US healthcare costs are unsustainable and a large amount of money is being wasted on unnecessary treatment.  There was general agreement about these statements among the audience, speakers and panelists at the recent Avoiding Avoidable Care conference, held in Boston. The summit was organized by the Lown Cardiovascular Research Foundation, the New America Foundation, and co-hosted by the Institute of Medicine.

One goal of the conference was to bring together clinicians and health policy leaders to discuss what drives unnecessary care. Is it defensive medicine, inappropriate patient expectations, or fee-for-service payment? Or might it be corporate interests? That was the view of panelist David Himmelstein, who suggested the problem was unlikely to get better “as long as you have large firms that can influence political processes.”

The sentiment was echoed by Dr Bernard Lown, peace activist and longtime advocate of conservative, low technology cardiovascular care, who called overtreatment “the illegitimate child of technology in an age of market medicine.”

He further suggested that “medicalization and overtreatment are an essential part of the “market system…withholding treatment from those who cannot afford it and overtreatment of those with means are profit maximizers.” He worried that “…we speak of overtreatment as if it were merely an improper financial transaction. It is more than that…”

Another goal of the conference was to discuss possible solutions to the problem, in particular how to change those aspects of medical and consumer culture that contribute to unnecessary treatment. Many ideas were discussed. Among them:

• Education to make new doctors more cost and value-conscious, including consideration of “a new Hippocratic oath” that would reflect a duty to society as well as the individual patient
• Shared decision making and better information for patients about treatment uncertainty and harms. “Fully informed patients trusting their physician do not insist on unnecessary tests,” said Dr. Lown.
• Payment systems that encourage frugality, such as Accountable Care Organizations  that receive a global fee for providing all care to a patient.

Himmelstein worried that Accountable Care Organizations are a “faith-based” solution to spiraling health costs without a “shred of evidence” that they can reduce unnecessary care. He expressed skepticism that tweaking payment systems, paying more for achievement of “quality indicators” or risk adjustment could produce improvements.

He warned of unintended consequences, saying research shows that paying people to do what is right actually erodes altruism: “Once you transform a moral duty into a financial transaction you can’t go back.”

The conference organizers pointed out that no organized group of medical professionals has yet emerged to tackle the problem of overtreatment and unnecessary medical care. Several speakers expressed the hope that this gathering was the start of such a movement, and pointed to encouraging signs that things are changing.  For example, the conference opened on the heels of the widely publicized Choosing Wisely campaign. This effort, led by the ABIM Foundation in conjunction with Consumer Reports was inaugurated by the release of “top five” lists from a number of high profile American medical specialty societies, each of which listed “five things that patients and physicians should question.” This initiative was framed as a way “to improve care and eliminate unnecessary tests and procedures.”

In speaking of the success of the Choosing Wisely project Christine Cassell, president of the American Board of Internal Medicine and the American Board of Internal Medicine Foundation, said “we’ve talked about this in the US for a long time but it feels different.” Judging by the attendance and enthusiasm at this conference, indeed it does.

Elizabeth Loder is US research editor, BMJ