rendered should be a combined decision between the patient and physician collectively after all available options are presented.

Physicians are not powerless in the fight toward reducing costs in health care. In fact, we may be armed with the most important information to assist in identifying areas of waste. Small changes made in our individual practices can have large impacts in aggregate and help combat the crisis of medical waste.

Dr. Albright is a podiatric surgeon and researcher with Stamford Health Medical Group in Stamford, CT and currently serves on the medical group’s Board of Directors. She currently serves as a section editor for the Journal of Foot & Ankle Surgery (JFAS) and associated editor for the Journal of the American Podiatrist Medical Association (JAPMA). She also serves on the Board of Directors for the Connecticut Podiatric Medical Association.

References
1.    Centers for Medicare and Medicaid Services. NHE Fact Sheet. Available at https://tinyurl.com/mvdm6fcu.
2.    Brody H. From an ethics of rationing to an ethics of waste avoidance. N Engl J Med. 2012;366(21):1949-1951.
3.    Wennberg J, Gittelsohn. Small area variations in health care delivery. Science (New York, NY). 1973;182(4117):1102-1108.
4.    Bauchner H, Fontanarosa PB. Waste in the US health care system. J Am Med Assoc. 2019;322(15):1463-1464.
5.    Health Affairs. The role of clinical waste in excess US health spending. Available at https://tinyurl.com/yc8p7puu. Published June 9, 2022. Accessed December 28, 2022. 
6.    Brook RH. The role of physicians in controlling medical care costs and reducing waste. J Am Med Assoc. 2011;306(6):650-651.
7.    American Board of Internal Medicine. Choosing Wisely. Available at https://www.choosingwisely.org/. Accessed December 28, 2022. 

8.  American Podiatric Medical Association. Ten Things Physicians Should Question. Choosing Wisely. Available at: https://www.choosingwisely.org/societies/american-podiatric-medical-association/ . Accessed December 28, 2022.