Maryland is the only state testing an "all payer" model for Medicare insurance payments. This model pays hospitals a fixed amount for each patient, in contrast to standard fee-for-service payments for each test or doctor's visit. A recent report in the New England Journal of Medicine showed Maryland's experiment has resulted in a 26 percent drop in infections, surgical errors and other preventable conditions. The model's success is counter-intuitive and throws into question our belief that more medicine means better health.
It is not surprising that we believe more medicine is always better; modern medicine has saved countless lives. Killer diseases like smallpox, measles and tetanus have been so effectively prevented by vaccines that we easily forget some still exist. Immediate care for a heart attack can return a person to health with a long life. The same is true for antibiotics, ICU care of critically ill patients and surgery for traumatic injuries. The brilliance of these and other breakthroughs makes us trust and believe that medicine always makes things better.
However, a new field has developed studying how medical care can result in more harm than benefit, known as medical overuse. Research on overuse is coming from traditional bastions of medicine, Oxford University, Dartmouth, the Mayo Clinic, Harvard and locally, Johns Hopkins and the University of Maryland.
Overuse is not a recent phenomenon. The past is full of examples of overuse that we have labeled bad science, ignoring the potential lessons for modern medicine. In the middle ages, physicians bled patients with leeches and dosed them with mercury. Although we scoff now, these were accepted practices. Oliver Wendell Holmes bucked convention in 1860 at the Massachusetts Medical Society when he stated "if the whole material medica, as now used, could be sunk to the bottom of the sea, it would be better for mankind — and all the worse for the fishes." More recently discarded practices include thalidomide for nausea in pregnancy after it led to thousands of babies with massively deformed arms or legs in the 1950s. Likewise, the female hormone estrogen was widely used by older women in the 1990s until a randomized-controlled trial showed it increased cancer and heart disease (akin to current use of the male hormone testosterone, which has similar possible harms). These examples are obvious in retrospect, but the true benefit and harms of treatment are often not clear in the present.
Recent studies have shown that common back or knee surgery as well as many blood transfusions are worse for patients, yet they are still frequently done. Studies have found up to one third of medical services may be unnecessary. Currently most patients experience unnecessary care such as antibiotics for the common cold or overaggressive treatment of diabetes, leading to sometimes fatal hypoglycemia. These harmful practices continue because our disease focused culture encourages doing more. Doctors and hospitals are generally paid for each test, visit or procedure without regard to whether they are keeping patients healthy. Doctors often know treatment is unnecessary but believe it is what patients desire or that unnecessary tests and treatments protect them from lawsuits. Finally, even the scientific literature is biased toward publication of positive results (instead of studies showing what does not work).
Although there are many factors promoting overuse, there are a few things clinicians and patients can do to limit unnecessary care. Clinicians can educate themselves to the problem of overuse and become more thoughtful in how they use tests and treatments. Physician groups have determined lists of over 250 current practices that should not be done. The British Medical Journal has a section "Too Much Medicine" and JAMA Internal Medicine has a "Less is More" section, including a yearly clinician "update" on practices to reconsider. Physician groups educate on "Right Care" or "High-Value Care." Likewise, it is important for patients to educate themselves. Consumer Reports has a Choosing Wisely series for patients describing key types of care to avoid, and books by the Dartmouth primary care doctor Gilbert Welch or journalist Shannon Brownlee are readable and informative.
The growing awareness that medicine can do too much and harm patients is a fundamental change that will improve medicine. The Maryland all payer model is an advance that provides the right environment for clinicians and patients to advocate for the best medical care that avoids the harms of excess.
Dan Morgan is an infectious disease physician who serves as hospital epidemiologist at the Veterans Affairs (VA) Maryland Healthcare System; he is also an associate professor in the Department of Epidemiology and Public Health at the University of Maryland School of Medicine and visiting fellow at the Center For Disease Dynamics, Economics and Policy in Washington, DC. He works on issues of medical overuse including a recent Research Agenda for Overuse in the BMJ and yearly Updates on medical overuse in JAMA Internal Medicine. His email is firstname.lastname@example.org.