Schlesinger, Mark and Rachel Grob (2017). Treating, Fast and Slow: Americans’ Understanding of and Responses to Low-Value Care. The Milbank Quarterly, 95: 70–116. DOI:10.1111/1468-0009.12246.
Policy Points: -Effectively addressing low-value care calls for engaging the public, including the one-third of Americans who currently cannot envision benefits from avoiding low-value care. -Public awareness of and response to low-value care can be enhanced through revised media messaging. These efforts are more effective if they emphasize health risks rather than the financial costs associated with unnecessary tests and treatments. -Long-term robust public support for addressing low-value care may require shifting the focus from particular tests and treatments to emphasize, instead, the potential for better communication and more personalized attention if clinicians spend more time talking and less time testing. Context: As much as 30% of US health care spending may be unnecessary. The Choosing Wisely campaign, now active in a dozen countries, addresses this problem in part through public education campaigns. This article explores Americans’ understanding of low-value care in 2015, assesses the impact of media messaging, and tests alternative message framing. Methods: We use a mixed-methods design incorporating (1) 8 focus groups exploring Americans’ understanding of and language for low-value care, (2) 48 intensive interviews with patients on their interactions with physicians regarding questions of cost and value, (3) a national survey of 920 respondents examining their awareness of low-value care, and (4) a survey experiment with 785 participants, testing the impact of media messages on attitudes about low-value care, treatment choices, and selection of a primary care clinician. Findings: One-third of Americans have difficulty envisioning benefits from avoiding low-value care, a figure that increases to half for less educated and minority respondents. Most Americans who anticipate benefits hope that less testing and treatment will be replaced by more interactive and personalized care. Even without media priming, many Americans would avoid common forms of low-value care like unnecessary antibiotics or excess imaging for lower back pain, but few favor clinicians who avoid these practices. Although the public's awareness and actions are increased and disparities are reduced by media messaging, conventional messages also exacerbate the blame placed on providers. Avoiding low-value care is enhanced, blaming providers is reduced, and disparities are further diminished if messages put more emphasis on the health risks of these tests and treatments. Conclusions: The public's awareness of low-value care is incomplete, with substantial disparities related to race, ethnicity, and socioeconomic status. Media messaging can help fill these gaps but, in the short run, would be enhanced by fine-tuning how low-value care is characterized. In the longer run, building robust public support for reducing low-value care may require refocusing attention away from specific tests and treatments and toward the relational benefits for patients if clinicians spent less time on testing and more time on personalized care.
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