Scott Hensley, NPR News, Author at �鶹Ů�� Health News

Trump Health Plan Recycles GOP Staples And Adds A Populist Wrinkle

Scott Hensley, NPR News — Thu, 03 Mar 2016 19:10:03 +0000

Republican front-runner Donald Trump released a seven-point plan to change the country’s health care system that includes several familiar GOP proposals and one that puts him in agreement with, believe it or not, Democratic hopeful Bernie Sanders.

Right off the bat, Trump calls for the elimination of the Affordable Care Act, ringing the repeal bell that has been popular among a wide swath of Republicans and that has fueled dozens of votes to overturn Obamacare in Congress, including another .

The prime target is the individual mandate, the requirement that almost every American have or buy health insurance — or pay a penalty. “No person should be required to buy insurance unless he or she wants to,” the Trump proposal declares.

Obamacare relies on the mandate to make sure it isn’t just the sick and people at high risk of getting sick who buy coverage, driving up insurance costs.

While Trump decries the mandate, the . The mandate was seen as a market-friendly alternative to a national health system or a strict requirement on employers to provide coverage.

Still, the mandate and its associated tax penalties for people who don’t comply has become a lightning rod for people dissatisfied with the Affordable Care Act. In 2014, the first year that the fine for lack of coverage was in place, about 7.5 million Americans for not having insurance according to the IRS. In 2015, to greater of 2 percent of annual income or $325 per adult. And this year they rise again to the greater of 2.5 percent of income or $695 per adult.

In a second plank, Trump calls for the sale of health insurance plans across state lines to bolster competition by increasing the number of policies being sold. Health insurance is regulated largely at the state level. And critics of the multistate approach, a for years, say it would erode consumer protections.

Trump hedges his call for multistate plans by saying they would have to comply with regulations in each state where they are offered. It’s hard to see how, if states continue to regulate insurance differently, the theoretical benefits he touts could be achieved in practice. In fact, over the years six states, including , enacted laws to encourage insurance sales across their borders and a Georgetown University analysis found that they into their markets.

Some Trump proposals would change the tax treatment of health coverage.

One would let individuals who buy insurance deduct its cost, as employers do for coverage they make available to workers. Many health economists argue that the opposite tack — — would be more beneficial. The employer tax break obscures the cost of health coverage and thereby contributes to health cost inflation. The benefits from the break also tends to accrue to more highly paid people. Under Obamacare, people with low-to-moderate incomes can get a tax credit to help defray the cost of insurance purchased on marketplaces.

The second proposal argues in favor of letting individuals take advantage of Health Savings Accounts, or HSAs. But that’s something that is already possible, and the accounts are quite popular. Right now, those accounts are tied to high-deductible health plans.

“Is Trump calling for every American to have access to an HSA, not just those in high-deductible health plans (HDHPs)?” on Forbes.com by Ryan Ellis, an adviser on tax policy for the Conservative Reform Network. “That would seem to be undermined by his statement about how young people should want to enroll in high-deductible plans–why mention them at all?”

Then there’s the chicken-in-every-pot plank that would require providers of health care to disclose prices. “Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure,” the Trump proposal says. Not many people disagree with the intent. But it’s difficult to pull off in a way that help the average person shop. Health care prices are negotiated between insurers and providers, and people’s coverage and copays vary depending on their networks and insurance particulars.

Trump also argues for a change in financing Medicaid, the joint federal and state health insurance program for the poor and disabled. His plan calls for block grants, or lump-sum payments, to the states that they could spend as they wish. The idea has been popular with Republicans going back to President Reagan, has been as a way to cut costs and has been part of Republican proposals to repeal and replace Obamacare. Critics say block grants would and by shifting responsibilities to the states would ultimately saddle them with .

Finally, Trump throws his support behind the importation of drugs to cut costs. “Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers,” the proposal says. This is the one where Trump and Sanders have common ground. Sanders supports the importation of drugs from Canada and about a 1999 bus trip that took a bunch of Americans up north to get better deals.

The Food and Drug Administration, under both Republican and Democratic presidents, has opposed drug importation on safety grounds. And drugmakers restricted supplies of medicines to combat a rise in online pharmacy sales to Americans more than a decade ago.

�鶹Ů�� Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at �鶹Ů��—an independent source of health policy research, polling, and journalism. Learn more about .

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Medicare Budget Woes Coming Sooner Than Experts Thought

Scott Hensley, NPR News — Fri, 25 Oct 2013 18:57:18 +0000

This story comes from our partner

‘s Shots blog.

Americans are living and working longer than ever. And Medicare, the health plan that’s supposed to help senior citizens, is facing budget problems .

By 2023, about 70 million people will get health care paid for by Medicare, and their tab in that year.

So it’s no surprise that the idea of raising the eligibility age for Medicare to 67 from 65 keeps getting floated as a way to trim federal spending. “I don’t think you can look at entitlement reform without adjusting the age for retirement,” Republican Sen. Lindsey Graham of South Carolina, said late last year on . “Let it float up another year or so over the next 30 years, adjust Medicare from 65 to 67.”

And the Congressional Budget Office, the scorekeeper for federal finances, had that raising the eligibility age to 67 would trim about 5 percent from Medicare spending over the long haul.

Well, there is a problem, it turns out. Thursday, the CBO said the overall savings wouldn’t amount to as much as it had previously estimated. Instead of saving the federal government about $113 billion over a decade, CBO now figures it’s more like $19 billion over eight years starting in 2016.

What changed? Mostly it reflects a new analysis of how much 65- and 66-year- olds cost Medicare. To a lesser extent, CBO said, the federal government could be liable for more costs for those near-retirees under the federal health law.

The estimate is an important one, according to NPR’s Julie Rovner, because Republicans and some Democrats have long eyed the Medicare age change as a way to pay for deficit reduction. Now it’s a much less attractive target.

That’s an understatement, according to health economists Aaron Carroll and Austin Frakt, who blasted the idea — . Writing on The Incidental Economist blog, they called the change to save what amounts to less $3 billion a year “insane.”

Why is it so little? “Well, once again, the more people you kick [out] of Medicare, the more you get on Medicaid,” they wrote. “That increases federal expenditures. More people will also need exchange insurance, too, which means more people needing subsidies. That will also increase federal expenditures.”

In case you weren’t sure where Carroll and Frakt come out on this, the title of their post bears mentioning, “Raising the Medicare eligibility age is now a REALLY bad idea.”

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Medicare Data Show Wide Variation In Hospital Pricing

Scott Hensley, NPR News — Wed, 08 May 2013 16:58:52 +0000

This story comes from our partner

‘s Shots blog.

When it comes to health care, the biggest of the big data are all about Medicare.

So, it’s kind of a BIG deal when the government releases what individual hospitals charge Medicare — and what they actually get paid — for the most common diagnoses and treatments.

In a first, the Centers for Medicare and Medicaid Services .

A quick spin through the data shows that what hospitals in the same town or state charge for the same procedure is often very different. And, as previous studies of anonymized data have shown, there are big variations from one part of the country to another.

Now, it must be said, that what a hospital charges Medicare isn’t what the government pays. Medicare and private health insurers get discounts and don’t pay anything near the hospital rack rate. The uninsured may pay something closer to these master prices, though, because they don’t have bargaining power.

“If you’re uninsured, they’re going to ask you to pay,” , director of the Johns Hopkins Center for Hospital Finance and Management, .

But the Medicare data that were just released includes the amount of money the government actually forked over.

Take, Hartford, Conn., for instance, health insurance capital of the U.S. , the biggest one in town, charges a tad over $15,000 to treat a Medicare patient diagnosed with chest pain and receives $4,975 for the service. Little , in nearby Torrington, charges Medicare about $7,000 and receives $3,713.

Medicare pays teaching hospitals a little more to compensate them for that work. And hospitals in places with higher costs get more, too.

So, for the first time, anybody can get an idea of what their hospitals are billing Medicare for something and how much the government is paying. The database, such as it is, isn’t very friendly. But with the data now public, look for outsiders to make it easier to sort and analyze.

The Washington Post has already taken a crack at it. A handy lets you look at charges by state for some of the most common medical conditions, including heart failure, joint replacement and pneumonia.

So how useful is the information? If you’re a nerd, maybe quite useful. But the data are a slog.

�䲹��Ա𲵾��-�ѱ��ǲ�’��, a professor of economics and health policy applauds the move, while saying the numbers only tell us part of the story. “Charges are list prices,” he says. “They’re sticker prices.”

The data on what Medicare actually pays show less variation, and, he says, that’s expected, given that administrative formulas dictate the amounts. Data on what private insurers pay would help even more, and that’s something he’s working on through the .

Still, he says, there’s no harm and maybe some good to be had from the Medicare data dump. “Just sort of getting information out there, even if it’s not exactly what you want, it may have some use,” he says. “It may make hospitals think a little bit harder about what they’re doing.”

In some places, the details on charges could spark conversations or pushback about how well nonprofit community hospitals are doing at their public missions, he says.

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Federal Judge Strikes Down Restrictions On Morning-After Pill

Scott Hensley, NPR News — Fri, 05 Apr 2013 16:05:26 +0000

This story comes from our partner

‘s Shots blog.

A federal judge in Brooklyn, N.Y., has ruled that the morning-after pill for emergency contraception must be made available over the counter to girls 16 and under.

The ruling could end a more than decade-long battle over how easy or difficult it should be for teenage girls to obtain emergency contraception. The ruling would also make it easier for older women to obtain the drug because it wouldn’t have to be kept behind drugstore counters anymore.

The judge’s order effectively overturns a controversial 2011 by Secretary of Health and Human Services Kathleen Sebelius overruling the Food and Drug Administration. After years of study and internal debate, the that Plan B One Step should be allowed for sale without a prescription — and without age restrictions.

In the ruling dated April 4, Senior Judge Edward R. Korman of the Eastern District of New York held that Sebelius’s decision on Plan B was “arbitrary, capricious, and unreasonable.”

On page 47 of the 59-page decision, Korman skewers Sebelius’s decision, calling it “politically motivated, scientifically unjustified, and contrary to agency precedent ….”

He also slammed the FDA’s rejection of a so-called Citizen’s Petition dating to 2005 that argued for the agency to approve unfettered over-the-counter sale of Plan B. That rejection, he said, was a direct consequence of Sebelius’s ruling.

In the decision, Korman sends the Plan B case back to FDA with orders to make the morning-after pill “available without a prescription and without point-of-sale or age restrictions within 30 days.” If the agency decides the instructions for the drugs need tweaks, that’s OK.

When Sebelius essentially vetoed the FDA’s decision in late 2011, women’s health groups erupted in protest. “As doctors and researchers have repeatedly stated, ample research shows Plan B to be safe for women of all ages and appropriate for over-the-counter access. It is deeply disappointing that this administration would repeat the mistakes of the previous one,” said Susan Wood, an associate professor at George Washington University’s School of Public Health. Wood was an assistant commissioner for women’s health at the FDA but over its continued delay on over-the-counter approval for Plan B.

Advocates for Plan B kept up the pressure on the administration to reverse itself. They argued, in part, that the rules were just too complicated. “The unique dual-labeling of has led to confusion among consumers and health care professionals alike, particularly regarding age restrictions and whether men and women can purchase non-prescription emergency contraception,” said signed by more than three dozen women’s health, reproductive rights and individual providers of health care.

“A recent Boston University study of 943 pharmacies in five major cities revealed that, when called posed as 17 year olds seeking EC, one in five were told they could not purchase EC under any circumstances,” the letter said at the time. In fact, those 17 and older are eligible to purchase the product without a prescription; those 16 and younger may purchase it with a health provider’s written order.

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Why N.Y. City ER Doctors Won’t Write That Painkiller Prescription

Scott Hensley, NPR News — Wed, 06 Mar 2013 19:54:25 +0000

This story comes from our partner

‘s Shots blog.

Early this year, New York City Mayor Michael Bloomberg said public hospitals there would take steps to reduce overdoses and abuse of opioid painkillers.

“Faltered States” by Lisa Benson

The drugs have become a public health problem. Narcotic painkillers, such as Vicodin and Oxycontin, are involved in more than nationwide. A third of unintentional drug overdoses in New York City in 2010 .

So New York came up with for emergency room doctors to try to lower the risks.

Doctors who follow the advice will consider alternatives to opioids and prescribe only a few days’ worth of the drugs, if they decide that’s the best course for short-term pain relief. They’ll also avoid starting patients on long-acting opioids, like Oxycontin, and will refrain from replacing lost, or allegedly lost, opioid prescriptions without lots of due diligence first.

The steps strike some doctors as a common-sense way to rein in overuse of the drugs, though ERs are just one place, and not even the most important one, where patients get these prescriptions.

Will New York City’s latest public health push be copied elsewhere? Three doctors ��Ǵ��JAMA, the Journal of the American Medical Association, say it should be.

“Abolishing pain is a great idea,” says , head of clinical pharmacology and toxicology at the University of Toronto. But the options really are quite limited, says Juurlink, a co-author of the editorial, and the unintended consequences of aggressive pain treatment are real.

“The expectation that pain should be abolished is leading to prescribing of opioids often at doses that would have been unthinkable” only a few years ago he tells Shots. “While we can hope to eliminate pain, often what we can best do is lessen it.”

As the editorial put it:

“Many physicians and patients have had unreasonable expectations of opioids and have seriously underestimated their risks. It is time to collectively lower expectations and prescribe these drugs less readily, to fewer patients, at lower doses, and for shorter periods.”

Juurlink says the New York City move, and a similar push in Washington state, bear watching and repeating. “I think front-line family medicine and internal medicine physicians should get on this bandwagon and re-examine how readily we prescribe these drugs,” he says. “How we’re doing things right now is generally unsafe.”

Doctors didn’t mean to cause harm, he says. “This problem originated in many respects with well-intentioned physicians, and it will take well-intentioned physicians to move it back.”

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Need A Price For A Hip Replacement? Good Luck With That

Scott Hensley, NPR News — Tue, 12 Feb 2013 14:01:49 +0000

This story comes from our partner

‘s Shots blog.

Let’s say your 62-year-old granny is feeling creaky. One of her hips has been giving her trouble, and her doctor tells her it’s time to get it replaced with an implant.

There’s a catch. Grandma isn’t old enough for Medicare and she doesn’t have health insurance. She does, however, have a stack of cash in the bank and is willing to pay for surgery right away.

So how much will it cost her?

Who knows. Seriously.

called 20 top-rated orthopedic hospitals across the country using a script based on Grandma’s predicament. They asked for the lowest price (everything included) for a total hip replacement. The researchers also asked two other hospitals in each state and Washington, D.C., for good measure.

Getting an answer wasn’t easy. Of the top 20 hospitals, only 9, or 45 percent, provided a bundled price that included fees for both the doctors and the facilities.

But that response looks terrific compared with how the other hospitals did. The researchers were able to get a bundled price estimate from only 10, or about 10 percent, of the other 102 hospitals they queried.

The researchers were able to piece together prices in quite a few instances by contacting doctor groups when hospitals provided only their fees.

Even after incorporating those figures, however, total pricing information was available for only 60 percent of the top hospitals and 63 percent of the others.

The prices obtained varied widely: from a low of $11,100 to more than $125,000.

The findings were just by JAMA Internal Medicine.

Why couldn’t more hospitals comply? Some said a doctor would need to see a patient before an estimate could be given. Others said they didn’t give out prices over the phone. Some just said there was no way they could do it.

“Our calls to hospitals were often greeted by uncertainty and confusion by the hospital representatives about how to assist us,” the researchers wrote. “It is sobering to compare our experience with the best practices we have come to expect from other service industries.”

Buying a car used to be like this, an points out: “A 2013 hip replacement looks a lot like a 1954 Buick.” But a that required dealers to post sticker prices on vehicles began a long road to fuller disclosure about prices and specifications that have changed the marketplace for automobiles.

Now it’s time for hospitals and doctors to do a better job, the authors of the editorial write. “There is no justification for the inability to report a fee estimate, or a 12-fold price variation for a common elective procedure,” they declare.

As a matter of fact, they argue, the health care business is even worse off than the car business was. Many doctors and hospitals don’t know the price of their products, unlike car dealers.

Still, there’s hope, the editorialists say.

“The history of the automobile industry shows that information asymmetry is treatable,” they write. “Health care will need to travel down a similar path. It is time we stop forcing people to buy health care services blindfolded — and then blame them for not seeing.”

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Will Men And Their Doctors Change Course On PSA Tests?

Scott Hensley, NPR News — Wed, 23 May 2012 19:46:51 +0000

This story comes from our partner

‘s Shots blog.

The dust is nowhere near settled over advice that men of all ages should forgo a routine blood test to detect prostate cancer.

Gerry Roll says people don’t understand the health problems in southeastern Kentucky: “You can get whatever you need as far as traditional medical care goes. Yet we have the highest levels of chronic disease in the nation. So when I hear people talking about access to health care being a problem, I am livid.”

The harms, such as false alarms and unnecessary surgeries that leave some men impotent and incontinent, outweigh the benefits of the PSA blood test, according to the U.S. Preventive Services Task Force.

So the influential group this week against a regular PSA test.

To be sure, if doctor and patient want to go ahead with a PSA test, that’s OK, as long as there’s been a frank discussion about the pros and cons. “The decision to start or continue screening should be an informed one that re?ects an understanding of the possible bene?ts and harms and should respect an individual man’s preferences,” as a puts it in the Annals of Internal Medicine.

Love or hate the recommendations, will they stick?

Probably not.

Previously, for instance, the task force had recommended against PSA testing of men over 75. And, as the case of 81-year-old financier Warren Buffett’s case showed recently, that advice has not been universally heeded.

“I’m going to predict that people will continue to be unscientific,” , chief medical officer of the American Cancer Society, told a group of reporters and editors at NPR in Washington Tuesday. And, among other things, that means doctors will “continue to practice faith-based medicine” instead of one rooted in the best evidence, he said.

The latest guideline shouldn’t be such a surprise. The American Cancer Society has been saying since 1997 that the evidence for benefits from PSA screening haven’t been proved.

And even the American Urological Association, which over the task force’s latest advice, has acknowledged in :

“Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion.”

But habits haven’t changed, Brawley said, adding, “Nobody is listening to us.”

Ultimately, Brawley says men and their doctors need a better test than PSA, one that can detect prostate cancers that both can be cured and need to be cured. Many men with slow-growing prostate cancers will die of other causes.

For more on the fallout from the recommendation, on Twitter Wednesday featuring Brawley, Nancy Metcalf from Consumer Reports and urologist Deepak Kapoor. Liz Szabo, health reporter at USA Today, moderated the lively discussion.

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FDA Leans On Device Makers To Cut X-Ray Doses For Kids

Scott Hensley, NPR News — Wed, 09 May 2012 18:24:34 +0000

This story comes from our partner

‘s Shots blog.

The Food and Drug Administration has a proposition for the companies that make X-ray machines.

Make sure your new equipment has settings and instructions that minimize radiation hazards for kids, or the agency will look to slap a label on the machines that recommends they not be used for children at all.

Photo by Benjamin Deutsch via Flickr

The agency proposed the approach today (); it’s the latest move to curb radiation hazards from imaging equipment.

X-rays and CT scans can provide doctors with lots of useful information. But the radiation that creates the helpful images also increases a person’s risk for cancer. There’s been an explosion in the use of imaging tests. And , particularly from , have drawn concern.

The cancer risk increases with the dose of X-rays received during a person’s lifetime, so kids’ exposure is particularly important. It’s also the case that .

The FDA is also telling parents to speak up. If a doctor orders a test or procedure that uses X-rays, parents shouldn’t be afraid to ask if it’s really necessary. Also, it doesn’t hurt to ask if there’s an acceptable alternative, such as ultrasound or MRI, that doesn’t rely on X-rays.

Even so, the agency doesn’t want people to forgo needed X-rays. “The risk from a medically necessary imaging exam is quite small when compared to the benefit of accurate diagnosis or intervention,” Dr. Jeffrey Shuren, head of FDA’s Center for Devices and Radiological Health, . “There is no reason for patients who need these exams to avoid them.”

The agency scheduled a to talk about the proposal.

�ճ��, a trade group, said it looks forward to commenting on the FDA’s proposal and working with the agency.

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Pediatricians Recommend HPV Vaccination For Boys

Scott Hensley, NPR News — Mon, 27 Feb 2012 22:25:13 +0000

The leading group of U.S. pediatricians says it’s now time for boys, as well as girls, to be vaccinated against human papillomavirus.

The American Academy of Pediatrics has to parents and doctors in favor of routine immunization for boys against the virus.

Connor Perruccello-McClellan, a senior at Providence Country Day School in Rhode Island, has been vaccinated against HPV, something less than 1 percent of U.S. males can say (Photo by Richard Knox/NPR).

Previously, the group had said it was OK to vaccinate boys against the HPV, but it only became part of the pediatricians’ this month.

HPV can cause cervical cancer. And girls have been the prime focus for vaccination, though that has stirred controversy almost from the start.

But the sexually transmitted virus also causes genital warts and anal cancers. It’s also been implicated in the , though the HPV vaccines aren’t approved to reduce that risk.

The vaccine is most potent if given before the onset of sexual activity. Boys and girls should be vaccinated when they’re 11 or 12, the doctors say. Older boys and young men, ages 13-21, should get the vaccine, if they weren’t immunized earlier.

Last year, the Centers for Disease Control and Prevention , paving the way for the pediatricians’ decision. Immunizing boys against HPV can help curb the spread of the virus to girls.

Side effects, such as pain and redness at the site of injection, are generally mild.

The . Full immunization takes three shots (either with Merck’s Gardasil or GlaxoSmithKline’s Cervarix), which run about $100 or more each.

The cost-effectiveness of vaccination for boys is an issue. The recommendation notes that “a range of assumptions,” including the vaccination rates for girls, can affect how much each prevented case of illness costs. Still, the group concluded HPV vaccination would be worthwhile for boys and men up to 21.

In response to a question about potential financial conflicts, the American Academy of Pediatrics said that the members of its policy-writing committees have to provide disclosures to the group. “Neither Rodney Willoughby, the lead author of the HPV policy, or Michael Brady, the chair of the Committee on Infectious Diseases, had any financial disclosures,” a spokeswoman for the group told Shots in an email.

In Rhode Island, where HPV vaccination of boys has been common, there’s been no backlash, NPR’s Dick Knox . “There’s been a surprisingly muted reaction,” , a Brown University oncologist, told him. “We tend to believe that girls are chaste and are going to ‘save themselves for marriage.’ But, you know, sexual activity is something that’s almost expected of boys.”

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Shortage Of Research On When There’s Too Much Health Care

Scott Hensley, NPR News — Wed, 25 Jan 2012 16:02:29 +0000

This story comes from our partner ‘s Shots blog.

Photo by Images Money via Flickr

There’s little doubt that the U.S. wastes a lot of money on unnecessary health care. But pinning down the worst offenders isn’t easy, as a fresh analysis of the scientific literature finds.

Published research on overuse is in pretty short supply, so rooting out waste by looking at the existing studies can be a little like limiting your late-night search for lost car keys to the spots right under streetlights.

Still, you’ve got start somewhere.

And a group of researchers combed the literature, zeroing in on 172 papers (out of more than 114,000 relevant ones published between 1978 and 2009) to see where the evidence for overuse was strongest.

What did they find?

Improper use of antibiotics to treat upper respiratory infections (think colds and other viral infections) got the most scrutiny: 59 studies.

After that came a bunch of cardiology tests and treatments:

Coronary angiography (17 studies)
Carotid endarterectomy, or cleaning out the neck arteries that feed the brain (13)
Heart bypass surgery (10)

�ճ�� in the latest Archives of Internal Medicine.

Overall, the literature review revealed there’s not a lot to go on. “There are very few interventions that have been studied,” says , an internist at Mount Sinai School of Medicine and co-author of the analysis.

One reason, she tells Shots, is that it’s quite difficult to define what constitutes inappropriate use. The key factor for overuse is when the harms of the test or treatment exceed the benefits. In many cases, the standards aren’t clear.

There’s some evidence that use of antibiotics for viral respiratory infections has declined, she says, and that’s also true for some of the the overused heart procedures. All the more reason, she says, to get more serious about studying excess use of health care.

Screening tests are ripe for study. The number of people who get screened for various maladies, such as colon cancer, is so large that even a small amount of overuse can affect a lot of people, she says.

And there are examples that boggle the mind. Take, for instance, a that 10 million women in the U.S. were getting Pap smears for cervical cancer despite having had their cervixes removed.

“The fact there’s so much overuse when we looked at extreme cases suggest that it’s likely there will also be overuse when we look at gray areas,” Korenstein says.

Even when the data are present, it’s can be difficult to change behavior. “I think people have a hard time understanding that overuse is harmful. If a procedure is good then more of it must be better,” says Korenstein. “Attempts to stop overuse have come across as rationing and have not been received well.”

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