Overkill: Unnecessary Care Is Low-Value Care
Solution lies in adhering to evidence that shows what works.
Last month, Dr. Atul Gawande published a thought-provoking essay in The New Yorker about the millions of tests, drugs and surgeries that American people undergo every year, which won’t make them better, may cause harm, and costs billions. Sadly, this avalanche of unnecessary care is not confined solely to physical health care. Behavioral health and substance use disorder systems are also guilty of deploying what researchers call “low-value” care.
This message is jarring, and the data indicating system failure is even more so. For example, only 25 percent of the 30 million Americans prescribed an antidepressant in a primary care setting every year show substantial clinical improvement. Given that common side effects of antidepressants include nausea, insomnia and reduced libido, millions of people take these medications for a net-negative impact. A recent article in the British Medical Journal posited that psychiatric drugs are responsible for the deaths of more than half a million people aged 65 and older each year in the Western world. The benefits would need to be colossal to justify this, yet they are minimal. Psychotherapy isn’t faring much better. Many people referred to psychotherapy will receive an insufficient number of visits and/or ineffective forms of it, leading to response rates as low as 20 percent.
Perhaps the biggest culprit for low-value behavioral health care is that we simply don’t measure the impact of what we, as clinicians, do. The absence of any widespread adoption of a measurement-based philosophy through standardized assessments means that we are rarely capturing patient-reported outcomes over time to assess treatment response. For example, the “integration” of behavioral health care expertise into primary care settings is currently in vogue. Yet the reality is that seemingly intuitive efforts to screen for mental illness, educate PCPs and develop treatment guidelines – alone and in combination – have not led to improved outcomes. Co-locating a mental health professional in a primary care setting has shown promise for treating common anxiety and depression. However, proximity alone does not improve patient outcomes at a population level and is at risk of being a “low-value” intervention in the absence of a systematic approach to assessment, treatment planning and progress measurement.
Managed care companies and other payers have a responsibility to keep the system on track. At Beacon, we strive to promote the delivery of high-value care by adhering to the evidence about what will work: the collaborative care model, for example, is backed up by more than 70 randomized controlled trials. We are using payment models to increase rapid access to practices that have more capability and scale with the models that work, including walk-in/same-day and next-day appointments. We want our members to have rapid access to specialists working in a team-based approach, employing principles of measurement-based care. Failure to systematically adopt such evidence-based models perpetuates low-value models of care for an already under-served population, the general public and for a health care system that is going broke. It’s time for stakeholders to look at the hard facts and act accordingly.
Gawande, A. Overkill, The New Yorker. May 11, 2015
Fortney, J., Sladek, R., Unutzer, J. Fixing Mental Health Care in America: A National Call for Integrating and Coordinating Specialty Behavioral Health Care into the Medical System. An issue brief released by the Kennedy Forum. Feb. 26, 2015.
Valenstein, M., Adler D.A., Berlant, J., Dixon, L.B., Dulit, R.A. Goldman, B., Hackman, A., Oslin, D., Siris S.G., Sonis, W.A. Implementing Standardized Assessments in Clinical Care: Now’s the Time. PubMed. Psychiatric Services. 2009. Oct., 60(10): 1372-5. DOI: 10.1176/appi.ps.60.10.1372 http://www.ncbi.nlm.nih.gov/pubmed/19797378
Unutzer, J., Harbin H., Schoenbaum, N., Druss B. The Collaborative Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid Health Homes. Center for Health Care Strategies and Mathematica Policy Research. Health Home Information Resource Center. May 2013. http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Downloads/HH-IRC-Collaborative-5-13.pdf
Davies, J. 2013. Cracked: Why Psychiatry Is Doing More Harm than Good. London, England. Icon Books Ltd.
Gøtzsche, P., Young, A., Crace, J. Does long term use of psychiatric drugs cause more harm than good? BMJ 2015;350:h2435 http://www.bmj.com/content/350/bmj.h2435