Decreasing the Use of Healthcare Services

A number of actions can decrease the use of healthcare services; most of these involve limiting access. Insurance companies have done this by denying coverage to those likely to need care (for example, those with preexisting conditions) and by dropping coverage of, or refusing coverage to, the at-risk population. The Affordable Care Act has introduced provisions that have curbed these practices by insurance companies.
Payers may also increase out-of-pocket costs, providing economic incentives for patients to limit healthcare use themselves. For example, they may

  • Limit the type and number of reimbursed visits (for instance, mental health care or physical therapy)
  • Increase deductibles and copayments
  • Decrease allowable accounts for procedures
  • Establish or decrease maximum lifetime expenditures
    These strategies seem effective because evidence suggests that many patients avoid necessary care (in addition to unnecessary care). A woman, for example, may avoid screening (for example, a mammography) and subsequently present with late-stage cancer. By erecting administrative hurdles to healthcare—such as requiring approval for tests, referrals, procedures (including enrollment procedures) and regulations—payers are decreasing use by a small amount without technically denying care to employees.
    Be aware, however, that limiting access to healthcare can also present problems. For example, when people who are denied healthcare become seriously ill (which becomes more likely when routine care is insufficient), they are often treated in public hospital emergency rooms—but this is largely uncompensated and thus increases the burden on those who pay into the healthcare system at large. This scenario might prove more expensive than if routine care had been initially provided. This was a major selling point in favor of The Affordable Care Act.
    There have also been a number of attempts to eliminate unnecessary care. This is easy to define, as it applies to care that does not improve the outcome of a patient. However, it is often difficult to recognize, and therefore it is even more difficult to eliminate.
    The first step in this process is to conduct numerous and more extensive studies of comparative effectiveness, as well as cost-effectiveness, to identify the best practices. Comparative effectiveness studies can evaluate areas other than the use of drugs; this includes exercise and physical therapy, in addition to different providers, systems, settings of care, and reimbursement systems. Education and monitoring of providers may result in decreasing practice variation and increasing cost-effectiveness. Better service coordination among providers—because of closer communication and the use of universally readable electronic medical records—may make evaluation and treatment more efficient by eliminating the duplication of tests.
    An increased use of inexpensive preventive services, such as screening, diagnosis, treatment of diabetes, hypertension, and so on, may decrease the subsequent need for more expensive treatments later. Strategies to increase this type of preventative care include the following:
  • Incentives to increase primary care physicians who can provide appropriate screening measures and prevent complications
  • Pay-for-performance measures that reward adherence to preventive care guidelines
  • The elimination of copayments for preventative procedures
  • Outright free preventative services

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