The Medical Professionalism Blog

Recent reports of the shortage of Ritalin for individuals who suffer from Attention Deficit Disorder made me think of the effects overuse has on the quality of care provided.

According to a Dartmouth Atlas report, overuse results in:

• worse access
• lower patient satisfaction and
• poorer outcomes.

The authors also note that “disorganized, poorly coordinated, and inefficient care… results in the underuse of effective medical interventions and the overuse of physician visits, consultations, hospitalizations and stays in intensive care units, particularly in treating chronic illness.” (my italics)

Overuse is as much a quality and value issue as it is a cost issue.

That brings me to the theory of bad gold driving out good gold. Gresham’s law is the observation in economics that “bad money drives out good.” More exactly, if coins containing metal of different value have the same value as legal tender, the coins composed of the cheaper metal will be used for payment, while those made of more expensive metal will be hoarded or exported and thus tend to disappear from circulation. Gresham was not the first to recognize this monetary principle, but it was his elucidation of it in 1558 to explain to Queen Elizabeth I what was happening to the English shilling that brought it to light.

It follows then, that when health care is overtaken by overused services, appropriate services are more difficult to deliver because capacity is full. When health systems decrease overuse, they free up access to their system and thus provide higher quality care. 

With 30 million people estimated to receive coverage under the Affordable Care Act with increased access to care, it is more imperative than ever to rid the system of overused services so the current number of physicians, ambulatory clinics and hospitals can deliver the appropriate, high value care to patients and their families.