December 1, 2016
One third of spending on "low-value" pediatric health care is paid for out of pocket.
In 2014, more than 140,000 children in the United States were given oral antibiotics for an upper respiratory tract infection. Probable benefit: little or none, perhaps even some harm. Almost 55,000 children were screened for low vitamin-D levels, again with minimal gain, since taking supplements is easier and cheaper than screening. Health care professionals recommended cough and cold medicines for 42,000 young patients, to no avail. They also prescribed acid blockers for 30,000 infants to prevent them from spitting up – something that healthy infants do multiple times a day.
"As long as your baby is healthy, content and growing well," according to the Mayo Clinic's health website, reflux should not be "a cause for concern."
Academic pediatricians euphemistically refer to these treatments as "low-value services." They seldom, if ever, improve child health. They may do damage, sometimes significant harm.
Unnecessary antibiotics, for example, can disrupt a healthy microbiome and trigger various side effects, such as enabling the growth of dangerous antibiotic-resistant organisms. Early exposure to antibiotics has been linked to obesity, asthma and celiac disease. Unnecessary imaging can detect irregularities that may never become problems. The radiation involved, although minimal, can slightly increase the long-term risk of radiation-induced cancers. And, most of these interventions, whether effective or not, come at a hefty cost.
In their paper, "Use of Low-Value Pediatric Services among the Commercially Insured," published November 28, 2016 in Pediatrics, health policy researcher Kao-Ping Chua, MD, PhD, and colleagues Anna Volerman, Rena Conti and Elbert Huang plus Aaron Schwartz from Harvard – estimate that in 2014, the families of 4.4 million children with commercial health insurance spent $27 million on 20 low-value services. One-third of that cost was paid, out-of-pocket, by the families.
"The services we assessed are not just expensive for the health care system," Chua said "They also can cause physical, emotional, and financial harm to children and their families."
A commentary accompanying their paper, submitted by pediatricians Ricardo Quinonez of Baylor College of Medicine and Eric Coon of the University of Utah School of Medicine, agreed that reducing wasteful care is crucial to avoid harm.
"How many pediatric cancers," they asked, "are contributed to the population as a result of unnecessary radiation exposure to evaluate headaches, seizures and sinus symptoms?"
They found an answer, a 2012 paper published in the Lancet, that estimated one excess brain tumor and one excess case of leukemia for every 10,000 scans of children under age 10.
How they got to 10 percent
There are far more than 20 low-value pediatric interventions to choose from, but the researchers – using sources such as the U.S. Preventive Services Task Force and the ABIM Foundation's Choosing Wisely initiative, designed to help patients chose care that is truly necessary – picked six diagnostic tests, five imaging tests and nine prescription drugs.
Then they turned to the 2014 Truven Market Scan Commercial Claims and Encounters Data base, which includes health care claims from 12 million U.S. children. Not all of these children had sufficient billing information. That narrowed the pool down to 4.4 million children – about 12 percent of all commercially insured children in the country. About 29 percent of the 4.4 million were aged 0 to 5 years old, 36 percent were 6 to 12 and 35 percent were 13 to 18.
Next Chua and colleagues looked to see how many children received low-value services during 2014. They found that almost ten percent (9.6%) of the children in the study received at least one of the 20 low-value services selected by the study authors.
"The fact that we demonstrated frequent overuse despite using a limited number of measures suggests that waste in pediatrics may be widespread," Chua said.
Of the 4.4 million children in the study, about 4 percent received a low-value diagnostic test, about .5 percent had a low-value imaging test, and 6 percent received a low-value prescription drug.
Although overuse of low-value imaging tests was infrequent, affecting less than one-half of one percent of children in the study, these tests nevertheless had a real impact on the bottom line. They accounted for almost 27 percent of out-of-pocket spending and almost 34 percent of all spending on low-value services.
"Our study shows that children are at high risk for receiving unnecessary and potentially harmful care", Chua said. "Ultimately, pediatric providers are the gatekeepers to overuse, so we need to develop interventions that target the factors that drive their decision to provide low-value care."
The damage caused by low-value interventions "should resonate the loudest for pediatricians," Quinonez and Coon suggest. Denying payment for such costly and minimally helpful services "may not only be justified," they wrote. It is "arguably a moral imperative."