Determining what medical spending is wasteful is the hard part. What procedures should doctors not provide, and insurance companies not pay for? Figuring out which treatments are wasteful is both a policy and politics challenge, one that can often invoke accusations of “rationing” or denied care.
Despite all those hurdles, a new campaign called Choosing Wisely aims to answer just that question. Run by the American Board of Internal Medicine, Choosing Wisely has brought nine major medical societies on board to identify five common procedures that are often wasteful and unnecessary. The groups will provide their answers at the end of January and make them public in April.
On Wednesday, I spoke with Christine Cassel, president and chief executive of the American Board of Internal Medicine, about the new project, why it’s happening and the big challenges in finding waste in health care. What follows is a transcript of our discussion, lightly edited for length and content.
Sarah Kliff: Tell me the back story on this. How did the Choosing Wisely initiative get started?
Christine Cassel: The back story started exactly 10 years ago, when we published a charter on physician professionalism. It was a kind of update to the traditional Hippocratic Oath, an ethics statement for the profession in the modern environment that was endorsed by 130 different medical associations. In that document, there were 10 commitments that we agreed were central to the profession, and one was stewardship of medical resources.
In the past two years, the financial crisis combined with the discussion of rising health-care costs have revived that discussion, and people are talking about it in every way. The ABIM Foundation decided to focus all its efforts three years ago in resource stewardship, and develop ways to foster more conversation among physicians on these issues. We also began partnering with Consumer Reports, which will be providing a lot of this information. The idea is to get more evidence-based information out to patients.
SK: Patients don’t want to undergo unnecessary medical treatment, and doctors probably don’t want to provide it. So why hasn’t this problem resolved itself without intervention?
CC: One of the clearest reasons is our fee-for-service payment system, where doctors get paid more for doing more. Very few doctors do things that they know are wasteful, but if there’s a gray zone they could say, why not, it may help and it doesn’t hurt the patient.
Patients also haven’t been as informed as they are now. Now, unfortunately there are a lot more of us having to pay out of pocket. It used to be, if you were lucky, you didn’t see the bills. Now, people are asking themselves if certain treatments are necessary.
SK: How much of unnecessary care has to do with defensive medicine, doctors looking to avoid a medical malpractice lawsuit?
CC: That comes up a lot in our discussions. Physicians hate the threat of malpractice. The data show it’s a very small part of the cost of health care, but in terms of a doctor’s attitude, if you’re in the emergency room and have any doubt, the thought is probably it’s better to order the test. I hope this will help offer doctors some backbone not to.
SK: From what I understand, the speciality societies will have to get their recommendations to you by the end of January. How is the work going for them? Is it difficult to settle on which treatments are unnecessary?
CC: The good news is we had a conference call last week and they are taking this very seriously. They have set up major committees of experts to review the evidence and come up with things that matter. We’ve said to them, “We don’t want you to have things that are hardly done anyway, things that aren’t going to make difference.” They’re looking for real interventions where new evidence has emerged, where something used to be done routinely but may not need to be.
SK: Is there disagreement between doctors over whether a certain treatment is necessary?
CC: There are some hard questions and might be disagreements among different experts within a given speciality. In cancer, for example, there may be people who have different experience, and who may question the literature. But that’s what you want scientists. It’s going to force them to all look at the same evidence and come up with their best answer.
SK: You all will publish the results of your work in April. These aren’t going to bind physicians’ practice in anyway, so what’s the hope for how they’ll change medicine?
CC: The way we’ll communicate this is through Consumer Reports, through their Web site and magazine. We hope that patients will start asking questions and also doctors will want to know more. They’ll come to their societies, see it in their journals. I sense some real enthusiasm, and these groups taking it seriously. They recognize the pressures of professionalism.
Another factor that is related to this is the new methods of paying for health care, which pushes doctors to be more efficient with resources. These are things like the Patient-Centered Medical Home and Accountable Care Organizations. If you look at the budget and sequestration, there are federal pressures, too. Consumers have a tighter budget, and so does the whole health-care system.
SK: Identifying unnecessary treatments can be politically challenging. I think we saw, during the health reform debate, a lot of accusations about doctors or governments “rationing” or denying health care. How do you handle those kinds of challenges?
CC: My hope here is we can get away from that rhetoric, which is really misleading to the public and is, I think, scare tactics. None of this is rationing. Rationing is withholding care that is needed. And we’re not talking about needed care here. We’re talking about prudent uses of resources to get what is best for each patient.