Some medical services are unnecessary. Is it your first day of uncomplicated lower back pain? You don’t need an x-ray.
But many patients continue to receive such services anyway, perhaps because they demand them or, perhaps, because their providers keep recommending them. But does the likelihood of unnecessary services depend on your insurance?
Specifically, do Medicaid enrollees receive fewer unnecessary services than people with private insurance, because of the relative stinginess of Medicaid reimbursement? Or do they receive more, because people on Medicaid have more need or greater demands?
The answer is–yes and yes. Medicaid enrollees receive more of some unnecessary services and fewer of some other unnecessary services. That, at least, was what Christina Charlesworth and colleagues found when they studied people in Oregon. They assessed the frequency with which Medicaid enrollees and privately insured patients received 13 unnecessary services, things like imaging tests for uncomplicated low back pain and arthroscopic surgery for wear-and-tear arthritis of the knee. Overall, the rate of unnecessary services didn’t differ by insurance, but did differ for specific services. For example, Medicaid enrollees received more x-rays for low back pain and more head CTs for fainting spells, but they also received fewer x-rays for plantar fasciitis and fewer blood tests for low thyroid:
What’s going on here?
Well, if I understand the study correctly (a big if!), then the researchers could determine how likely people were to receive, say, imaging studies for lower back pain. That’s the first service in the figure, and it shows Medicaid enrollees receiving significantly more such imaging. But they couldn’t determine the likelihood of such imaging tests among people with low back pain. They can’t tell whether Medicaid enrollees simply had more lower back pain than privately insured patients or whether they had similar rates of lower back pain but simply received more imaging tests when they presented to clinicians with that complaint (or whether it was some combination of the two).
Perhaps figuring out the specifics of these differences doesn’t matter. The bigger issue: why are people with non-specific lower back pain still receiving imaging studies? Why are people with garden-variety sinusitis receiving CT scans? We need to stop paying for such services when it’s feasible and not too burdensome for practitioners.
The whole idea of expecting physicians to voluntarily reduce unnecessary services for the social good, while still paying them if they decide to order such services? That’s insane.