The unspoken health care crisis

A group of 25 of the nation's leading medical societies recently released recommendations on treatments and tests they say are overused, or used inappropriately. They based their recommendations on a review of medical studies about the procedures. Called Choosing Wisely, this is a worthy effort by physicians to match medical practices with the underlying proof that they offer value.

Unfortunately, the effort may not go far enough. That's because there is a new kind of health care crisis brewing in the United States, one that threatens the health of millions and, as far as costs are concerned, already wastes billions.

It is called underuse. Think of this as the flip side of the "overuse" coin, and one that is just as detrimental to our health and welfare. Unfortunately, we aren't talking much about it.

Underuse refers to our tendency to underuse medical tests and treatments that are backed by solid evidence and are well-proven in helping people avoid sickness and preventing those who are sick from getting worse. Underuse often occurs in chronic disease care, which constitutes some three-fourths of all health spending. The result is that we don't catch chronic diseases early, when they are easiest — and least costly — to stop.

Studies by the RAND Institute in the New England Journal of Medicine found underuse of preventive testing and treatment in such areas as cervical, breast, and colorectal cancer; HIV; heart disease; and diabetes. RAND concluded that, on average, Americans receive only about 55 percent of recommended preventive care.

For example, only 24 percent of patients with diabetes received the appropriate number of hemoglobin A1c tests, even though these are critical in reducing diabetes complications such as blindness and amputation.

Though the RAND studies were published in 2003 and 2004, the Centers for Disease Control and Prevention in 2012 concluded that "tens of millions of Americans currently are not getting the preventive services they need," including HIV tests, colorectal screening, and diabetes care.

Consider what underuse means for health costs. The U.S. spent $245 billion on diabetes in 2012 — up 41 percent from 2007, according to a new study in Diabetes Care. Almost 63 percent of the cost of diabetes care is paid for by government insurance, and, in fact, the Medicare program alone spends one in three dollars on diabetes. As for productivity, American workers miss 25 million days of work each year because of the disease at a cost of $5 billion.

In contrast, it costs about $1,800 per year to manage diabetes and control its complications, and the tests to identify and monitor the disease cost between $7 and $13.50.

Similarly, in heart disease, the tests to help detect and manage cholesterol cost about $7 and may help prevent a heart attack that costs $28,000.

By stopping the underuse of the tests that can arrest diabetes and other chronic diseases, we have a chance of stopping the tidal wave of costs headed our way. The Choosing Wisely campaign rightly encourages providers and patients to have conversations about what tests and procedures are right for them, based on evidence.

Underuse needs to be just as much a part of that conversation as overuse. Underuse is a health care crisis that, if we act now by starting the conversation, we might be able to actually prevent.

Ronald L. Weiss is a professor of pathology at the University of Utah School of medicine.