Excess Medical Care Spending: An Opportunity but a Communication Challenge

Speer et al. (p. 1743) helpfully document the magnitude and describe major categories of wasteful spending in US health care. Although they rightly note that a lack of political will poses a barrier to change, they argue that changing public awareness of the magnitude, scope, and typologies of this waste could help “catalyze health system transformation” (p. 1743) to promote a more equitable allocation of beneficial resources to other high-priority needs. Although these goals are laudable, several communication-related barriers are likely to impede public acceptance of the concept of medical care waste, their understanding of the scope of the problem, and their advocacy for broader change. Successful strategies to shift public understanding of wasteful medical care spending will need to acknowledge and respond to these (nontrivial) communication challenges. We offer thoughts on strategies and opportunities to address them.

An overarching challenge is that most people think about health and health care in individualistic ways. This tendency may be driven by fundamental psychological tendencies (a bias toward blaming problems experienced by others, including health outcomes, on individual traits or behaviors rather than systemic or environmental forces) and the broader value of individual responsibility that permeates US ideology. This is also true when it comes to how people think about health care, which people tend to conceptualize as an individual good that their doctor provides and insurance pays for (if they are so lucky to be insured). They think about the problem of health care costs as what they actually pay from their pocketbook, not the costs to the health care system or to society at large.¹ These experiences with the health care system are concrete and tangible. Categories of wasteful spending are abstract and are of such a magnitude (hundreds of billions of dollars) that they seem far removed from lived experience.

To counter such individualistic interpretations of health and health care, successful efforts to increase awareness of systemic, wasteful health care spending will likely need to “scale up” by explaining how individual experiences with the health care system translate into larger patterns of cost and waste. This might be accomplished by starting with an experience that many people have (e.g., receiving a health care bill that seems excessive) and connecting that experience with the larger system of actors and processes that produce it (e.g., how providers bill for services and why this can differ dramatically by insurance coverage).

Another related challenge involves communication about health care service overutilization, the largest category of wasteful spending that Speer et al. identify. Public understanding of the value of medical care does not come from evidence alone, or even predominantly. People interpret the value of medical care services through their cultural, emotional, and narrative experiences with services. Here, another dominant public belief in the value of medical testing and procedures looms large. For example, health officials have long touted the importance and value of early screening and detection as well as of preventive well visits. More recent evidence, however, has raised critical concerns about the risks and benefits of many screening tests as well as the value of some common services many Americans have grown accustomed to receiving, including antibiotics for viral infections, imaging for low back pain, and annual well visit exams for adults. Research demonstrates that it is difficult to convince patients to forgo these types of services.²

This places doctors, policymakers, and advocates of eliminating wasteful spending in a bind: patients desire routine services they have come to expect over time that may be categorized as wasteful spending in light of limited evidence of efficacy, and these pressures occur amid a backdrop of patient empowerment and strong cultural beliefs in the power of screening, detection, and prevention. Moreover, public opinion research suggests that people understand the problem of health care costs mainly as one about too high prices, not about overutilization, and the very idea of overutilization of care requires a population-level, systems perspective that is difficult for people to grasp.¹ There is also evidence that people are psychologically inclined to resist messages they interpret as requiring them to give something up.³ Using less care—even if wasteful—is likely to sound like a demand to relinquish something of value and may lead to a broader concern that this constitutes rationing of care.

Effective communication to generate public will in support of reducing health care service overutilization will likely require considerable effort to reframe these discussions away from what is lost by eliminating procedures or tests. Instead, there would likely be value in emphasizing both health risks of unnecessary medical services,² as well as the larger picture of what could be gained by the resources that are saved and redistributed to high-value interventions outside the realm of health care, including college tuition, universal child care, and wage replacement for family leave, as Speer et al. note. Such reframing nevertheless raises the additional challenge of making the complex case for how these social interventions and policies, those that are not traditionally conceptualized as related to health and health care, influence people’s health and well-being across the life course. This is a very difficult task that has proven elusive to date.

A third noteworthy challenge lies in the fact that broad social changes, of the magnitude required to dramatically reduce wasteful spending in health care, historically benefit from a clear identification of an adversary or villain.⁴ Take, for example, the public health success in massive reductions in cigarette smoking that have been achieved across the past 50 years in the United States. The vilification of the tobacco industry as dishonest, manipulative, and greedy at the expense of public health has likely contributed to large-scale changes in the social and political acceptability of tobacco and the tobacco industry. Complex, systemic problems like wasteful health care spending implicate numerous potential villains that include doctors, hospitals, insurers, health administrators, pharmaceutical companies, and even governments themselves. All of these actors play some role in wasteful spending. At the same time, as COVID-19 ravages US communities, the public has relied on life-saving medical professionals, mobilization of hospital resources, and (at least the hope for) pharmaceutical companies to produce vaccines. There is no obvious entity for the public to vilify and rally in opposition to advocate large-scale change.

There are some signs of hope, however. As noted earlier, rising health care costs are widely shared and bipartisan concerns. Pre–COVID-19 surveys demonstrated high public concern with rising and unsustainable health care costs (including cost sharing, premiums, and burdens on businesses).² Bridging these shared concerns with excess medical care spending has promise if experts can link solutions to the costs of wasted medical care to individuals’ own expenses and experiences. Yet, health care reform is among the most politicized topics of the past decade, with partisan disagreements about the role of government in shaping health care access, quality, and costs.⁵ Clear and vocal champions for reducing wasteful medical spending from both political parties will be essential to move these discussions beyond partisan politics to meaningful action. Further, finding credible messengers from outside public health, including physicians (given their existing level of public trust on these topics)⁶ and other community leaders, will be essential to shifting public will toward addressing unnecessary medical spending.