A. For people who had been awaiting the rollout of the Affordable Care Act in order toobtain health insurance for the first time, the major problem associated with Americanhealthcare has been a lack of access to it. But for a surprising number of Americans,the greater problem may be exactly the opposite: They are receiving too muchhealthcare. And that's not good news for either their wallets or their physical well-being.
 B. The most recent estimate from the Institute of Medicine is that about 30 percent oftotal healthcare expenditures in America go toward unneeded care. Doctors, too, haveacknowledged the problem: In a 2011 survey published in the Archives of InternalMedicine,42 percent of American primary care physicians said that patients in theirown practice were getting more care than necessary.
C.Excessive care typically takes the form of overabundant referrals ( 转诊病人 ) tospecialists, more diagnostic tests than would be medically necessary, or too manyprescriptions--but in some cases, it can extend to actual treatments or surgeriesthat are not clinically indicated. Richard Baron, president of the American Board ofInternal Medicine, is candid ( 直言不讳的) about the problem. "There were and arelots of things being done in healthcare that don't reliably benefit patients," he says.
D.From a patient perspective, it can be hard to see at first glance how too much carecould be a problem. But unneeded healthcare can be physically damaging. "Anythingwe do in medicine and healthcare has expected benefits and harms," says BrendaSirovich, a research associate at the VA Medical Center in White River Junction,Vermont. "Any time you have an intervention for a patient, no matter how small thereis also the chance that it's going to do some harm."
Even for initial screening tests that pose no risk in themselves, there's the problemof the "downstream effect"; if the first test produces an ambiguous result or a falsepositive, it can lead to more invasive testing that does carry substantial risk. "As youintervene on patients who have less and less reason to intervene and less and lesschance of benefiting, you still retain that probability of harming them," says Sirovich.
"In a word, that is the biggest problem with doing too much--the risk of harm."
In some cases, the roots of the excess care are noble: Doctors just want to provide thebest possible care for their patients. The operating assumption for many both insideand outside the medical field tends to be that if a little care does a little good, a lot ofcare will do a lot of good. Given the time constraints that many physicians are under,it can seem safest to default to over-ordering.
G.But there are several other major drivers of overutilization ( 过渡医疗 ) , as well.
Experts debate exactly how much the threat of lawsuits influences physicians in theirpractice of medicine, but physicians themselves say that fear of legal challenges is asubstantial factor in motivating them to provide too much care.
H.Skeptics challenge that physicians might not be in the best position to know exactlywhat motivates their own behavior. But a study published in Health Affairs thissummer suggests that the malpractice effect is real. According to the report, doctorswho acknowledge having a strong fear of malpractice are more likely to show apattern of ordering aggressive diagnostic tests, and they're also more likely to referpatients to the ER ( 急诊室 ) for treatment. This makes intuitive sense: Doctors arerarely asked if they did too much, but they are constantly questioned as to whetheror not they did enough--and they know they can wind up in legal trouble if patientsdon't think their care was sufficient.
I.Perhaps more troubling than medical liability issues are the financial incentivesinherent in the American healthcare system. Most American healthcare currentlyoperates on a fee-for-service model, where physicians receive payment for everyservice performed, regardless of whether that service actually benefits the patient ornot. In some eases, especially where physicians self-refer their patients for expensivediagnostic tests and treatments, there can be substantial financial incentives forordering interventions that might not be medically necessary.
J.Several recent studies have explored whether financial incentives influence howphysicians practice, and the answer, unsurprisingly, is that they do. In October, forexample, a report in the New England Journal of Medicine examined the "self-referraleffect" among urologists ( 泌尿科医师 ) treating patients for prostate cancer ( 前列腺癌) . The study found that doctors are substantially more likely to order radiationtherapy for their prostate cancer patients if those doctors have ownership interests inthe radiation services they are offering. Over the five-year period from 2005 to 2010,the use of radiation therapy by self-referring urologists in private practice jumped19.2 percentage points, whereas the rate among their non self-referring peers barelybudged, going up just 1.3 percentage points.
K. Jean Mitchell, a professor of public policy at Georgetown University and the authorof the report, acknowledges that her study can't ultimately speak to the motivationsof the physicians involved. But she sees reason to be concerned. "There's been thisdramatic trend toward aggressive treatment of prostate cancer, even though basicallythe clinical data suggest that we should move away from that," she says. "The issueis that it seems like being steered toward the treatment that is going to have the mostfinancial benefit for the urologist."
L. The self-referral effect isn't unique to radiology. Earlier this summer, a report ofthe United States Government Accountability Office examined rates of referrals forbiopsies (活组织检查 ) and found that between 2004 and 2010, referrals for biopsiesmore than doubled among self-referring physicians, even while they increased only38 percent among those who referred outside their own practices.
M. As physicians, researchers, and policy experts have grown to recognize the problemof excessive care, there have been a number of attempts to combat the problem. Oneof the most talked-about provisions of Obama's Affordable Care Act, for example,is the provision for Accountable Care Organizations (ACOs). Under this provision,a network of doctors and hospitals that agrees to act as an ACO receives financialincentives to figure out how to maximize quality while simultaneously reducing costsand eliminating waste in the system. The idea is to encourage healthcare networks totake more collective responsibility for population health and reward better care, ratherthan simply more care.
N. Physician groups are also stepping up to solve the problem. One widely publicizedeffort is the Choosing Wisely campaign which is set out to promote conversationsbetween doctors and patients about utilizing the most effective tests and treatmentswhile avoiding unnecessary care. To this end, organizers began calling on physiciansocieties to compile lists of the top five tests and procedures in their respectivespecialties that were most susceptible to overuse. To date, more than 50 physiciansocieties have joined the campaign, each contributing their own "top 5" list.
O.For Sirovich, these initiatives offer signs of hope. Fifteen years ago, she says,conversations about the harms of medical care or excessive spending weren't likely tocome up, but today, she hears more patients--and fellow physicians--talking aboutthe harms of overuse.
P. But despite hints of change, the problem of overutilization is likely to persist for sometime. After all, it took more than a century to construct the current healthcare system,and change does not come easily.