When less health care makes sense

One seemingly contradictory notion in health reform, which generally aims to improve everyone's access to health care services, is that in most medical situations, less is actually more. I've written previously about why it may be better to "just say no" to blood tests that you don't really need. Recently, Forbes.com published an article that highlighted several medical tests or procedures that doctors commonly provide, but probably have no health benefit compared to no treatment or safer, less expensive therapies. I list these below, with links to some relevant scientific articles and guidelines:

1) Vertebroplasty for spinal fractures from osteoporosis

2) Minimially invasive ("robotic") surgery for prostate cancer

3) Continuous fetal heart rate monitoring during labor

4) Coronary artery disease screening

5) Excessive high-tech (CT) imaging

6) Newer drugs for schizophrenia (remember my mental health success story? That patient likely would have done just as well taking an older, cheaper drug with fewer side effects)

7) Hospitalizations for syncope (fainting spells)

8) Spinal fusion for back pain

9) Knee arthroscopy for arthritis

The Forbes article suggests that as much as $650 billion of the United States's $2.5 trillion annual health care expenditures are probably unnecessary; other experts, such as the New America Foundation's Shannon Brownlee, suggest that the tab could be even more. (If you want to read more about this issue, I strongly recommend her book Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.)

If these therapies don't work, then why do doctors keep providing them, and insurers, for the most part, keep paying for them? Are they just not familiar with the evidence? Do they have some ulterior financial motive? Or is there something else going on here? What do you think?