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“With policy adjustments, healthcare systems are better supported to reduce low-value care by addressing these factors.^17,26-28 For example, moving from pay for performance toward other payment structures, such as capitation or paying for quality instead of quantity can remove the pressure on clinicians to generate volumes.²⁹ Most physicians in the United States and Canada receive a fee for service, while in the Netherlands, half of the specialists is salaried and general practitioners receive a capitation fee per registered patient. The United States is trying to shift towards value-based payment.³⁰ The predominantly capitated National Health System in England,³¹ and no longer reimbursing care in Canada¹³ have shown to reduce low-value care use. In addition, local strategies such as global budgets for hospitals,³² a fixed budget contract between hospital and insurer and fixed income for specialists,³³ and a cost accounting and shared savings program34 have potential to reduce low-value care.”

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“Echocardiography was consistently overused, for instance in ‘routine perioperative evaluation of ventricular function with no symptoms or signs of cardiovascular disease’, whereas other tests (urinary cultures, upper endoscopy and colonoscopy) were overused at varying rates. The overuse of echocardiography was studied in the UK⁵¹ and the Netherlands.⁵² The rates of overuse varied between the two settings: between 77% (Netherlands) and 92% (UK).”

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“With clinicians incentivized to do and bill for more, some focus efforts on protecting the viability of their jobs and their specialty. Some, however, even in light of these barriers advocate for the reduction of low-value care. For example, a Choosing Wisely recommendation from the Netherlands aims to reduce unnecessary x-rays for acute abdominal pain. One expert observed that this was resisted due to the risk that it may lead to several radiologists losing their jobs. Depending on the payment structure, generating revenue is sometimes not a direct factor for clinicians, but an indirect factor through the managers who want to maintain organizational financial health. Also, there exist risk that low-value care can increase when new care practices, especially new technologies, are reimbursed before the cost effectiveness is evaluated.”

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“Several Dutch experts suggested that malpractice lawsuits are less frequent in the Netherlands, possibly because the claims are lower, and therefore there might be less defensive medicine. According to the experts, it is not only the lawsuit but also the fear of making a mistake and having dissatisfied patients that motivate clinicians to overuse tests, procedures, or treatments.”

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“Studies confirm that malpractice concerns are a reason to provide low-value care.^22,24,25,38 As the experts in this study suggested, the Netherlands has a high claim rejection rate and relatively low payments compared to other countries.³⁹ Nevertheless, Dutch physicians still experience fear of complaints.⁴⁰“

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World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems and policies in the US and sixteen other nations.

Page last updated August 8, 2025 by Doug McVay, Editor.