Clinical guidelines often not so precise when it comes to cost

When developing clinical guidance policies, 57% of the 30 largest physician specialty societies in the U.S. explicitly considered costs in recommendations they made between 2008 and 2012, research shows.

Despite an increasing focus on how to reduce costs in the nation’s health care system, 13% of the professional organizations implicitly considered costs, 10% intentionally excluded costs and 20% made no mention, according to a study posted online May 6 in JAMA Internal Medicine, formerly Archives of Internal Medicine.

Among the 17 societies that explicitly considered costs, researchers found that 53% consistently used a formal system in which the strength of the recommendation was influenced in part by cost. The remaining 47% were inconsistent in their approach or did not mention the exact mechanism for considering costs.

“We saw this as holding a mirror up to the profession at large,” said Steven D. Pearson, MD, a study author and president of the Institute for Clinical and Economic Review at the Massachusetts General Hospital Institute for Technology Assessment in Boston. “My hope is that this will spark conversation. … I do think there is an important role for professional societies.”

He said people in general are uncomfortable with an individual doctor making a decision based on costs and that there is a role professional societies can play. For example, societies can look at resources and recommend against an intervention because the additional benefit is not enough to justify higher costs.

“It is about cost and quality,” Dr. Pearson said.

Price as part of the discussion

Some societies see the connection and are part of the broader conversation, Dr. Pearson said. He and the study pointed to the Choosing Wisely campaign as one example.

The American Board of Internal Medicine launched the national campaign in April 2012, and 25 specialty societies each have created a list identifying common tests or treatments that evidence has shown are not always beneficial.

The American Academy of Family Physicians, which is part of the Choosing Wisely campaign, is one of the professional societies the study cited as having done a thoughtful job of incorporating costs into what it recommends to its members.

AAFP President-elect Reid B. Blackwelder, MD, a family physician in Kingsport, Tenn., said physicians should remember they are treating patients, not just a disease or condition.

“If you keep that in mind, it changes your decision-making,” he said.

He said costs are not the main driver, but doctors need to be aware of costs and benefits. He said family physicians are trained to talk to patients about risks and benefits of treatments and that costs are a part of that conversation.

“Our goal is to make sure the patient gets the right care at the right time by the right person,” Dr. Blackwelder said.

The study notes that those who oppose explicitly considering costs believe “physicians should place individual patient needs ahead of societal needs, regardless of costs,” and they worry that factoring in costs to any decision will “ultimately lead to bedside rationing and cause a permanent rift in the physician-patient relationship.”

But study authors said that as more clinical care is delivered by physician-led groups such as accountable care organizations, it “seems timely for all physician specialty societies to consider costs when developing clinical guidance to help set standards for appropriate care.”

Dr. Pearson said: “If the professional societies don’t consider costs, then someone else will do it.”