Avoiding the Unintended Consequences of Growth in Medical Care

GROWTH IS A MAJOR FEATURE OF American medicine. Over the course of this century, the proportion of the economy devoted to medical care has more than quadrupled. TABLE 1 details this growth over the past 2 decades. Price-adjusted spending on hospital and physician services has doubled, while spending on home health care has increased more than 10-fold. The number of physicians per capita has increased by 50%, while the number of cardiologists has doubled and the number of radiologists has increased 5-fold. Differences of a similar magnitude are found across US communities. Although medical care has obvious benefits, many assume that more medical care must lead to improved health and well-being. There are theoretical reasons, however, to believe that additional growth will be associated with progressively smaller returns (FIGURE 1). The law of diminishing returns also suggests that at some point additional growth will yield no benefit (the “flat of the curve”). And while the debate about where we sit on the curve is far from settled, the theory suggests that there is some point at which additional growth might actually produce harm. Although harm may be more likely in theory, such a broad generalization provides little guidance. In this article we explore how harm might occur. Our aim is both to stimulate discussion and, where possible, to provide guidance about how to avoid the unintended adverse consequences of growth. The first section highlights 2 distinct levels at which more medical care may be introduced, both of which will require attention if we are to minimize the risks of harm. The second section focuses on the mechanisms whereby harm may occur. In the third section, we turn to the fundamental challenge—reducing the risk of harm from more medical care. MORE MEDICAL CARE— 2 LEVELS OF ANALYSIS More medical care can be introduced at 2 distinct levels: discrete and systemic. Discrete clinical decisions entail choices to adopt in practice a specific diagnostic