It’s Not All About the Money

Since its launch in April 2012, the Choosing Wisely campaign has aimed to reduce unnecessary care—defined as tests and treatments that carry greater risks than benefits—through conversations between patients and physicians. With the engagement of 75 specialty societies, the release of nearly 500 recommendations and Consumer Reports working with more than 100 consumer and employer partners, Choosing Wisely has grown from an education and awareness campaign to one that is also focused on implementation of the recommendations by health systems and medical practices.

I have heard and continue to hear criticism from some that the society recommendations are “low-hanging fruit” that will not decrease the revenue of physicians or health systems, generate significant cost savings or improve care. Still others minimize the value of a 2.7 percent reduction in Medicare spending that could be accomplished if a core group of Choosing Wisely and other overuse recommendations was implemented. I counter that the Medicare Trust Fund could benefit greatly from savings of $10–15 billion annually, the dollar amount of that “minimal” 2.7 percent reduction. Of course, these criticisms also miss that the point of the campaign is to improve care, not reduce cost. But potential savings are still a gauge of the recommendations’ utility and whether they adhered to our established criterion that societies should focus on tests and treatments that are done frequently.

Recently, I spoke with Beth Bortz, the President and CEO of the Virginia Center for Health Innovation (VCHI), about its work with Choosing Wisely. Virginia has a voluntary all-payers claim database, with data on 5.5 million covered patients, including those covered through Medicaid, Medicare fee-for-service, and many commercial payers. Using the Milliman MedInsight Waste Calculator, VCHI estimated that $650 million is spent annually on care that is contrary to 45 of the Choosing Wisely recommendations. For commercial payers, this expense amounts to $12.79 per member, per month.

VCHI has enlisted a number of partners for its project to reduce unnecessary care, including the Medical Society of Virginia, the Virginia Hospital and Healthcare Association, the state chapters of the American College of Physicians, the American Academy of Family Physicians,  AARP and the Virginia Chamber of Commerce, along with area employers and commercial health plans. Interestingly, different partners looked at VCHI’s data in different ways: the state employee health plan wanted to look at tests and procedures that are the most harmful to patients, understanding the downstream implications of unnecessary care for their members’ health. Hospitals and health systems wanted to know which tests and treatments were most frequently ordered unnecessarily at their institutions, along with individual physician data. Others wanted to look at lower and higher cost-sharing based on the value of the test or treatment, a philosophy espoused by V-BID (The Center for Value-Based Insurance Design).

Generally, efforts to just save money worry us because the campaign has always been about improving health care through better quality and safety and doing less harm. But VCHI has assembled a community-wide coalition that aligns with our preferred way of approaching the campaign, with substantial physician engagement and partnership with consumers and employers. This mirrors our approach with the Robert Wood Johnson Foundation grantees that have developed coalitions among physician organizations, consumer-driven organizations and delivery systems, all focused on improving the quality and safety of health care.

We are seeing in Virginia that it doesn’t have to be all about the money.

Daniel B. Wolfson
EVP & COO, ABIM Foundation