to support an estimate of 8% ($210 billion) in unnecessary services, without explaining the discrepancy. This IOM 2012 report also said there were $555 billion in other wasted spending, which have an "unknown overlap" with each other and the $210 billion. The United States National Academy of Sciences estimated in 2005, without giving its methods or sources, that "between $.30 and $.40 of every dollar spent on health care is spent on the costs of poor quality," amounting to" slightly more than a half-trillion dollars a year... wasted on overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency. In 2003 Fisher et al. found that there was "no apparent regional health benefit for Medicare recipients from doing more, whether 'more' is expressed as hospitalizations, surgical procedures, or consultations within the hospital." Up to 30% of Medicare spending could be cut in 2003 without harming patients. When care is overused, patients are put at risk of complications unnecessarily, with documented harm to patients from overuse of surgeries and other treatments. Causes Physicians' decisions are the proximate cause of unnecessary care, though the potential incentives and penalties they face can influence their choices. Third-party payers and fee-for-service When public or private insurance cover expenses and doctors are paid under a fee-for-service (FFS) model, neither has an incentive to consider the cost of treatment, a combination that contributes to waste. Fee-for-service is a large incentive for overuse because health care providers (such as doctors and hospitals) receive revenue from the overtreatment. Atul Gawande investigated Medicare FFS reimbursements in McAllen, Texas, for a 2009 article in the New Yorker. In 2006, the town of McAllen was the second-most expensive Medicare market, behind Miami. Costs per beneficiary were almost twice the national average. In 1992, however, McAllen had been almost exactly in line with the Medicare spending average. After looking at other potential explanations such as relatively poorer health or medical malpractice, Gawande concluded the town was a chief example of the overuse of medical services. Gawande concluded that a business culture (physicians viewing their practices as a revenue stream) had established itself there, in contrast to a culture of low-cost high-quality medicine at the Mayo Clinic and in the Grand Junction, Colorado, market. Gawande advised: Medical malpractice laws and defensive medicine To protect themselves from legal prosecution U.S. physicians have an incentive to order clinically unnecessary tests or tests of little