ROCHESTER, Minn. — Policy experts say one of the most challenging aspects of the health care marketplace is that Americans are both under- and over-treated. Too little healthcare has given rise to calls for new preventive screening and expanded access to coverage, while too much medicine has long been identified as a hazard for older Americans subject to unneeded tests, scans and medications.
But children can experience so-called low-value care as well, including the ordering of antibiotics for colds, cough medicine for children under 6, and scans for head trauma, sinusitis and headache. Besides draining family dollars and taking up clinician time, these interventions can subject children to risks of sedation, radiation, side effects and, in the case of antibiotics, an increased likelihood of antibiotic resistance.
If market forces drove the problem of low-value care, health officials could focus their messaging on parents of children with private insurance. New findings, however, suggest that children on Medicaid receive unnecessary health services just as readily. "It's kind of a general problem for all children," says Dr. Kao-Ping Chua, University of Michigan pediatrician and author of a study published today in the journal Pediatrics examining low-value care in children according to payer type.
After narrowing a list of over 400 low-value services to 20 tests, imaging orders or prescriptions capable of analysis via claims data, Chua and coauthors analyzed the payment source of health services provided to over 8.5 million children in 12 states during 2014. The results: they found 1 in 9 publicly-insured children received low value care, compared to 1 in 11 children with private insurance.
"We found a slightly higher probability that publicly-insured children got low-value care," says Chua. "We think some of that is driven by an overuse of antibiotics with the publicly insured." The paper identified antibiotics for fluid in the middle ear space, ultrasound for undescended testicle and steroids for lung infections among the leading low-value services given to children on public insurance.
"It's really important for clinicians to avoid low-value interventions that don't improve health," says Chua, "for example, antibiotics for colds. The reason for that is, there are side effects of these interventions, both immediate and long-term. In many cases, some of these services can hurt families financially, because they have to pay for it out-of-pocket. Also, these services can waste health care dollars that can be used for more valuable causes."
Chua says the reason children receive so many interventions known to be ineffective often has to do with doctors' mistaken belief that doing so will make parents happy.
"In my view, ultimately the responsibility for decreasing low-value care falls on the clinician, because with few exceptions, it doesn't occur unless we order it... I understand first-hand how difficult it can be when a parent comes in thinking the antibiotic is the only way to go. But at the end of the day, it's my job to manage that expectation, and do the right thing and not prescribe the antibiotic."
For parents, he says, it's important to understand the limitations of any given procedure.
"I think parents can take a number of steps to decrease the likelihood they are going to receive low-value care. One is to take steps to understand why any intervention is being ordered, and what the risks and benefits are. Another is to recognize that in most cases, for children in good health, the vast majority of illnesses just get better on their own, so the probability of any intervention altering the ultimate course of illness is pretty low."
"Taking a wait-and-see approach is often a wise approach," he says, "even though the tendency in the health care system, and American culture more generally, is to favor an interventionist approach."