Wednesday, March 20, 2013

Why Choosing Wisely Will Have Limited Success



Foreword: The views expressed in this essay are my own and do not reflect the opinions of the GeriPal Blog editors and other GeriPal contributors participating in Choosing Wisely.  I support the ultimate goal of Choosing Wisely and have the highest respect for those working on this important endeavor. 
Choosing Wisely is a campaign led by the American Board of Internal Medicine (ABIM) Foundation with strong collaboration from specialty societies representing nearly all medical disciplines and support from various health and health care organizations.  Choosing Wisely seeks to reduce wasteful and unnecessary health care services.  The underlying premise is that health care is too expensive due largely to waste and unnecessary utilization.  Berwick and Hackbarth (JAMA 2012) demonstrated that 20% to 50% of expenditures are wasteful.  Choosing Wisely seeks to address several categories of waste that are particularly expensive for Medicare and the broader health care system (e.g., overtreatment) and those categories of waste that physicians can be strong advocates for improvement (e.g., failures in care coordination and in execution of care processes).  Targeting physicians makes sense because their decisions ultimately account for over 80% of all health care expenditures.  Choosing Wisely appeals to an individual doctor’s sense of medical professionalism and belief in evidence based medicine.
The design of the Choosing Wisely campaign is elegant (each medical society identifies five specific decisions that lead to waste or harm as defined by best clinical evidence) and action-oriented (each is specifically described and stated in the language of professional directives).  The Choosing Wisely campaign has been very careful to avoid any notion of cost control, government or insurance-based rationing, or weighting of group over individual good.  Their focus group data, in addition to a recent study in Health Affairs (February 2013), suggests that doctors and patients will react instinctively and negatively to any campaign grounded in claims for societal  good or distributive justice.  To remove any doubt that Choosing Wisely is based on professionalism rather than rationing, Jon Tilburt and Christine Cassel recently published a Viewpoint in JAMA (February 2012) titled, “Why the Ethics of Parsimonious Medicine is Not the Ethics of Rationing.”  They make the narrow claim that rationing is about limiting potentially beneficial resources ‘due to resource scarcity’ for societal good while parsimonious medicine is about ‘delivering appropriate health care that fits the needs and circumstances of patients’ and that ‘avoids wasteful care when that care does not benefit patients’.  At its simplest level the difference between parsimonious care and rationing is a focus on individual needs versus societal good.  The politics of the Choosing Wisely campaign is quite intelligent.  Most Americans frown on central planning (whether by governments or monopolistic capitalism), believe that medical decision making should occur primarily at doctor-patient encounter, and have a romantic obsession with the early 20th century ideal of medical professionalism.  Choosing Wisely is on the right side of each of these normative beliefs about medicine and health care.

Despite all these strengths, I believe the Choosing Wisely campaign will ultimately only be a minor success.   Despite remaining a darling of public opinion, it fails to address the primary drivers of waste, especially drivers of overtreatment by physicians.  My judgment is based on the emphasis Choosing Wisely has placed on medical professionalism and its exclusive focus on physicians’ “good, sound judgment.”  One might ask, how is parsimonious medicine any different from how doctors are supposed to act now?  How effective has professionalism been over the past half century in reducing costs and waste? For example, most physicians understand that common back pain (without alarm signs or symptoms) does not warrant extensive imaging (e.g., MRI) unless it persists for many weeks.  The doctor can talk about evidence suggesting very low risk of something serious occurring balanced against the potential harms of a diagnostic test, and some personalized discussion of costs (e.g., copays).  However, when the patient states that he’s in severe pain and his wife told him to demand an MRI, relates a story about his uncle whose doctor misdiagnosed his metastatic prostate cancer, and that his copay is only $50; the distinction between rationing and parsimoniousness becomes quite blurred for the treating physician.  This patient isn’t rare. He is your typical medical consumer (despite his romantic notions about professionalism)--who is neither quality nor cost conscious.  Quite frankly the financial incentives for both doctors and patients are weighted towards overtreatment and against shared and informed decisions, and Choosing Wisely does little to shift these incentives.  Furthermore, Choosing Wisely has ignored the elephant-in-the-room which is the perception among many doctors that defensive medicine drives overtreatment decisions.  The perception of defensive medicine is critical (not the actual prevalence of malpractice-aversion) and this perception should be a central theme of the professionalism push by Choosing Wisely.


No matter how much the Choosing Wisely campaign wants to avoid arguments about resource scarcity—this is simply why the campaign began in the first place.  Our health care system (government, insurers, providers, and patients) is spending too much for the quality of care that is received.  While I agree that government based rationing is un-American and unlikely to take root; I simply don’t believe in the quaint and romantic notion of parsimonious medicine changing health decisions.  The Choosing Wisely campaign should be set within the context of a high cost, high waste, and comparatively lower quality health care system.  The target should be quality-consciousness at the patient level and focused equally on patient and physician drivers of over-utilization--beyond patient education.  We should be clear that rationing is the issue, but rationing at the individual doctor-patient encounter not the societal level.   A patient who doesn’t benefit from an MRI for his uncomplicated back pain (based on the evidence) but still demands one—should be charged a significantly higher copayment for choosing a low quality (but anxiety averting) option.  Doctors that act transparently within an evidence-based pathway should be shielded from not only frivolous lawsuits but also the rare cancer case that presents as uncomplicated low back pain.  Diagnostic or treatment decisions based on quality-conscious, patient-centered communication do not occur frequently within American health care, however such decision making represent the most ‘American’ form of medical rationing.  One might even call it the beginnings of an actual, functioning health care marketplace.  
by: Aanand D. Naik @empoweringpts

7 comments:

sei said...


Disclosure: I am a member of the Am Geriatrics Society Choosing Wisely Committee and helped draft the AGS recommendations.

Overall, I agree with most of the points the Aanand raises but end up with different conclusions.

I agree that focusing only on physician professionalism is unlikely to substantially change the current state of healthcare in the US. However, I view the Choosing Wisely campaign as targeting both physicians and patients. The ABIM has been adept at engaging consumers of healthcare to spread the basic message that more healthcare is often bad for you. ABIM has a list of consumer partners including AARP and Consumer Reports. Over the long run, I believe that changing the way the public views more healthcare will be much more powerful than trying to change the way physicians practice.

I believe that the fact that we are having this discussion is in itself a victory. One of the basic lessons of messaging is that you need to be able to focus the public on the topic and control the framing of the topic. Here we are, talking about the Choosing Wisely campaign, how it is being covered in the NY Times and Consumer Reports. We are not talking about "Death Panels" or how someone's grandmother died because some treatment was unavailable. Just by raising this issue with consumers, I feel that the Choosing Wisely campaign has achieved an important good.

As Aanand points out, many medical decisions are driven by patients. However, as a professional organization, I think the ABIM would have had much less traction if they had launched this effort solely on changing patient behavior. By aiming the effort at both consumers and physicians, the ABIM has been able to raise this issue and start an intelligent conversation about how best to allocate (yes, ration) finite healthcare resources.

Regarding Aanand's specific suggestions, I agree with them in substance if not style. Regarding being explicit about rationing, I have made that point at many informal settings, how we are currently rationing but in a haphazard, irrational way. However, I believe that the word rationing is fairly radioactive at this point, and embracing this word will make it very difficult to have a constructive national dialogue.

Regarding higher co-pays for patient-requested low-quality care, the devil is in the details. How is the patient going to feel when he knows that the doctor could save him $50 by checking a box that says it's medically necessary? Overall, I like the concept that if you are going to treat healthcare like any other commodity, you should pay for it like any other commodity. But I'm not sure how this would work.

Regarding shielding doctors that act transparently in an evidence-based way, I could not agree more. However, I am again at a loss on how to operationalize this.

I'm glad that we're having this conversation here and elsewhere. It is long overdue.

Eric Widera said...

As a disclosure, I was involved in AAHPM's list. For most of the items listed on the AAHPM list, I really don't and can't imagine that the main force behind their continued use is driven by patient preferences or demand. I think it one would be hard pressed to find a patient who can describe the difference is between single versus multifraction radiation or demand that you use one over the other. They just want their pain treated. I also don't think any patient would ever ask for yet alone demand ABH gel is and indeed many patients don't even know that deactivation of an ICD is possible.

I do think you raise some great points and agree with most of what you said, however I personally think no one intervention will fix the issues we have in our health care system (even co-pays for low value interventions). Choosing Wisely is a great start but we have a long way to go.

Bruce Scott, MD said...

Dr. Widera is right to include "most" in his comment about the main force not being patient preference or demand. The AAHPM list includes PEG tubes in advanced dementia, and these quite often ARE driven by family preferences. (Although doctors not sufficiently outlining alternatives or sufficiently explaining natural history of dementia are ultimately responsible for some of these demands).

The AGS list includes PEG tubes and also includes antibiotic treatment for asymptomatic bacturia. Families are often drivers of obtaining urinalyses when they aren't warranted as well as for requesting/demanding treatment of asymptomic bacturia as well.

Don't you have picketers outside your office chanting "ABH! ABH! ABH!"

I agree that considerably more blame lays at the feet of practitioners in regards to both the AAHPM and AGS lists, but patients and their families do drive some of it.

Interestingly enough, in their excellent plenary presentation, the Olivers discussed a situation where they demanded medical treatment that seemed to be against current evidence. (Admittedly, I don't have all of the information to know if there is anything I'm missing about their case...and you always run the risk of missing something when commenting on a case you weren't involved in.) The hospitalist (?) wasn't inclined to transfuse with a liberal transfusion strategy. Evidence fairly well supports a conservative transfusion strategy except in certain circumstances which it does not appear applied. This transfusion at an arbitrary (and high) hemoglobin cutoff seems to run contrary to one of the items on the Society for Hospital Medicine's Choosing Wisely list.

Allison Musante said...

This is certainly an interesting debate, and it remains to be seen whether resources such as this can improve patients' healthcare literacy so that they make better, wiser healthcare decisions. In Clinical Geriatrics, Dr. Barney Spivack, MD, has commented on the new Choosing Wisely campaign and the involvement of the American Geriatrics Society. Read the commentary here: www.clinicalgeriatrics.com/articles/Making-Wise-Healthcare-Decisions-Five-Things-Physicians-and-Patients-Should-Question.

Anonymous said...

It's not always patients demanding MRIs. Recently a pre-surgery chest x-ray (undergone only because the hospital requires it of all surgery patients) led to an incidentaloma in my arm. The radiologist recommended an MRI IF I had pain there, which I did not. I talked my primary doctor out of the MRI, but my oncologist insisted on it (citing my history and malpractice concerns). The MRI confirmed the lesion was benign.

Janice Reynolds said...

I have just a few comments. While I think Choosing Wisely is a good idea, I also agree with Dr. Naik it may not work out so well. I am certified in pain management, oncology, and hospice and palliative care. I retired last year (although a nurse really never retires) however my career was spent as an inpatient nurse. I see medical interventions which are medically unnecessary as an ethical problem, whether it is financial, invasive, or medically futile (the last is one of the largest causes of moral distress in nurses and physicians). There are several other issues other than defensive medicine (which admittedly is a huge one). One is the physician or family who wants to know the answer (or reason why). CS was a 75 yo male admitted after a fall (with multiple comorbidities). He began having seizures and was placed in ICU where he went into RF. The PCP, hospitalist, and family decided to place him on comfort measures. The neurologist was very upset because “now we will never know what caused the seizures.” We see this many times when “knowing the answer” will not do anything to change the outcome but physicians and/or family insist. Another issue is quantity vs quality. I hope most have read D. Lewis Cohen’s book “No Good Deed”. There are families and some providers who will do anything and everything to prolong life (when in actuality it may shorten it (think TPN). Lastly in the case of hospital admissions (and also in some clinics) using a set plan for every patient whether the test or procedure is necessary or not.

Ken said...

I agree with SEI that we need to promote Choosing Wisly with patients. It may be that appraoch is even more important than convincing physicians. My local medical society is currently hesitant to climb on board the initiative, and I think some of that is fear of it affecting reimbursement.