Susan Dentzer: Do we need a Department of Healthcare Sanity to eliminate low-value healthcare?

Zoe Chance, who teaches at Yale’s School of Management, tells students that they should ask a “magic question” when they are faced with a difficult situation: “What would it take?”

That question can open their thinking “to ditch conventional ideas and consider a new approach,” Chance writes in her book, Influence is your superpower.^a

I found myself contemplating that question amid the sickening outburst of schadenfreude following the recent murder of UnitedHealthcare executive Brian Thompson. Polls have long shown that the public distrusts health insurers, with 68% of the public telling Gallup pollsters that they held an “only fair” or “poor” opinion of the sector in 2023, similar to the 65% that held the same opinions in 2003.^b But while that antipathy has now grown toxic, what would it take to get the public as outraged about the waste in U.S. healthcare — estimated to be as much as much as 25% of spending, or some $1.3 trillion in 2025 — as they are about efforts to rein it in, including those often undertaken by health insurers?^c

Gallup Survey respondents’ ratings of the quality of medical care or medical services provided by U.S. health insurance companies

	Percentage of respondents rating care or services
Year	Excellent	Good	Only fair	Poor	No opinion
2023	5%	26%	36%	32%	1%
2010	6%	36%	32%	24%	2%
2003	3%	30%	44%	21%	2%

Waste does not equal administrative expense alone

The health insurance sector’s critics make a plausible case regarding the extent to which insurers bear responsibility for that waste by contributing to the excessive administrative expenses that plague our complex, fragmented healthcare system. But these administrative expenses, such as prior authorization, exist in a nasty symbiosis with other aspects of the system, including the drive for profits and even fraud. Would we seriously want a system in which every claim submitted by any healthcare provider was paid automatically, without question? Should we even tolerate a system like traditional Medicare, with its relatively few constraints on routinely paying most fee-for-service claims?

Where to focus waste-reduction efforts

There is ample evidence that channeled outrage over healthcare waste can lead to effective policy action. Witness the public’s outrage over clear pricing excesses, such as inflated pharmaceutical prices, which helped to pave the way for Medicare to negotiate drug prices directly with manufacturers. But what would it take to stimulate public outrage over another key area of waste: low-value healthcare?

University of Michigan’s Center for Value-Based Insurance Design defines low-value care as “services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary cost to patients, or waste limited healthcare resources.”^d Although some sources have pegged the annual costs of overtreatment and low-value care at $75 billion to $101 billion, the center calculates them at more than $345 billion, a sizable chunk of the overall systemwide waste.

Case example: Excessive spending on low back pain

A classic, costly example of low-value care is diagnostic imaging for low back pain, less than 5% to 10% of which is due to a specific spinal pathology.^e Low back pain has been described as the leading cause of disability worldwide and among the most common reasons U.S. patients visit physicians.^f Routine diagnostic imaging in response to a very non-exotic condition well illustrates how insidiously low-value care can stretch its costly tentacles throughout the healthcare system, triggering other high-priced interventions along the way.

Low back pain and its treatment have been studied extensively, and multiple clinical guidelines recommend against routine imaging, favoring other approaches. There is clear consensus that “most patients with acute or subacute low back pain improve over time regardless of treatment” and that heating pads and massage can be effective responses.^g Imaging is only deemed necessary in the small subgroup of patients where there is suspicion of red-flag conditions such as cancer, infection, inflammatory disease, fracture and severe neurological deficits. 

That consensus should have shut the door on routine back pain imaging long ago, and although there is some evidence it has decreased recently, it is far from gone. One study calculated that imaging resulted in 16% of encounters in which patients ages 18-64 presented to a primary care provider with low back pain in 2016.^h  Nearly 13 out of every 100 Medicare beneficiaries underwent imaging for low back pain in 2018, at a cost of $263 million.ⁱ Imaging prices vary substantially as well, with employer-sponsored insurance plans paying more than three times Medicare rates for standard X-rays in hospital outpatient departments.^j

Unnecessary imaging can cause harm from even modest exposure to radiation, but even more egregious is the “treatment cascade” that can follow a diagnostic intervention, such as equally unnecessary surgeries. The nonprofit Lown Institute recently identified 200,000 instances of low-value procedures such as spinal fusion/laminectomies, 14% of which it said met criteria for overuse, accounting for more than $2 billion in wasted Medicare spending at U.S. hospitals from 2020 through 2022.^k

Action needed to counter low-value care

There is evidence suggesting that, in some contexts, clinical practice can be changed to diminish low-value care. One recent study showed that simple “nudges” in electronic health records across a large safety-net health system reduced lumbar X-rays by nearly 53% in inpatient settings, 24% in ambulatory settings, and 17% in emergency departments, while also reducing CT and MRI scans.^l

But what would it take to motivate more action against low-value care, with greater public outrage as a powerful tailwind to prompt far broader policy change?

One obstacle is that the costs of wasted care are diffuse — borne in higher taxes or premiums for hundreds of millions of individuals — while the benefits accrue to a relatively small number of suppliers.

Solutions have been suggested, but not all seem plausible. For example, David Goldhill, a business executive who writes about health policy, has long inveighed against insurance as the cause of the disconnect, and suggests broadly scaling back health insurance coverage to let the markets guide prices and purchasing decisions.^m But it’s unlikely that can happen anytime soon.  

Far more sensible would be to encourage the spread of two-sided risk payment models that place providers at risk for the quality and costs of healthcare and inescapably force them to find ways to weed low-value care out of the system.ⁿ

Another approach would be to harness lessons from the modestly successful Choosing Wisely campaign (choosingwisely.org), launched in 2012 by the American Board of Internal Medicine Foundation, and which formally ended in 2023 (although international offshoots remain active). Choosing Wisely’s key first step was transparency: having specialty societies publicly identify at least five routinely performed interventions that they already knew should not be done.

A far broader transparency effort across all aspects of healthcare — providers, payers, patient groups and key government programs such as Medicare — is needed to vastly increase efforts to identify all instances of low-value care, with their attendant costs and resulting patient harms. Coupling clinical guidelines with data from the 25 states with all-payer claims databases to help identify physicians and hospitals practicing low-value care could be one place to start.^o

A crucial charge for the new administration — and for everyone

What else would it take to fan public outrage about low-value care? Here’s a thought: If the Trump administration’s proposed Department of Government Efficiency wants to sink its teeth into something productive, it could ramp up efforts to ferret out low-value care in Medicare, Medicaid and other government-funded  areas of healthcare. Such efforts could help underscore that the “problem” in this respect isn’t government spending per se; the problem is waste in the healthcare system for which everyone eventually foots the bill. And just imagine the outrage-inducing X posts that could follow. 

Footnotes

a. Chance, Z., Influence is your superpower: The science of winning hearts, sparking change, and making good things happen, Random House, 2023.
b. Gallup,  “Healthcare system,”  Trends A-Z, page accessed Jan. 17, 2025.
c. Shrank, W.H., Rogstad, T.L., Parekh, N., “Waste in the US health care system: Estimated costs and potential for savings,” JAMA, Oct. 15, 2019; and McGough, M.,
et al.,  “How much is health spending expected to grow?” Peterson-KFF Health System Tracker, Oct. 7, 2024.
d. Center for Value-Based Insurance Design, “Reducing utilization of low-value care,” page accessed Jan. 14, 2025.
e. Hall, A., Aubry-Bassler, K., Thorne, B., and Maher, C.G., “Do not routinely offer imaging for uncomplicated low back pain,” The BMJ, Feb. 12, 2021.
f. World Health Organization, “Low back pain,” fact sheet, 2024.
g. Qaseem, A., et al., “Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians,” Annals of Internal Medicine, Feb. 14, 2017.
h. Pakpoor, J., et al., “Diagnostic imaging use for the initial evaluation of low back pain by primary care providers in the United States: 2011-2016,” Journal of the American College ofRadiology, November 2019.
i. Medicare Payment Advisory Commission, A data book: Health care spending and the Medicare program, July 2021.
j. HCCI staff, “On average, ESI pays nearly 3 times Medicare for hospital outpatient services,” Health Care Cost Institute, Dec. 14, 2023.
k. Lown Institute, “Unnecessary back surgery: Older Americans put at risk while billions in Medicare funds wasted,” video, Nov. 14, 2024.
l. Tsega, T., et al., “Imaging Wisely campaign: initiative to reduce imaging for low back pain across a large safety net system,” Journal of the American College of Radiology, January 2024.
m. Goldhill, D., “Insurance is what makes U.S. health care prices so high,” The Washington Post, Dec. 26, 2024.
n. Boudreau, E., Schwartz, R., Schwartz, A.L., et al., “Comparison of low-value services among Medicare Advantage and traditional Medicare beneficiaries,” JAMA Health Forum, Sept. 9, 2022.
o. Baron, R.J., Lynch, T.J., and Rand, K., “Lessons from the Choosing Wisely campaign’s 10 years of addressing overuse in health care,” JAMA Health Forum, June 24, 2022.