Choosing Wisely list is about good judgment, not curtailing care, medical societies say
■ Physicians caution that payers shouldn’t use a list of potentially wasteful tests as a license to reject payment for them arbitrarily.
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When the American Board of Internal Medicine Foundation published its list of 45 overused tests and procedures that physicians and patients should think twice about, it did so with the caveat that these aren’t things doctors should never do — nor are they actions that should never be covered by public and private insurers.
“It’s about cutting waste; it’s not about rationing,” said Christine Cassel, MD, president and CEO of the American Board of Internal Medicine and the ABIM Foundation, which released the list as part of the “Choosing Wisely” campaign.
The list of 45 tests and procedures, released April 4, was compiled by the American Academy of Allergy, Asthma & Immunology; the American Academy of Family Physicians; the American College of Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Assn.; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology.
They run the gamut from the cautionary, “don’t diagnose or manage asthma without spirometry,” from the AAAAI, to the urging from nuclear cardiologists to “use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.”
The listed services are not presented as always unnecessary, but rather as “things physicians and patients should question.”
Dr. Cassel said they deliberately did not list anything in absolutes.
“For every one of these items, there are times when it is indicated,” she said. “We aren’t saying you should never do it — these are times you ought to have a conversation about whether you need it or not.”
The Choosing Wisely campaign was sparked by a 2010 article in The New England Journal of Medicine by medical ethicist Howard Brody, MD, PhD, calling on physicians to think about five things that are overused, Dr. Cassel said. That article prompted the National Physicians Alliance to publish a list of overused tests and procedures in primary care. The ABIM Foundation wanted to spread the idea to as many medical specialties as possible.
The campaign sponsors also are focused on encouraging patients to ask questions so that physicians aren’t faced with trying to talk a patient out of a test or procedure. For that reason, the ABIM Foundation recruited nearly a dozen consumer groups, including Consumer Reports, to help disseminate the list.
The American Medical Association also supports the campaign.
“The medical specialty societies who participated in developing the ‘Choosing Wisely’ recommendations are all members of the AMA-convened Physician Consortium for Performance Improvement,” AMA President Peter Carmel, MD, said in a statement. “We applaud the efforts of our colleagues in this group to identify procedures and tests that are subject to overuse or inappropriate use, and we have worked with them to address many of the same problems through the development of quality measures. The AMA remains committed to working with medical specialty societies and other stakeholders to address areas of our health care system where our joint efforts can improve health outcomes for patients.”
Robert Zirkelbach, spokesman for the trade group America’s Health Insurance Plans, said one positive of the campaign was its reliance on consumers and physicians to make informed decisions before the insurer is involved.
“It’s encouraging to see employers, physicians and consumer groups all coalescing around these types of issues,” he said. “It’s great to see these specialty societies taking a leadership role in identifying these areas for improvement.”
Physicians often complain that insurers demand undue justification and documentation for tests and procedures. No health plan has announced any changes in compensation or pre-approval for items on the Choosing Wisely list, and those behind the list say insurers shouldn’t use it that way. But some physicians worry that could happen and are keeping a sharp eye on insurance companies to see what they do.
Mike Sevilla, MD, a Salem, Ohio, family physician and blogger, has written about his issues with the list. He said he agrees with the Choosing Wisely campaign but is “concerned about the unintentional consequences of this.”
“There is no doubt that we are on an unsustainable course [with] health care costs in this country. While I applaud physician groups and patient/consumer groups stepping up to try to address the problem, will insurance companies and payers compound the problem and deny care that my patient and I agree is necessary for appropriate care? Time will tell.”
The ABIM Foundation announced that eight other societies plan to release their own lists in the fall of 2012. They are: the American Academy of Hospice and Palliative Medicine; the American Academy of Otolaryngology—Head and Neck Surgery; the American College of Rheumatology; the American Geriatrics Society; the American Society for Clinical Pathology; the American Society of Echocardiography; the Society of Hospital Medicine; and the Society of Nuclear Medicine.
Beyond targeting individual procedures and tests, Dr. Cassel hopes the Choosing Wisely campaign will be part of a change in mindset by physicians. “I have a friend who is chief of medicine at a medical center, and now every time they have Grand Rounds, he asks the person, ‘When are the times you would not need to do this?’?”