October 30, 2017
This post first appeared on the Heath Affairs Blog, October 24, 2017, and was written by Michael Chernew and Daniel Wolfson.
The US health care system is plagued by the use of services that provide little clinical benefit. Estimates of expenditures on overuse of medical services range from 10–30 percent of total health care spending. These estimates are typically based on analyses of the geographic variation in patterns of care. For example, researchers at the Dartmouth Institute focused on differences in care use between high-spending and low-spending regions with no corresponding reductions in quality or outcomes. An analysis by the Network for Excellence in Health Innovation (formerly known as the New England Healthcare Institute) identified significant geographic variation in the rates of both surgical and non-surgical services such as coronary artery bypass grafting, back surgery, cholecystectomy, hip replacements, diagnostic testing, and hospital admission.
This variance-based approach to estimating overuse has been very useful at highlighting the problem of inefficiency in the health care system but has done little to direct initiatives designed to reduce unnecessary tests and procedures. The aggregate approach does not help clinicians or managers identify exactly how they should change their practice patterns. As a result, it has been hard to reduce overuse. Identifying the significant overuse of medical services in the health care system is only the first step; now we need to develop evidence-based solutions to reduce unnecessary services and improve efficiency.
The History Of Choosing Wisely
The Choosing Wisely initiative, announced in 2012 by the ABIM Foundation and Consumer Reports, was designed to spark conversations among physicians, patients, payers, and purchasers about the overuse of tests and procedures, and to support physician efforts to help patients make smart and effective care choices. Specialty societies identified specific services that were unnecessary in specific situations. With more than 80 participating specialty societies, Choosing Wisely has identified more than 500 commonly overused tests and procedures and published recommendations for their proper use. For example, the American College of Emergency Physicians recommends avoiding computed tomography (CT) scans in low-risk patients with minor head injury.
The Choosing Wisely campaign began in an environment when efforts to reform health care were polarized by discussions of “rationing” and “death panels.” The initiative focused on quality, safety, and doing no harm to counter suspicions of dual agency and cost reductions motivated by profit; this allowed both the public and clinicians to begin to see reducing unnecessary care as in the best interest of the patient.
Choosing Wisely appealed to the professionalism of physicians and other clinicians as articulated in the Physician Charter on Medical Professionalism, which included a commitment to manage health care resources. The campaign was conducted in a way that respected the autonomy of physicians, relying on and enhancing their professional pride and sense of mastery, instead of functioning as yet another quality initiative imposed from above. Specialty societies took a leadership role in partnership with a wide swath of consumer and patient groups, helping physicians and patients accept the message of “more is not always better.”
Through Choosing Wisely, physicians were socialized toward a new norm in the culture of medicine against low-value care, which was reflected in the medical literature. From 2014 to 2015, the number of articles on overuse nearly doubled. The adage that “culture eats strategy every day” became a guiding light. Manya Gupta, MD, from Rush University Medical Center, summed it up as, “Once culture change starts, improvements become expected.”
The unexpected nature of societies taking the lead on this issue, potentially in conflict with their members’ economic self-interest, helped make the campaign stick. Similarly, the simplicity, concreteness, and credibility of the recommendations allowed them to be deployed in a variety of settings at a variety of levels in the organization.
Implementation has been accelerated through the support of the Robert Wood Johnson Foundation (RWJF), which has provided two grants to support putting the Choosing Wisely recommendations into practice.
Choosing Wisely In Action
The front line empowerment fostered by Choosing Wisely was evident when the University of Vermont Medical Center asked faculty and residents to submit ideas for high-value care projects targeting tests and treatments that could be performed less frequently. Interventions on seven projects were completed. Key reported outcomes included:
- a 72 percent reduction in the use of blood urea nitrogen and creatinine lab testing in patients with end-stage renal disease who were on hemodialysis and hospitalized;
- a 90 percent reduction in dual-energy x-ray absorptiometry (DEXA) screening on women ages 65 and older without clinical risk factors for osteoporosis; and
- a 71 percent reduction in the use of portable chest x-rays in mechanically ventilated patients who were not intubated that day and did not have a procedure performed.
Vanderbilt University Medical Center drove cultural change through a “challenge” to all house staff and residents aimed at reducing unnecessary daily lab orders. After educational sessions, teams were sent weekly emails on tracking use in a friendly monthly competition. This resident-originated focus and intervention resulted in significant reported decreases of daily blood counts and basic metabolic panels.
Crystal Run Healthcare, a multispecialty practice with 350 clinicians, also sponsored a contest designed to advance Choosing Wisely recommendations. Eric Barbanel, MD, a practicing physician at the clinic, was the champion for the winning project, which focused on four recommendations from the American Academy of Family Physicians. The interventions included peer education, clinical decision support, and data feedback. Decreases in annual electrocardiograms (EKGs), magnetic resonance imagings (MRIs) for low back pain, and DEXA screening were reported.
The campaign has also relied on regional health collaboratives to help drive local public awareness of the issue of overuse. Two grantees supported by RWJF, HealthInsight Utah and Maine Quality Counts, have used town hall meetings to engage in conversations with patients and the broader public about Choosing Wisely.
The Choosing Wisely campaign has focused first on adaptive change—on “why” there is concern about overuse by clinicians and patients, and on developing a consensus set of common values and purposes. The campaign has emphasized evidence about benefits and harms and the pursuit of enhancing quality, safety, and doing no harm. The aim has been to win both the hearts and minds of physicians so that they would be more engaged in improvement efforts, something often missing in efforts to change behaviors in clinical practice. The rapid introduction of purely technical solutions (that is, clinical decision support through electronic medical records) often alienates clinicians who don’t know the values and motivation behind the need for such solutions.
Choosing Wisely has had some success in raising awareness of overuse and incorporating recommendations into practice. But results from national studies have been mixed, highlighting the need for further formal evaluation of the initiative’s impact.
More importantly, other strategies needed to complement Choosing Wisely must be jumpstarted. Specifically, more needs to be done to address some of the other underlying drivers of overuse in the health care system, notably perverse payment incentives; eliminating unnecessary services will be challenging as long as providers face financial incentives to provide more care and patients have no incentives to avoid care. Choosing Wisely is an attempt to change attitudes and mindset, but changing attitudes is hard when incentives are misaligned.
Payment reform can play a role in changing physician behavior by minimizing rewards for doing unnecessary tests and procedures. In fact, some evidence suggests population payment has disproportionately reduced use of potentially unnecessary tests and procedures. But it is not always easy to design payment reform such that the incentives are fully experienced at the point of care. Moreover, although evidence suggests these payment models lower spending without sacrificing quality, the effects have generally been modest and surely more could be done. And reinforcement works both ways: Just as payment reform can make the task of changing attitudes through Choosing Wisely easier, winning hearts and minds can amplify the effectiveness of any payment reform strategy.
Benefit design can also help reduce use of potentially unnecessary services by increasing patient out-of-pocket spending for those services. However, higher out-of-pocket spending can be a significant financial burden on patients, and in many cases they are not well suited to make nuanced decisions about care. Most evidence suggests that when faced with higher cost sharing, patients reduce use of appropriate and inappropriate care in similar proportions. Value-based insurance design (VBID)—which aims to increase cost-sharing for less effective treatments and decrease cost sharing for more effective treatments—can help encourage patients to specifically reduce overuse of low-value care. However, VBID is not a panacea and must be implemented in a way that avoids adverse selection and excessive complexity. Engaging clinicians in explaining and implementing benefit design changes will be necessary to help patients better navigate the choices they will confront.
Even if Americans were not grappling with high health care spending, avoiding potentially unnecessary services would be important. But with fiscal pressures driving changes by private and public purchasers that often have deleterious consequences, eliminating potentially unnecessary services—and thus delivering cost savings while increasing quality—is more important than ever. Choosing Wisely exemplifies efforts of the professional societies to engage on the issue; by appealing to the professionalism of physicians and other clinicians, it can provide the foundation for promoting delivery of appropriate care.
Professionalism as a force to improve quality has an opportunity to show its value along with the technical approaches and the environmental changes needed (for example, payment reform). The design of Choosing Wisely, which included few rules, much autonomy for engagement and design, and little central control, produced an activated professionalism. Appealing to the intrinsic motivations of physicians offers an underused path to achieve widely shared policy goals such as reducing the cost of our health care system while enhancing its quality. Professionalism can also appeal to patients and give them confidence in their physicians’ counsel that unnecessary care truly is unnecessary. Given the activity that has been unleashed in health systems and clinical practices throughout the United States, professionalism should not be overlooked as part of our broad health care transformation strategy.