Low-value care, or patient care that provides no net benefit in specific clinical scenarios, remains one of the most pressing problems in healthcare across the world—namely because it raises costs, causes iatrogenic patient harm, and often interferes with the delivery of high-value care. Many have argued that above all else the primary cause of low-value care lies in an unchecked fee-for-service payment system, which creates a pervasive culture that rewards providers for delivering more care, not necessarily the right care. Results reported by McAlister et al in this issue of BMJ Quality & Safety seem to up-end this belief.1 In their analysis of 3.4 million beneficiaries in the globally-budgeted health system of Alberta, Canada, they found that low-value care commonly occurred—at a rate of approximately 5% of beneficiaries seeking care, and as high as 30% among those aged >75 years. Notably, these rates are comparable to rates in America’s largely unrestrained fee-for-service system for both commercially insured (~8%) and older Medicare beneficiaries (~25-42%) seeking care, even while McAlister and colleagues used fewer low-value care measures (10) than the latter two American studies (28 and 26 respectively).2 3 Moreover, similar to the USA, the extent of the problem also varied substantially across frequently presumed examples of overuse. For instance, carotid artery imaging in adults without symptoms of cerebrovascular disease occurred in only 0.3% of patients, whereas 55.5% of men 75 years or older without a history of prostate cancer underwent prostate-specific antigen testing.

Although both Canadian and US physicians operate in fee-for-service payment models, Canadian physicians practice within a broader system of strict global budgets for hospitals and regional health authorities.4 Such financial restrictions may reduce the overall volume of certain services: for instance, researchers found higher overall rates of CT utilisation in the USA compared with Canada.5 While global budgets …