The Case for Choosing Wisely® and American College of Emergency Physicians

The nine specialty societies that were part of the launch of the Choosing Wisely campaign in April were courageous in identifying medical tests and procedures that physicians and patients should question. More than 20 additional societies will be issuing lists in 2013. They should be commended for their leadership and putting the interests of their patients above their economic interests. But for some societies, questions remain, and they have decided not to participate in the campaign.

A notable example is the American College of Emergency Physicians (ACEP) who has very publicly engaged in a discussion with its members about participating in the campaign. ACEP brought it to the floor of its most recent annual meeting, the 2012 ACEP Scientific Assembly. Ultimately, ACEP decided not to participate.

After that decision, Mark Plaster, MD, JD, Executive Editor of Emergency Physician Monthly, hosted a conversation with William Sullivan, DO, JD, Clinical Assistant Professor, Department of Emergency Medicine at the University of Illinois, discussing and debating ACEP’s decision to not join the Choosing Wisely campaign.

Dr. Sullivan articulated several reasons why he supported ACEP’s position not to join the campaign:

• The campaign puts ER physicians at risk for medical liability.
• One of the campaign’s goals is to save money.
• Other specialty societies were telling ER physicians what to do and not do, creating a culture of “finger pointing”.
• Payers will use these recommendations to deny reimbursement for specific tests and procedures.

I understand Dr. Sullivan’s concerns, and feel Dr. Plaster did a more than adequate job in responding and making several key points advocating for ACEP to join the campaign. I’d like to take some time to address Dr. Sullivan’s main points:

Medical Liability

Dr. Sullivan notes that one reason ACEP has not joined the campaign is because it does not address tort reform. The Choosing Wisely campaign is about conversations between patients and physicians. Studies have shown a strong association between physician/patient communication and reduction in malpractice claims. There is an argument that limiting the overuse of medical tests and procedures might decrease liability exposure. Just as this campaign is not about payment and reimbursement, it is not about tort reform. It is sharply and clearly focused on tests and procedures that may not be necessary, and the importance of collaboration and communication between physicians and patients. That sharp focus is part of the reason why it has resonated with the public and our community.

Saving Money

The Choosing Wisely campaign is about quality, safety and eliminating waste. Providing care with those elements will likely result in lowering health care costs, but that is not the focus of this effort. At its heart this campaign, is about doing what is right for patients, it is about professional values and physician leadership.

Finger Pointing

Dr. Sullivan worries that other specialty societies will dictate ER practices. This is a misperception on Dr. Sullivan’s part. One of the basic tenets of the Choosing Wisely campaign was that societies only develop recommendations in their area of specialty – tests and procedures that their physicians order. Not one of the 45 recommendations issued in April mention ER physicians. There are some medical tests and procedures that ER physicians may do that are also done by other specialties. For example, AAFP and ACP both discuss when CT scans for sinus infections are not appropriate (and when they are). This is not, however, finger pointing.

Payers

ABIM Foundation, the medical societies and Consumer Reports have been very clear on this – these are not never events and it would be difficult to define payment rules for them. Members of the Consumer Reports’ employer and consumer/patient coalition understand the difficulty of embedding these into coverage decisions because of exceptions to clinical evidence and expert consensus opinion.

I appreciate the thoughtful comments by Drs. Sullivan and Plaster regarding ACEP’s participation in Choosing Wisely, and we remain hopeful they will ultimately join the campaign.

What is your advice to ACEP regarding Choosing Wisely?