How it became cool to choose wisely
Created in 2012 by the American Board of Internal Medicine Foundation, the Choosing Wisely® initiative encourages physicians to use evidence-based recommendations when making care decisions for their patients. The initiative’s goal is to identify and promote healthcare that is:
• Supported by evidence
• Not duplicative of other tests or procedures the patient has already received
• Free from harm
• Truly necessary
Choosing Wisely began with recommendations from just nine medical organizations. It’s expanded to include more than 70 specialty societies. Each one produces an evidence-based list of tests and procedures they consider to be overused and potentially harmful. Many – though not all – of the services are related to diagnostic imaging.
Making care decisions based on evidence sounds great! So what’s the issue?
The cost of being wise
Physicians are increasingly being asked to embrace financial stewardship and payment reform. This also pushes them to consider the value of the services they provide. Low-value services are defined as common tests and procedures that are frequently overused or misused. But there continues to be little agreement on which services to classify as low-value. And there’s no consensus on which mechanisms are most cost-effective in reducing the use of these low-value services.
Although widely discussed, the healthcare system has been slow to effectively discourage service overuse. According to a recent study from The Dartmouth Institute for Health Policy and Clinical Practice, most physicians agree that while they have a responsibility to control costs, more than one-third don't know how much tests and procedures actually cost. And about one in three say they don’t consider cost when making medical decisions.
Wisely addressing the elephant in the room
Change can be hard, even when physicians agree to the need behind it. There are a number of barriers to changing how physician’s practice. One is the undeniable presence of the elephant in the room — the incentives, particularly financial ones, for ordering low-value tests and treatments. After all, in a fee-for-service system, most delivery systems continue to be paid for tests and drugs, regardless of their appropriateness or indication. Payers are then able to pass on these costs to employers and patients, creating a vicious cycle.
Despite the elephant in the room, it’s natural to wonder: Is Choosing Wisely working? Analysis points to the fact that while there’s a willingness on the part of physicians to forgo low-value care services, there needs to be further engagement with more than just physicians. To really begin to see the impact of Choosing Wisely, and to see a meaningful reduction in the use of low-value services, there must be appropriate support to address patient demand, malpractice concerns, and other drivers of overuse. The behaviors and attitudes of patients, regulators, pharmaceutical companies, and other stakeholders also play a crucial part in the consumption of low-value services.
The challenge of being wise
Efforts to reduce low-value care can decrease spending while helping patients avoid potentially harmful treatments. However, these efforts face enormous challenges.
One major challenge is patient understanding of health information. According to the U.S. Department of Health and Human Services, nearly nine out of 10 adults have difficulty using the everyday health information that’s routinely made available to them. Without clear information and an understanding of how to prevent and self-manage conditions, these individuals are more likely to skip necessary medical tests and insist on those that are unnecessary. They also end up in the emergency room more often, and have a hard time managing chronic diseases.
Another challenge is agreeing on a strategy to reduce low-value care. Currently, there are two approaches for reducing low-value care.First, professional societies are exhorting physicians to consider both cost and value when deciding among alternative treatments. This strategy appeals to a physician’s sense of professionalism by promoting the idea that they are stewards of societal resources. Second, payers are promoting healthcare system innovation and implementing payment reforms to reduce incentives for providing ineffective treatments. Unfortunately, discussions about how to reduce low-value care often gloss over a crucial third strategy: a sustained effort to generate evidence that will distinguish between high and low-value care.
When it comes to reducing unnecessary tests and treatments, clinical decision-making is just one piece of the puzzle. More targeted research, including comparative effectiveness, would help determine which treatments or services are low-value. While it’s not feasible to conduct a trial on every service mentioned in the Choosing Wisely recommendations, the lack of high-quality evidence will hamper efforts to reduce low-value care. Clinicians are more likely to respond to a recommendation to avoid a low-value treatment if it’s based on sound evidence, than if it’s justified on the grounds that the treatment has never proven to be superior to another one. The absence of evidence is not the same as evidence of ineffectiveness. And healthcare system leaders and administrators may have difficulty convincing front-line physicians to change practice patterns without appropriate evidence.
It takes a village to be wise
Based on a recent survey, only one in five doctors is aware of the Choosing Wisely initiative. Even more disappointing, of those doctors who do know about the campaign, 53 percent say that when a patient asks for an unnecessary test or procedure, they order it anyway.
In a healthcare system that continues to reward volume, the switch to evidence-based medicine remains an up-hill battle. To effect real change, patients must be advocates for their own health and learn that “Choosing Wisely” means making thoughtful, well-reasoned healthcare decisions. By normalizing conversations that have been notoriously off limits, Choosing Wisely will continue to drive care that focuses on the physical, mental, emotional and financial health of the patient.