Choosing Wisely: The politics and economics of labeling low-value services

January 27, 2014, The Geisel School of Medicine at Dartmouth

The Choosing Wisely campaign, lists of services developed by physicians' specialty societies, is a good start to spark discussion between physicians their patients about treatments and tests that may not be warranted.

But researchers, led by Dr. Nancy Morden of The Dartmouth Institute for Health Policy & Clinical Practice, writing in a New England Journal of Medicine Perspective say the list could be improved to include more common services and higher cost services.

The Choosing Wisely campaign started in 2009 as an effort to get specialty societies to develop "Top Five lists" – lists of five low-value services that patients and physicians should discuss and question before pursuing.

It was initiated and funded by the American Board of Internal Medicine Foundation. As of 2013, there were more than 40 specialty specific lists to help physicians, patients and other stakeholders think and talk about overuse of health care resources in the United States. Consumer Reports leads a patient-education component.

On the surface, the creation of low-value lists suggests that physicians are willing to make recommendations to improve care value even against their own financial interest. But, many specialty lists include only or mostly low-impact services for physicians and patients to question.

For example, the American Academy of Orthodpaedic Surgeons listed such things as over-the-counter medications on its list of low-value items but "strikingly, no major procedures – the source of orthopedic surgeons' revenue," the authors said.

And, societies generally named other specialties' services as low-value rather than their own services. They commonly named such services as radiology, cardiac testing, medications and lab tests or pathology, the authors said. The notable exception is the Society of General Internal Medicine, which listed the routine annual physical exam as an item of low value.

The campaign was not intended to inform cost-containment and quality measures, but will probably be leveraged for that purpose, the authors said. Payers may use the lists to inform coverage, payment and utilization-management decisions. For this to be effective, the lists need to be translated into measurable activities and valid quality indicators "– a manageable but difficult task, because many services listed are, appropriately, finely nuanced and directed at precisely defined populations," the authors said.

The lists could prompt meaningful practice change if items were incorporated into quality-measurement efforts that are linked to incentives, such as the CMS Physician Quality Reporting System and National Committee for Quality Assurance practice standards.

Public education and reporting are critical as well, the authors said, and posited, "What will it take to purge the 'annual physical' from the American lexicon? … or convince with cardiac conditions that routine cardiac imaging is no longer needed and is in fact potentially harmful?" Such change will require physicians to revise their practice patterns and patient expectations that have been shaped and reinforced by habitual overuse of health care, the researchers said.

More lists should be developed, published, and heeded, they said. Partnerships with payers should also be considered, "but success will require skill and patience."

Efforts such as Choosing Wisely could advance a physicians' professionalism in medicine and their role as stewards of limited health care resources. "General acceptance of this effort to date by and the public is encouraging… This trust must not be squandered; rather it should be leveraged to restore balance in our nation's health investment," the authors said.

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