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Overuse and Systems of Care: A Systematic Review

The Issue

Rising health care costs have focused attention on reducing the overuse of health care services, which, according to one estimate, accounted for up to $226 billion in unnecessary spending in 2011. Misaligned incentives and the fee-for-service payment system are thought to be significant drivers of overuse of health care.

What the Study Found

In their Commonwealth Fund–supported review of the published literature, the researchers found no consistent indication that any particular system of care or insurance ― whether fee-for-service or managed care ― has been more effective than another in minimizing overuse of health care services. For example:

  • In one study, there were similar rates of overuse of coronary angiography nationally in Medicare HMOs and in Medicare fee-for-service (about 13% for both).
  • In three studies comparing overuse in Veterans Administration hospitals with that in other care settings, researchers found antibiotic overuse was found to be similar in four cities across four VA and non-VA emergency departments, though higher in three VA emergency departments versus non-VA facilities. Rates of myocardial perfusion imaging, however, were similar in the VA and in private settings (22% vs. 16.6%). 


Despite an increased focus on overuse in recent years, “this attention has not translated into tangible investment in overuse measures,” the authors say. Given that the VA and managed care organizations have in the past successfully incorporated performance measures to reduce underuse of preventive care and improve chronic disease management, they should also be able to support efforts to reduce overuse “if relevant performance measures were developed and if national reporting created an incentive to decrease rates of overuse.”

Publication Details



S. Keyhani, R. Falk, E. A. Howell et al., “Overuse and Systems of Care: A Systematic Review,” Medical Care, June 2013 51(6):503–8.