The challenge of doing lessBMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f5904 (Published 01 October 2013) Cite this as: BMJ 2013;347:f5904
“It is difficult to get a man to understand something, when his salary depends upon his not understanding it,” said the US social reformer Upton Sinclair. But that is the challenge taken on by the Choosing Wisely campaign.
The idea of asking specialty societies to produce lists of five overused procedures was first suggested in 2010 by Howard Brody, professor of family medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston. Writing in the New England Journal of Medicine, he argued that physicians’ professional organizations were not doing their part to control rising costs, and in some cases had even made their support for reform contingent on promises that physicians’ income would not be negatively affected.1
“The myth that physicians are innocent bystanders merely watching healthcare costs zoom out of control cannot be sustained,” he wrote. “If physicians seized the moral high ground, we just might astonish enough other people to change the entire reform debate for the better.”
Brody’s challenge was taken up by the ABIM Foundation, a not-for-profit group that was established in 1999 by the American Board of Internal Medicine with a mandate to advance medical professionalism and physician leadership in improving the health system. The result was the Choosing Wisely campaign, which has recruited more than 50 specialty societies to each produce a list of five procedures that are overused in their field. The third, biggest, and final planned wave of Choosing Wisely lists is currently being released, and when it concludes early next year it will comprise more than 300 recommendations, all of them beginning with the word “Don’t.”
Consumer Reports will transmit the same cautionary advice to patients with help from the AARP (American Association of Retired Persons), SEIU (Service Employers International Union), and other partners, using the slogan “When to say ‘Whoa!’ to your doctor.”
The “don’t” is negotiable, says Daniel Wolfson, vice president and chief operating officer of the ABIM Foundation. “These are often things that were legitimate to do, but their indications expanded, so that a lot of the care became unnecessary. These are not absolutes that you should never do, rather they are areas where there should be discussion between doctor and patient. The lists should not be confused with guidelines.”
The informality of the process has attracted criticism. A team from the University of North Carolina’s Research Center for Excellence in Clinical Preventive Services questions the evidence base and methodology behind some of the lists. “We conducted a systematic review,” says Russell Harris, professor at University of North Carolina School of Medicine and director of the university’s program on prevention in education and practice, “and found that overall, the process is not transparent, it’s not evidence based, and it’s severely wanting. That’s our criticism and it’s not coming from an enemy, it’s coming from a friend. We don’t want to see this go away. But it’s only going to have an effect if the public and profession see it as credible, and updated over time.”
Howard Brody, when he first suggested “top five” lists in 2010, worried that “some societies will be tempted to bluff their way through the top five exercise, deliberately omitting cost cutting measures that would particularly affect members’ revenue streams.”
Brody says he sees evidence of this in some of the Choosing Wisely lists. “Some groups really bit the bullet and took on some of their own revenue-enhancing procedures, making lists that could anger some of their membership. The gastroenterologists, for example, did recommend reducing the number of endoscopies. Other organizations worked more gingerly, worried about their members’ pushback, and avoided taking on much that would potentially reduce revenue.
“If you look at what the surgical societies have tended to propose, you’ll see that doing less surgery is often not the prescription for these societies. A lot of the time they’re saying ‘we don’t need to do this testing preoperatively,’ which is very good, but does this mean that in that field there are no unnecessary surgeries being performed? I have a hard time believing that.”
Wolfson notes that expense is not a criterion that societies were asked to consider. The key factors were frequency, potential for patient harm, and lack of evidence of benefit. It makes sense to decouple these from cost in a political environment where any mention of savings is likely to trigger mistrust about rationing. The goal is winning the trust of patients who have long assumed that more treatment is better treatment.
Physicians must be the solution
Everyone agrees that medical societies are potentially superb vehicles for transmitting this message. “The idea is ingenious, because you’re taking people who are part of the problem and making them part of the solution, says Harris. “This degree of introspection on the part of different medical groups is really quite impressive,” says Brody.
In a recent survey published in JAMA, says Wolfson, only 36% of physicians agreed that it was doctors’ responsibility to control costs in the medical system.2 “But costs aside, in terms of overtesting, overtreatment, it’s the professional responsibility of physicians to take this on. No other body can take it on. They order the tests and procedures, the buck stops with them.”
That buck is part of the problem, of course. One man’s waste is another man’s income. Estimates of the cost of overtreatment run as high as 30% of US health spending3—$800bn (£495bn; €593bn) annually. Much of that money is paying physicians’ mortgages.
Brody acknowledges that “Choosing Wisely appropriately highlighted the fact that cutting these procedures doesn’t have to be a cost issue—there’s good reason for it in terms of quality of care and the duty to avoid patient harm. But in terms of physicians’ incentives to keep on doing it, cost does become an issue because there’s a conflict of interest there—you want to do well by your patient, but you also don’t want to see your income drop.”
The good intentions so evident in the Choosing Wisely campaign must push against a perfect storm of bad incentives that drive physicians to overtest and overtreat. These include: fee for service payment; performance measures that emphasize volume over value; defensive medicine (though tort reform, where enacted, has not substantially reduced unnecessary procedures); and patient expectations. Add to this the tendency of modern imaging to overdiagnose, thus adding more mild cases to the patient population, resulting in better outcomes, which then trick us into thinking our overtreatment is helping.
Otis Brawley, chief medical officer for the American Cancer Society, often recounts a conversation he had with a marketing executive at a major US hospital who boasted about his “prostate cancer business plan.” His hospital conducted free screening at a local mall every September for Prostate Cancer Awareness Month. The executive had calculated all the profits that would accrue from screening 1000 men, not just from treating cancers, but also from further in hospital examination of the many false positives, and from treating incontinence and sexual dysfunction caused by cancer treatment. He had numerical projections for almost everything, even the number of penile prostheses the hospital would implant—everything except the number of lives that would be saved, because, he told Brawley: “Don’t you know? No one knows if this stuff saves lives.”
But tellingly, the mall screening program was designed to bring two benefits to the hospital. Firstly, it would make money by overtesting and overtreating the local population—by harming them. Secondly, it would earn the hospital goodwill in the community. Patients want to be overtested.
In oncology, there is another driver of overtreatment: the all too human temptation to postpone bad news and conversations about death. Since 2000, oncology has seen the fastest growth in new diagnoses, the fastest increase in costs, and the greatest proliferation of interventions of unproved benefit. And meanwhile, oncologists’ incomes have risen the fastest, to stand well above the average for US doctors.3 The refusal to give up in the face of a grim prognosis has arguably benefited the physician more than it has the patient.
The cancer societies, in the main, have grasped the nettle of Choosing Wisely, targeting several of their core revenue streams. Their good intentions are hardly facilitated by a reimbursement system that pays them more for administering expensive patented drugs than generics, while barely recognizing their difficult work of talking to patients.
While the project’s architect Wolfson believes engaging physicians is key, Glen Stream, board chair of the American Academy of Family Physicians, places more faith in Choosing Wisely’s effort to educate patients on overtreatment. “Many physicians are already very aware of this issue, and a lot of the information isn’t really new. But it makes the conversation between me and the patient that much easier when they’re aware that there are tests and treatments that may have been common in the past that aren’t actually in their best interest.” One of the AAFP’s recommendations is the oft-repeated injunction against antibiotics in uncomplicated sinusitis, still being prescribed in about 80% of cases. It is the classic scenario where the patient simply will not take no treatment for an answer.
Strong disincentives to disinvest
Patient attitudes are a large factor, yet clearly the biggest reason for the overtreatment gap between the United States and other countries is perverse financial incentives in the US system. How many of us would voluntarily take steps that slash our income, and that of our employees, while simultaneously alienating our customers? That is what US physicians are being asked to do. Only a physician of rare moral courage could push back alone against these relentless pressures, which is why physicians are now being asked to try collectively.
If they fail, they will follow the usual course of industries in need of regulation. First an honor system, then a voluntary written code, then an industry appointed regulator, and when that finally proves toothless, government intervention. The current course is not sustainable even in the medium term. The recession brought a slight dip in the rate of increase in health spending, but next year is likely to see a spate of deferred elective procedures, and healthcare is still on course to consume one-fifth of the US economy in 2022.4
Research shows that most doctors want to change the bad behavior while keeping the bad incentives. Large majorities favor cutting unnecessary tests and treatments, yet only 7% support ending the fee-for-service system that creates them.2
“We need to evolve our payment model,” says Glen Stream, “and get away from pure fee for service, towards an idea of paying for value or quality. It’s where we need to be headed, but it’s a difficult transition—our current payment system has been around for decades, it’ll be slow to change.”
But budgetary imperatives may not wait. Preserving physicians’ bottom line is hurting the bottom line of big employers and government. In a country that has long been in denial about the link between physician income and runaway health spending, doctors could be knocked off their pedestal quite brutally.
“When I wrote my original article,” says Brody, “the idea, perhaps totally naive, that I had in mind, was that this was an opportunity to show professional leadership. To see whether we could, as physicians, bite the bullet and actually do something helpful for society and for patients. And if not, it would really be an admission that if the government doesn’t come in and beat us with a stick, that we just can’t manage this, we can’t handle it.”
Choosing Wisely has been criticized for lacking an implementation phase, and lacking practical measures to reduce overtreatment. But the project already represents a huge lobbying effort for a small foundation. If Wolfson had demanded enforcement mechanisms, Choosing Wisely would never have got off the ground. Instead the societies are at least on record acknowledging the wastefulness of many of their daily practices.
A longtime president of the Alliance of Community Health Plans (formerly The HMO Group), Wolfson knows that an implementation phase lurks over the horizon anyway. It will be imposed from outside if the profession cannot show it is different from other industries that needed to change themselves and failed. “My prediction is that if you’re not interested in value and you’re focused on volume, you’re on precarious ground in the future. I think incentives are going to change, payment systems are going to change and what is rewarded will be value and a purpose directed towards improving health.”
The group practice that just invested heavily in a new magnetic resonance imaging scanner is unlikely to draw up a plan to minimize its use just because their professional society put out a voluntary list of five that recommends less imaging. But who is more naive, Choosing Wisely for hoping they will listen, or the group practice for thinking they can keep this up while the government goes bankrupt? There is already a law against doctors owning scanners—the Stark law—government only has to close its loopholes.
“Choosing Wisely is now in the ether of American healthcare,” says Wolfson. “There’s a lot of talk about incentives, a lot of talk about measurement, but I think in the end, physicians want to do the right thing because it’s their calling, and this campaign has called attention to their core values. Our campaign was not about measurement, it was aimed at changing the conversation. Are we about changing the health of our population, or are we just producing units of service so we can bill more? Those kinds of conversations: ‘what are we in business for?’ are the most important we could be having now. It’s about professionalism. Financial incentives are not an excuse to do the wrong thing. Physicians take an oath to do no harm. I understand those perverse incentives and how they influence, but I think that physicians don’t feel comfortable providing care that’s not needed. We think that professionalism should trump financial concerns, particularly as this involves potential harm to the patient and sacrifices quality and safety.”
It is an idealistic view. Is it a naive one? Certainly, if the Hippocratic oath is a naive oath.
Cite this as: BMJ 2013;347:f5904
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.