The harm done by the overutilization narrative

Overutilization, Overutilized

By Deborah Levine and Jessica Mulligan
Journal of Health Politics, Policy and Law, April 2015


Overutilization is commonly blamed for escalating costs, compromising quality, and limiting access to the US health care system. Recent estimates suggest that nearly one-third of health care spending in the United States is a result of unnecessary care. Despite the surge of exposés that purport to uncover this “new” problem, narratives about overutilization have been circulating in health policy debates since the beginnings of the health insurance industry. This article traces how the term overutilization has spread in popularity from a relatively small community of mid-twentieth-century insurance experts to economists, physicians, epidemiologists, and eventually the news media of the early twenty-first century. A quick glimpse at the history of the term reveals that there has been constant disagreement and debate over the meaning and impact of overutilization. Moreover, the term has been put to very different uses, from keeping socialism at bay to preserving the fiscal integrity of Medicare to protecting the health of patients. The overutilization narrative, seductive in its promise of cutting costs without sacrificing access to quality care, too often drowns out other difficult conversations about social welfare, health equity, prices, and universal coverage.

Conclusion: Overutilization Has Overreached

For sixty years, overutilization has been a key term in health policy debates. The term emerged in literature about the potential demise of voluntary insurance and then spread to new domains: first with inpatient hospital stays and then eventually with almost every other form of care. The audience for this narrative expanded as well: from industry insiders to economists, physicians, public health researchers, the media, and finally, patients.

Utilization review and other techniques for curbing overutilization like requiring prior authorization, capitated payments, and increasing patient cost sharing have now been employed by insurers and providers for decades. Yet the overall impact on health care costs appears negligible; costs continue to rise. Moreover, some analysts point out that the United States may be underutilizing a host of important services relative to other countries, especially primary care.

Overutilization of certain services probably is one of the many problems in our health care system. But there are grave consequences to considering overutilization the central problem. For one, the increased patient cost sharing that is supposed to rein in overutilization has contributed to a situation in which 31.7 million people with insurance are considered underinsured because they dedicate such a high proportion of their household income to medical bills. And as to the sizable uninsured population, the prospect of expanding coverage has too often been cast as a menace to the system rather than a laudable and socially responsible achievement.

There is a need for a more critical conversation about who wins and loses thanks to the present system setup. Some work is already happening in this regard, but it has yet to reach the wide popular audiences and become “common sense” in the way that overuse has. Academic researchers have called attention to how much we pay for services and pointed out that our high prices are largely to blame for runaway health care costs. Others have argued that risk-pooling techniques need to be resocialized by turning away from the highly segmented, experience-rated pools that currently dominate insurance marketplaces. But it is too difficult for these counternarratives to be heard above the seductive din about overutilization and the attendant need for individual consumer restraint that continues to dominate discussions of health care costs in the United States.

Overutilization is a management neologism that has become an economistic health policy fairy tale where costs can be cut, services denied, and hospital days reduced with no harm — financial, physical, or otherwise — to patients, providers, or payers. Curbing overutilization alone will not redeem our health care system. And real people stand to lose when reducing utilization and increasing efficiency is seen as the primary goal of health policies.



By Don McCanne, MD

Yesterday's Quote of the Day message on the prevalence of underinsurance and its consequences, largely caused by the increased use of high deductibles designed to decrease utilization of health care, is a prime example of the pervasiveness of the misguided concept that "overutilization" needs to be the primary target of reform.

Hopefully this article, "Overutilization, Overutilized," will become a landmark paper in the chronology of health care reform. The concept of overutilization of health care has driven much of the political and policy decisions in our reform efforts. This is tragic because it “too often drowns out other difficult conversations about social welfare, health equity, prices, and universal coverage,” according to the authors.

The policies designed to correct alleged overutilization have not only been relatively ineffective in reducing spending to a meaningful degree, often they have also been harmful, impairing access to health care and frequently creating financial hardships for those with health care needs.

This is particularly shameful when there remains disagreement on which particular applications of health care are clearly excessive, and whether they are truly as pervasive as is often claimed. Further, if this waste is as common as is often claimed, most of it is not recoverable because of the difficulty of establishing precise guidelines that can be applied reliably to complex clinical settings.

We have a much greater problem with health care underutilization and its adverse consequences which are compounded by policies designed to curtail utilization.

The Abstract and Conclusion above describe the general theme of the article, but the details are important if we are to turn the reform process into one that aims to provide health care for everyone, and away from our current processes that are blunt instruments designed to reduce utilization while ignoring harm to the patient.

For those who do not have access to the current issue of the Journal of Health Politics, Policy and Law, this article can be downloaded at the link above for a fee of $15. It is unfortunate that this article is behind a paywall, because it does need to be distributed widely.

We need to do all that we can to change the dialogue on reform. Instead of imperiling our health care system with misguided policies to haphazardly reduce utilization, we need to advance policies that would make health care truly universal, comprehensive, equitable, accessible, and priced appropriately, while increasing efficiencies through policies that would actually be effective in recovering waste - the prime example being the replacement of our expensive, fragmented system of financing care with an efficient single payer national health program.

Let's change the narrative.