by Eve A. Kerr, MD
and John Z. Ayanian
December 11, 2014
Doctors and patients in the United State must work together to minimize waste in health care. The millions of health care decisions made each day — to see a provider, complete a medical test, fill a prescription, or undergo a procedure — come with benefits, risks, and costs. Many of the choices are well informed by clinical evidence and expertise. But all too often they are driven by habit, hunches, or misaligned economic incentives, leading to substantial overuse of unnecessary, even harmful, services. The Institute of Medicine estimates that unnecessary services represent about 10% of all U.S. health care spending — nearly $300 billion a year.
In 2012, the American Board of Internal Medicine Foundation launched the Choosing Wisely campaign to encourage doctors and patients to discuss the issue of unnecessary tests and treatments, also known as “overuse.” Building on initial efforts by primary care organizations, more than 60 medical specialty societies have identified more than 300 recommendations that should be addressed. The Choosing Wisely campaign focuses almost exclusively on professional education (through participating medical societies) and on public education in the form of videos and brochures for patients produced by Consumer Reports. As more and more health care organizations, medical groups, and individual doctors implement its recommendations, Choosing Wisely is helping to transform the culture of health care. That cultural shift helps to ensure that new approaches to quality management, price transparency, and economic incentives for providers ultimately bear fruit in reducing overuse.
Choosing Wisely has renewed the focus on overuse, but the campaign had its precursors. In the 1980s, researchers at RAND developed an approach for classifying health care into four categories of appropriateness, ranging from necessary services, whose benefits clearly outweigh the risks (not performing these services constitutes underuse), to inappropriate services, whose risks for harm exceed the potential benefits (performing these services constitutes overuse). Subsequent studies have documented substantial overuse of common procedures such as hysterectomy, common medications such as antibiotics, and even chemotherapy. Overuse of surgery or chemotherapy clearly has potential harms.
Other examples of overuse, however, are subtler. For example, an estimated 25% of Medicare beneficiaries undergo an imaging test for uncomplicated low-back pain. That may seem harmless on its face, but almost all patients with this symptom recover without an invasive procedure — and, in response to the imaging results, some patients undergo additional procedures they don’t actually need. Similarly, more than half of antibiotics prescribed for common colds and coughs may be unnecessary.
During the past 15 years, our health care system has made substantial strides in reducing underuse of high-value services. However, progress on overuse of low-value services (to which one quarter of Medicare beneficiaries may be exposed) has lagged, especially in regions that have higher levels of spending and that have more specialists relative to primary care physicians.
Overuse in health care has been tough to address for several reasons:
1.Americans are prone to think that more health care is better, so they often bristle at recommendations that seem to limit choice or advise waiting to see whether a symptom improves. The prospect of not ordering a test or a treatment, even when that approach constitutes better quality, stokes fears about “rationing.”
2.Some erroneous beliefs, such as the benefit of treating a cold with antibiotics, are so ingrained that public education campaigns can take years to have an impact.
3.Doctors often overvalue their own services, despite evidence to the contrary. For example, in 2013, more than a year after the U.S. Preventive Services Task Force concluded that routine prostate cancer screening with PSA testing has more potential harms than benefits, a urologist advised viewers of NBC’s Today Show, “There are no complications to screening. What we want people to know is, get your PSA baseline at the age of 40.”
4.Economic incentives can be perverse, as when fee-for-service payments encourage potentially unnecessary services or when patients don’t know the cost of a service they are receiving.
Choosing Wisely and other ongoing reforms in health care aim to address each of those impediments to progress, as we discuss below.
As early as 1986, RAND researchers wrote, “Physicians today face mounting pressures to use procedures only when clinically valid criteria indicate that they are appropriate.” Nearly 30 years later, those pressures persist. The Choosing Wisely campaign and the broader medical community are beginning to make a dent in overuse by focusing on these dimensions:
Putting quantity in the context of quality. Choosing Wisely helps patients and doctors see that more care is not always better care. Doctors have long known about some of the opportunities for reducing the quantity of care without compromising quality, such as not getting an imaging test for uncomplicated low back pain or not ordering an annual cardiac stress test in patients without symptoms. In these instances, Choosing Wisely can help educate patients about why an unnecessary test could wind up being bad for them so that doctors and patients can have more constructive conversations about the tests. For other, newer recommendations, Choosing Wisely may need to gain traction with doctors first. For example, the American Geriatrics Society advises limiting aggressive treatment of older patients with diabetes to prevent harmful episodes of low blood sugar — this recommendation has the potential to change the way many doctors practice.
Changing how quality is managed. We need to move from a quality assessment system that merely tracks use of services to a quality management system that helps providers and patients make better decisions about when care is necessary or inappropriate. That means using personalized assessments of potential benefits and harms, as well as taking into account the preferences of patients who are well informed about their options. For example, new guidelines for preventing heart disease use a personalized assessment that helps doctors identify an individual patient’s risk for a heart attack — and whether that patient should take a cholesterol-lowering statin drug and at what dose. Although Choosing Wisely does not specifically develop such tools, they are consistent with the culture of more-efficient, patient-centered quality management that the campaign promotes.
Helping doctors reconceive the value of their services. Most physicians are enthusiastic about limiting access to expensive tests that have little or no benefit as a way to curb excessive health care costs. Nevertheless, nearly three-quarters of doctors believe that the average physician orders unnecessary tests at least once per week, most often stemming from fear of lawsuits and general clinical uncertainty. In its campaign to educate doctors through their professional societies and the public through Consumer Reports, Choosing Wisely is promoting the view that not ordering unnecessary services can have as much value for patients as ordering appropriate tests and treatments.
Re-envisioning payments and pricing. With reforms in how insurers pay for medical services, doctors will need to think more carefully about which services they provide and for whom. For example, a “bundled payment” for an episode of care, such as all services related to knee-replacement surgery, could result in fewer unnecessary services within that episode (though some episodes of care may be unnecessary to begin with). Global capitation — a fixed, per-person, per-month fee regardless of the services provided — may encourage doctors to focus on limiting overuse and less on reducing underuse. Greater transparency of health care prices may also prompt patients and doctors to discuss when medical services are unnecessary. Choosing Wisely does not directly address such cost-related initiatives, but its focus on limiting overuse (in the interest of optimal care for patients) complements those aims.
All of these reforms will require careful consideration of unintended consequences, so that our efforts to limit overuse do not foster underuse of high-value services. We must continue to test approaches to limit overuse while ensuring that necessary services are provided. The principles of the Choosing Wisely campaign are consistent with this type of judicious approach. In a 2014 survey, 21% of doctors indicated that they were aware of the Choosing Wisely campaign, and 62% of that subgroup reported taking steps to reduce unnecessary services (compared with 45% of doctors who were not aware of Choosing Wisely). Clearly, many doctors have taken note of the campaign in its first two years, but many others remain to be engaged, and we will need new data to determine whether overuse of health care is actually declining.
Thirty years after the concepts of health care appropriateness were first developed, professionalism, payment policies, and science are aligning to create incentives and tools to help limit overuse. Together doctors and patients can choose a less wasteful approach as they aim to improve both the quality and efficiency of health care.
Eve A. Kerr, MD, is the director of the Center for Clinical Management Research at the Ann Arbor Veterans Affairs Healthcare System and a professor of internal medicine at the University of Michigan.
John Z. Ayanian, MD, is the director of the Institute for Healthcare Policy and Research and the Alice Hamilton Professor of Medicine at the University of Michigan.