Whenever I give a talk on the sorry state of the US health care system, someone asks me what we should do. My first comment is always something along the lines of “if we knew what to do, we’d have already done it”. But if I’m pushed, I will usually note that the best first step would be for us to stop doing things that don’t work.
Reducing spending without negatively affecting quality is not entirely straightforward. However, there are numerous processes of care that we know are wasteful. They have been shown, by research and analyses, not to improve quality. Sometimes, they even result in harm. Regardless, they increase spending. By identifying – and eliminating – these wasteful processes, we can meet the goals of accountable care without unintended consequences. As clinical bonuses will be tied to meeting spending reduction targets in the future, these actions can also result in an improved financial outlook for the health care system.
A recent paper in JAMA explicitly singled out waste as a better way to reduce health care spending in the US. In this table below, from the manuscript, you can see that a reasonable estimate of waste in the US health care system could be more than $900 billion a year, $300 billion of which is spent by Medicare and Medicaid. The “overtreatment” category alone accounts for somewhere between $158 and $226 billion each year. Focusing solely on this area could still result in large savings.
With that in mind, it’s worth talking about Choosing Wisely. It’s an initiative of the ABIM foundation that “aims to promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.” About a year ago, they first made news when they had nine specialty societies release lists of five things physicians and patients should question.
Basically, they came up with lists of things that we shouldn’t do when practicing medicine. They identified over-treatment as waste.
I’ve been somewhat skeptical of these efforts in the past. Partly, that’s because without coupling these ideas to payment reform, the financial incentive to continue doing them remains. Additionally, I felt that the scope of some of the recommendations was limited. As a pediatrician, for instance, I couldn’t help noticing that none of them really focused on children.
Today, Choosing Wisely has addressed some of my concerns. They, along with seventeen leading medical societies, have listed more than 90 new tests, procedures, or therapies that are common, but likely unnecessary. Pediatrics is well represented among them. Here are the recommendations from the AAP:
- Antibiotics should not be used for apparent viral respiratory illnesses (sinusitis, pharyngitis, bronchitis).
- Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.
- Computed tomography (CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
- Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.
- Computed tomography (CT) scans are not necessary in the routine evaluation of abdominal pain.
Other highlights include:
- Don’t schedule non-medically indicated inductions of labor or cesarean deliveries before 39 weeks, 0 days of pregnancy. (American College of Obstetricians and Gynecologists; American Academy of Family Physicians)
- Don’t perform routine annual Pap tests in women 30 – 65 years of age. (American College of Obstetricians and Gynecologists)
- Avoid doing stress tests using echocardiographic images to assess cardiovascular risk in persons who have no symptoms and a low risk of having coronary disease. (American Society of Echocardiography)
- When prescribing medication for most people age 65 and older with type 2 diabetes, avoid attempting to achieve tight glycemic control. (American Geriatrics Society)
- Don’t routinely treat acid reflux in infants with acid suppression therapy. (Society of Hospital Medicine)
These recommendations cover a wide swath of care options, for problems that are both common and expensive. If we listened to them, we’d save a huge amount of money. We’d also do a fair amount of good. People often forget that these tests and treatments carry potential harms. When you do them, and achieve no benefit, you’re potentially hurting quality.
Unfortunately, I still believe that as long as we continue to pay for these things, they will still be performed far too often. Financial incentives drive behavior, even when they’re aligned in the wrong direction. I’m more than happy to be proven wrong, but I think it’s unlikely. Choosing Wisely continues to give us lots of good ideas to work with; it’s time to give them teeth by tying their efforts to payment reform.