Now Viewing: Patient safety and outcomes

Choosing Wisely: Intensifying the Spotlight On Health Care of Dubious Value

Apr 30, 2014, 8:52 AM, Posted by Susan Dentzer


“If you study the kinds of decisions that people make, and the outcomes of those decisions, you’ll find that humanity doesn’t have a particularly impressive track record,” write the brothers Chip and Dan Heath in their masterful book Decisive. Invoking research from psychology and behavioral economics, the Heath brothers demonstrate how people often make decisions by looking at what’s in the “spotlight”—the information immediately before them, sparse as it may be.

But what’s in that spotlight “will rarely be everything we need to make a good decision,” the Heaths counsel. To choose wisely, we need to broaden our focus, or “shift the light.”

That’s especially true in health care, where the consequences of any decision, poorly made or not, may be life or death.

Enter Choosing Wisely, a program that shifts the spotlight onto many of the tests and treatments that both providers and patients should question, if not abandon completely.

(Editor's note: On May 2, 2014, RWJF held a First Friday GoogleHangout to explore how Choosing Wiselysprang from critical examination of the overuse of medical care in the United States—and how it’s changing how care is delivered in communities. Watch an archived version of the Hangout, above.)

This two-year old campaign, launched in 2012 by the American Board of Internal Medicine Foundation, has identified more than 250 tests and procedures that warrant scrutiny because they are ineffective, unnecessary, unsupported by evidence, or possibly harmful. Even so, physicians and other clinicians perform them regularly, and patients sometimes request them.

Fifty-four of the nation’s premier medical specialty societies have joined the Choosing Wisely effort, and most of these have contributed to their own lists of questionable care. This week, three non-physician groups will also sign on to the campaign. Among the categories of dubious care identified on various societies’ “top five” lists are these:

  • Excessive imaging: CT or MRI scans for low back pain shouldn’t be ordered within the first six weeks of treating a patient, unless there are severe neurological symptoms, while patients with minor head injuries shouldn’t routinely get a head CT unless they have a skull fracture or are bleeding. Excessive scans expose patients to radiation that increases their lifetime risk of cancer.
  • Unnecessary medications: Antibiotics are not effective against viruses and should not be prescribed for viral illnesses such as sinus infections or bronchitis, particularly in children. But doctors say they frequently feel pressured to write these prescriptions by anxious parents.
  • Superfluous screening or diagnostic tests: Patients with no symptoms of heart disease and are at low risk of developing it are still frequently subjected to electrocardiograms when they get routine physical exams, despite evidence that this routine screening doesn’t improve patient outcomes. By the same token, hospitalized patients may have their blood drawn countless times for costly diagnostic testing that often yield little useful information, and can contribute to anemia.

The Robert Wood Johnson Foundation is supporting Choosing Wisely with a $2.5 million grant to extend the influence of these lists beyond medical specialty societies and into communities. State medical societies in Texas, Oregon, Minnesota, Tennessee, Washington, and Massachusetts have undertaken steps to promote the lists, including developing continuing medical education courses for doctors. So have ten regional health collaboratives, such as Maine Quality Counts and the Washington Health Alliance outside Seattle (both are among RWJF’s Aligning Forces For Quality communities as well).

Consumer Reports and AARP are among organizations that have taken the lead in publicizing the lists for consumers. All told, these efforts have reached an estimated 170,000 or more physicians and 16 million-plus consumers. There’s even a Wikipedia page for the campaign, with the lists of tests and procedures curated by a “Wikipedian” in residence.

Caveats: Although more than 200 articles have been written about aspects of the campaign in medical journals, there is as yet little hard evidence that is has reduced superfluous care. A recent perspective in the New England Journal of Medicine noted that the specialty societies’ lists “vary widely in terms of their potential impact on care and spending”—and suggests that some societies omitted lucrative elective procedures, such as knee replacement surgery, that also aren’t appropriate for many patients.

The bottom line: As a nation, we need to shine a spotlight on an even broader range of questionable health care in the future. But for now, the Choosing Wisely campaign is illuminating plenty of “care” that we can clearly pass up with impunity as we pursue our real objective:  better health.


Susan Dentzer: Toward a Healthy America

May 9, 2013, 4:38 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

Many of the nation’s health economists are reviewing recent history to figure out what factors, besides the weak economy, might have caused health spending to slow over the past few years.  That’s a useful exercise, of course, but it’s even more crucial that we be hyper alert to the rocky health spending ahead—particularly as millions of Americans prepare to gain health coverage under the Affordable Care Act.

Towards that end, the Robert Wood Johnson Foundation recently teamed with several other nonprofits to fund four major analyses on health costs. The resulting reports, listed below, offer strategies for achieving a sustainable rate of growth of health spending, up to a trillion dollars’ worth of federal savings over a decade, and major improvements in the care provided to Americans.

In an era characterized by a lack of national consensus on so many pressing issues, these reports have a surprising amount in common. Each calls for even greater acceleration of the move away from fee-for-service payments to health providers, and toward payments pegged to improved health outcomes.  Almost all the reports propose major changes in Medicare and Medicaid, as well as extending payment and reforms to the privately reimbursed segments of the health care system.

Four reports do not a national groundswell make, but they could do provide the rationale for federal legislation, regulations and private sector system transformation that could further constrain health spending while improving care.

Medicare. Most of the reports envision fixing aspects of the traditional Medicare and Medicare Advantage programs, while simultaneously engaging in far broader reforms.

For example, the National Commission report proposes jettisoning Medicare’s troubled physician payment formula, asserting that it “has not worked in practice and shows no prospect of ever working.”  The Bipartisan Policy Center proposes replacing the formula with episode-based or case-based payments tied to quality measures, again breaking the longstanding link to fee-for-service, while The Partnership for Sustainable Health Care report calls for gearing Medicare payments for new treatments to their effectiveness relative to other treatment options already available.

As for the people those programs cover, both the Bending the Curve and Bipartisan Policy Center reports propose a new benefit structure for the traditional Medicare program that would better protect patients from catastrophic costs while imposing a combined $500 deductible for hospital and physician services.  Higher income Medicare beneficiaries would pay higher premiums. And to encourage more appropriate use of care, there would be no more “first-dollar” coverage available in Medigap supplemental insurance – only coverage with a deductible of at least $250, and a limit on covering no more than half of an enrollee’s Medicare copayments or coinsurance.

New Care Systems. More important, the reports recommend that all of Medicare transition to a dramatically new system of care provision and payment.  The Bipartisan Policy Center uses the terminology “Medicare Networks; Bending the Curve calls it “Medicare Comprehensive Care,” and says it would build heavily on emerging accountable care organizations. Providers would be paid capitated rates for assigned patients, and would have to meet a set of quality and performance measures to receive full payment.  These payments would grow over time no faster than the overall economy.   Within five years, Medicare beneficiaries could be encouraged to join these organizations through incentives, such as reductions in Medicare premiums and copayments.

Tax and Antitrust. The reports also agree on a need to cap the federal tax exclusion for employer-provided health insurance.  Taxing individuals on any employer contributions to fund the most expensive health would both raise revenue and curb some of the inducement for greater consumption of health care. What’s more, the reports argue that federal antitrust enforcement should block hospital consolidations that simply give the institutions greater power to raise prices, but encourage such mergers if it results in integrated delivery systems that take on financial risk for delivering inferior quality or excessive costs.

Medical Liability. This favorite issue of physicians is also addressed, with several of the reports recommending major changes in medical liability that would sway doctors away from providing excessive care meant to prevent lawsuits.  One recommendation is for so-called “safe harbor” protections for clinicians who effectively practice recognized standards of care, and call for replacing tort claims with a new system that would directly compensate injured patients.

Of course, if effectuating any of these changes were easy, it would already have happened. Enacting any of these proposals will run up hard against defenders of the status quo. But change begins with a groundswell of agreement around what is possible and desirable.  These reports provide an important starting point for the next round of serious health care reforms.