An excerpt from Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.

The American epidemic of unnecessary medical treatment is one of the reasons your health care costs keep going up. Experts estimate it’s wasting hundreds of billions of dollars a year. That’s not some number that’s detached from you and me. We pay higher monthly insurance premiums and larger deductibles because of all this care the system is providing that people don’t need. Examples are all around us. Many women still get annual cervical cancer testing when it’s recommended every three to five years. Healthy patients are often subjected to a battery of unnecessary lab work before elective operations. Surgeons perform spine operations when patients might be better off with physical therapy.

What are you supposed to do about unnecessary medical care? Well, sometimes there’s nothing you can do about it. If you’re undergoing emergency treatment or something urgent, there may not be time to check and make sure everything they’re doing is necessary. But that’s not true in many cases. Thus, any strategy to protect your paycheck and pocketbook needs to address how your money gets thrown away on things you don’t need. Every medical procedure or drug comes with physical risks, especially when it’s unnecessary. And it all comes at a cost — we waste money and contribute to higher medical costs for ourselves and others.

In this chapter, you’ll learn about the extent of the unnecessary health care treatment and how to avoid it yourself. I will share the key questions you can consider and pass along to your doctor to ensure you don’t undergo treatment that you may not need.

The health care system wastes obscene amounts of money — and it’s costing you

It’s rare for anyone to try and tally the precise cost of unnecessary care. But when they do, the estimates are staggering. The Washington Health Alliance, a nonprofit dedicated to making care safe and affordable, analyzed insurance claims from 1.3 million patients who received one of 47 tests or services that are considered overused or unnecessary. What they found should make patients and doctors rethink that next referral. In a single year, more than 600,000 patients underwent a treatment they didn’t need, costing an estimated $282 million. More than a third of the money spent on the tests went to unnecessary care, their study found.

Unnecessary medical care has “become so normalized that I don’t think people in the system see it,” Dr. Vikas Saini told me. Saini is president of The Lown Institute, a Boston think tank focused on making health care more effective, affordable and just. Lown researchers have shown how overtreatment happens across the spectrum of medical care. Doctors may push for Caesarean sections for their own convenience, not so moms and babies can be healthy. Breast cancer, prostate cancer and thyroid cancer get over-diagnosed, leading to harmful and costly treatment. Around a third of colonoscopies are unnecessary, research has shown. That’s not just wasting our money. It’s also putting us at risk of harm.

Many studies highlight factors that contribute to the problem. Doctors who take money from pharmaceutical companies are more likely to prescribe the pricey brand-name drugs manufactured by those same companies. Research has also shown that doctors who own their own magnetic resonance imaging (MRI) machines ordered substantially more MRIs on their patients.

Saini and his research colleagues put it bluntly: “Physicians routinely act in conformity with their financial interests.”

Saini also pointed out that the whole industry is pushing clinicians to do more, whether the patient needs the treatment or not. “Providers are getting constant messages from superiors or partners to maximize revenue,” Saini said. “In this system we have, that’s not a crime. That’s business as usual.”

This has been going on for so long because patients can hardly push back. They have a hard time shopping for care and often don’t have control over the care they receive, Saini said. The medical evidence may support multiple paths for providing care, but patients are unable to tell what is or is not discretionary, he said. Time pressure adds urgency, which makes it difficult to discuss or research various options. “It’s sort of this perfect storm where no one is really evil, but the net effect is predatory,” Saini said.

Another surgeon used a different saying to describe the motives behind overtreatment: “Doctors eat what they kill.” In other words, they get paid a fee for performing an operation or doing treatment or seeing more patients. No action, no payment. The industry makes its money by doing stuff — whether you and I need it or not.

In other words, doctors are just like the rest of us. If my publisher paid me a dollar a word for this book, trust me, you’d be getting “overtreated,” too. I might write a million words!

It’s hard to question your doctors when they are pressing a course of treatment. But these are conversations you should be demanding. You are the customer, so you have every right to assert yourself. Plus, you will get stuck with the bill, and it’s likely to be overpriced. So your time for action is now. You must prepare in advance so you can ask the right questions. Here are some of the key questions you can ask to avoid unnecessary care.

1. Ask the Choosing Wisely campaign’s five key questions to make sure you receive the tests, treatment, and procedures you need—and avoid ones you don’t.

• Do I really need this test or procedure or medication? Ask how what’s being recommended will specifically address what’s ailing you or your loved one.
• What are the risks? All drugs and treatment have possible side effects. What are they? What are the chances that test results will be inaccurate or inconclusive? Could those results lead to more testing or another procedure? Project the treatment plan forward and see how certain it is to lead you where you want to go.
• Are there simpler, safer options? Sometimes the treatment is more dangerous than the disease. Or, something like changes to your lifestyle or eating habits or exercise can have the same effect.
• What happens if I don’t do anything? Will your condition get worse — or possibly better — if you don’t do anything right away?
• How much does it cost? Often there are less expensive tests or treatments. Sometimes the treatment is cheaper if you don’t use insurance, so check the cash price. See if there are generic drugs instead of brand-name medication.

2. Consult the recommendations of the U.S. Preventive Services Task Force next time you are considering some type of medical treatment. The National Institute for Health and Care Excellence, known as NICE, performs a similar function in England.

3. Get a second opinion before agreeing to any costly or invasive treatment or any medication.

4. Ask your doctor or medical practitioner what I consider to be the single most important question before undergoing any treatment or test or agreeing to take any medication: “What happens, or what are the risks, if we wait?”

Marshall Allen is a journalist and author of Never Pay the First Bill: And Other Ways to Fight the Health Care System and Win.

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