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When good care means less pay

BMJ 2013; 347 doi: (Published 04 October 2013) Cite this as: BMJ 2013;347:f5997
  1. Edward Davies, US news and features editor
  1. edavies{at}

Last year the BMJ launched its campaign against the harms of overtreatment (Too Much Medicine:

It did not do this as a lone voice in the wilderness but as part of a group of organizations and individuals who are slowly realizing that some screening, diagnosis, and treatment is doing more harm than good to patients.

One other such organization is the American Board of Internal Medicine, which launched the Choosing Wisely initiative ( at about the same time as the BMJ launched its Too Much Medicine campaign.

The basic aim of the ABIM initiative is to “promote conversations between physicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests and procedures, free from harm and truly necessary.” The way it has sought to start the conversations is to challenge national organizations, representing medical specialists, to identify “five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.”

The lists ( of the dozens of organizations that have risen to this challenge testify both to the importance of the campaign and the spread of the problem.

This week the BMJ looks at some of those lists and how easy it will be to translate a theoretical wish list into everyday practice (doi:10.1136/bmj.f5904). And the answer is that it won’t be easy.

Although individual physicians and their wider organizations agree with the theory of this initiative, the basic structure of the US healthcare system leaves the odds stacked against physicians making changes to their daily practice.

Not least, as the author Owen Dyer points out, because of the fee-for-service model, which represents a fundamental stumbling block. According to a recent survey published in JAMA, most physicians favor cutting unnecessary tests and treatments, yet only 7% support ending the fee-for-service system that often creates them (

Dyer writes: “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.”


Cite this as: BMJ 2013;347:f5997