Attributing Financial Incentives to Low-Value Care Leads to Misaligned Solutions

A HEALTH NEWS article from KFF regarding reducing unnecessary care recently caught my attention.¹ The article points out that efforts to decrease low-value care often fall short. It asserts that a primary cause is physicians being financially motivated. However, 1 of the examples was emergency department physicians who order CT scans as a workup for appendicitis in pediatric patients, where they won’t make an extra dime. Physicians surveyed in a study published in 2017 by PLoS One felt that 20.6% of care was unnecessary, and 70.8% believed that financial motivation was the primary cause.2 However, in the same survey, the 2 most common reasons given were fear of malpractice (84.7%) and patient pressure (59%). Of those who responded, 64.5% were salary only and 74.3% worked in academics, which may suggest a bias.

I do not deny that profiting from a procedure encourages more of it. Surgeons get paid to do surgery; obstetricians get paid to deliver babies; oncologists get paid to treat cancer. As part of a community oncology practice that participates in value-based care programs, I have seen regimens with small incremental benefits used. However, I have seen low-value treatments and recommendations just as often from academic centers, even though they usually do not have financial motivation. A study published by Lee N. Newcomer, MD, in the Journal of Oncology Practice looked at trying to change incentives by using an episode payment model in which drugs were reimbursed at the average sales price.³ This resulted in an overall savings, but the cost of chemotherapy went up.

Understanding why physicians continue to overtreat is critical to developing effective methods to reduce it, and blaming primarily financial incentives seems incomplete to me. In the PloS One study, the vast majority of respondents were worried about malpractice accusations even though only a small number of patients sue and very few win. However, payouts often feel like lottery winnings rather than justice served. I have reviewed cases and many times a potentially preventable outcome was missed because the physician did not get a basic test like a chest x-ray for recurrent pneumonias or did not physically see the patient in the office after they called with a complaint. A thorough examination of our tort system might lead to both better care and justice. Assistance from national organizations such as the Choosing Wisely campaigns is helpful. I use the American Society of Clinical Oncology’s early-stage breast cancer recommendations to educate my patients and avoid unnecessary tests.

Academic institutions share much of the responsibility, but their leadership is lacking. A study published in the Journal of the American Medical Association in 2014 showed that after training, physicians’ spending pattern practices mirrored those from where they trained.⁴ This is where minimizing low-value care can start. I call on academic institutions to stop using and recommending therapies that have little, if any, value. I challenge them to lead the charge in minimizing scans (eg, lymphoma patients do not need a PET/CT scan every 3 months indefinitely) and other low-value procedures. I think training young physicians early about the risks of low-value care and practicing what they preach will be more effective in the long term.

Leslie Busby, MD, is chair of the US Oncology Pharmacy & Therapeutics Committee and a medical oncologist and hematologist at Rocky Mountain Cancer Centers, Boulder, Colorado.

REFERENCES

1. Hawryluk M. Why it’s so tough to reduce unnecessary medical care. KFF Health News. November 13, 2023. Accessed March 4, 2024. https://kffhealthnews.org/news/ article/low-value-unneccessary-medical-care-tests-scans-incentives/

2. Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970. doi:10.1371/journal. pone.0181970

3. Newcomer LN, Gould B, Page RD, Donelan SA, Perkins M. Changing physician incentives for affordable, quality cancer care: results of an episode payment model. J Oncol Pract. 2014;10(5):322-326. doi:10.1200/JOP.2014.001488

4. Chen C, Petterson S, Phillips R, Bazemore A, Mullan F. Spending patterns in region of residency training and subsequent expenditures for care provided by practicing physicians for Medicare beneficiaries. JAMA. 2014;312(22):2385-2393. doi:10.1001/jama.2014.15973