Table 3 System-level arrangements that contribute to overuse of health services

Delivery

• Limited training or preparation of clinicians to contribute to addressing overuse

• Most healthcare providers currently do not have the necessary skills to have the conversation regarding procedures that may be unnecessary or harmful to the patient

• Limited time with patients

• Healthcare providers continually state that time constraints with patients is a barrier for practicing shared decision-making and explaining the reasoning behind not ordering specific health services

• Fragmented delivery of services across the system

• Patient information may not be shared effectively across providers, leading to duplicate and unnecessary testing for patients leading to inefficient care

• Co-dependency of service delivery

• It is challenging to withdraw resources from one health service without affecting others which are supplemental or dependent on the service being withdrawn from

Financial

• Financing systems

• Many health insurance cost-sharing approaches are applied to all services, regardless of clinical benefit

• Identifying the correct balance within cost-sharing is difficult

• High out-of-pocket spending may reduce the use of high-value services, while low out-of-pocket spending may lead to the overuse of unnecessary services

• Remunerating clinicians

• Fee-for-service remuneration incentivises the provision of services, regardless of their value, and providers may be reluctant to reduce their use as their income will be negatively affected

• Physicians also lack incentives to ration services

• Purchasing products and services

• The use of financial ‘levers’ to address overuse is only helpful in specific contexts (e.g. withholding funding for specific health services that are harmful), and are far too simple to be used to address the overuse of services that may provide minimal or no benefit for certain subgroups, but that may benefit others, or that may be more expensive or cost-ineffective, but are valued by some patient subgroups

Governance

• Role clarity in the system

• Many providers do not see themselves as resource stewards and therefore often do not consider or discuss the financial implications of ordering various tests, treatments and procedures with patients

• Tension between autonomy and accountability

• While clinicians and organisations are given autonomy to decide which services are necessary, there is also a need for accountability measures to be put into place to enforce appropriate use

• Stewardship and authority

• Overlapping authority on different governmental levels make withdrawing from services difficult

• Leadership to tackle the issue may be lacking