Mason D. Choosing Wisely: Changing Clinicians, Patients, or Policies? JAMA Forum Archive. Published online December 3, 2014. doi:10.1001/jamahealthforum.2014.0048
As a nurse, I know to rely on primary care providers who understand my health risks and will talk with me about what tests and treatments I should avoid, as well as those I need. But what do people do who are not health professionals?
Diana Mason, PhD, RN
Choosing Wisely (www.choosingwisely.org), an initiative of the American Board of Internal Medicine (ABIM) Foundation, is designed to spark conversations among patients, physicians, and other health professionals about appropriate tests and procedures—those “supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” That sounds like common sense, but our system doesn’t always support a common-sense approach.
A May 2014 telephone survey of 600 primary care and specialist physicians, commissioned by the ABIM Foundation, found that 72% said that at least once a week, the average physician prescribes unnecessary tests or procedures; 47% said that patients request these services; and when the patient insists, even after a discussion of the low value of a test or procedure, 53% order it. (The survey used a random sample of physicians in the American Medical Association’s Physician Masterfile. No response rate was reported. The margin of sampling error was ±4.0 percentage points.) Choosing Wisely proposes that reducing these low-value services is the responsibility of both the clinician and the patient. But will relying on the good intentions of clinicians and patients be sufficient to reduce the use of unnecessary, costly, and potentially harmful services?
In 2012, the ABIM Foundation launched Choosing Wisely in partnership with 9 other national medical societies to identify “top 5 lists” of low-value tests and procedures—those that evidence suggests are ineffective, unnecessary, and possibly harmful. For example, the recommendations of the American Academy of Family Physicians include “Don’t require a pelvic exam or other physical exam to prescribe oral contraceptive medications.”
Subsequently, other national medical societies joined in identifying low-value services that should seldom be provided, along with organizations representing other health professions, including the American Physical Therapy Association and the American Academy of Nursing (for which I am the president). Choosing Wisely has partnered with Consumer Reports, which has published many of the recommendations and launched a website to keep the public aware (http://consumerhealthchoices.org). The ABIM Foundation has included links to online resources organized by test or treatment and developed an employer toolkit.
Choosing Wisely appears to be a necessary initiative. In fact, an analysis of Medicare claims data from 2006 to 2011 found that the prevalence of 11 services identified as unnecessary in the Choosing Wisely lists ranged from 1.3% to 46.5%, with a great deal of regional variation and a cost estimated at more than $1 billion annually. The most widely used was “preoperative cardiac testing for low-risk, non-cardiac procedures.”
Given that the United States spent between $158 billion and $226 billion on overtreatment in 2011, should we be using payment and performance policies to encourage health professionals, patients, and organizations to choose health care services more wisely?
The Choosing Wisely website notes that the “recommendations should not be used to establish coverage decisions or exclusions,” perhaps because physicians are weary of practice mandates. Some have argued that incorporating the recommendations into performance measures and payment policies may discourage societies from continuing to identify low-value services, or it may interfere with providing individualized care. Nonetheless, it's tempting to consider linking the recommendations with value-based payments or incentives, but doing so is a complicated matter.
According to Daniel Wolfson, MHSA, the ABIM Foundation’s executive vice president, Choosing Wisely partners should use certain criteria to determine low-value services:
The society’s members determine each recommendation.
Services targeted should be those that are most often used or the most costly.
Recommendations should be supported by “generally accepted evidence.”
This process should be documented and made public.
This approach has been criticized as lacking in rigor and standardization, resulting in some procedural variation across societies. Some health policy experts concluded that some societies failed to select low-value procedures that generate substantial revenues, noting that groups such as the American Academy of Orthopaedic Surgeons and the American Academy of Otolaryngology—Head and Neck Surgery identified services from other specialties but failed to include any major surgical procedures that evidence reveals are inefficacious and overused. Still, researchers reported that 76% of the initial Choosing Wisely recommendations were based on evidence of higher health risk, higher cost, or both.
According to the ABIM Foundation survey, 58% of respondents believed physicians should address the issue of unnecessary care, whereas only 15% thought the government should do so. But 44% of physicians who had seen Choosing Wisely materials said they would refuse to order an unnecessary test a patient insisted on, compared with 37% of those who had not seen the materials. This suggests that relying solely on health care professionals may be insufficient in reducing unnecessary care.
The initiative seeks to raise patients’ awareness of the problem of unnecessary services and engage them in the solution. Increasing patient copayments for low-value services could help to change patient behaviors, but some of the recommendations are nuanced enough to require the professional’s interpretation and judgment.
Changing how clinicians practice is no easy task, particularly when a low-value service may be highly profitable for them or for the organization that employs them. Pay-for-performance and other payment reforms have been designed to change behaviors of clinicians and organizations, despite the continuing dominance of a fee-for-service payment model that may incentivize low-value tests and procedures. But even in the face of substantial evidence, medical societies sometimes disagree on whether profitable tests and procedures should be covered by payers.
Payers could design a benefits package that excludes paying for low-value services, particularly those that may cause harm. Selecting the most robust Choosing Wisely recommendations with the greatest potential for reducing harm and costs could also be used as quality indicators for the Physician Quality Reporting System and similar systems.
Still, Choosing Wisely rightly encourages the kind of shared decision making between professionals and patients that will require a culture shift by both. Payment policies that enable clinicians to have the time for these important conversations are essential, whether paying for health counseling or using global payment methods.
Policy recommendations that seek to reduce the use of health services are at risk of being framed as rationing. The ABIM Foundation emphasized unnecessary and even harmful services—a smart move, given the current political climate. But the potential collective power of the medical societies and the other professional organizations participating in Choosing Wisely provides an opportunity for the initiative's recommendations to lay a strong foundation for policies that can reduce harm to patients and control health care spending.
In a 2012 JAMA Viewpoint, the authors suggested as a next step, “moving beyond a list of low-value services toward the testing of approaches to reduce their use, ideally through a combination of benefit design, physician payment policies, and social and professional guidance informed by clinical evidence. Given fiscal realities, reducing low-value services is what will allow continued support for the coverage of high-value services.”
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