Patient after patient asks for relief for sinusitis. Doctor after doctor gives them a prescription for medication—even though most infections are viral, not bacterial, needing no drugs to treat.
When prescribing statins for heart ailments or high cholesterol conditions, doctors sidestep less-expensive generic brands.
These and other wasted costs amount to nearly $6 billion, according to the National Physicians Alliance (NPA), a Washington, D.C.–based physician research group.
Doctors must reevaluate their procedures, eliminating or minimizing costs where possible, physicians said at a conference this month that focused on cost savings and improved patient care in Medicare in Washington D.C., sponsored by Health Affairs.
As the nation’s healthcare system moves toward value-based care, physicians have to step up efforts to reduce wasteful spending, which is often linked to improper patient care.
“It’s a responsibility of the professional to be decreasing costs, decreasing the amount of unnecessary care, wasted care, care that is not beneficial to patients, but adds to costs,” says Steven E. Weinberger, MD, executive vice president and CEO of the American College of Physicians.
Over the last few years, more physicians and hospitals have been adopting care checklists, not only to ensure proper procedures but also to reduce duplication of services and errors. A speaker at this week’s Medical Group Management Association in Las Vegas, for instance, urged physicians to adopt checklists to become more efficient. The Johns Hopkins Hospital in Baltimore has saved $2 million with a five-item checklist that reminds hospital personnel to first wash their hands. Weinberger says the ACP has initiated a “high-value, cost conscious care initiative” to identify areas of “overuse and misuse” to educate physicians, patients, and medical trainees. He also calls for a “national, multistakeholder initiative to reduce marginal and effective care.”
But some physician groups are taking the checklist premise one step further, focusing on procedures that should be minimized or eliminated altogether.
One of the key proponents of such lists of wasted practices is Howard Brody, MD, at the Institute for Medical Humanities at the University of Texas Medical Branch at Galveston. “The myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained,” Brody wrote last year in the New England Journal of Medicine.
Brody suggests that each specialty society appoint blue-ribbon panels to create “top five” lists of diagnostic tests or treatments that are among the most expensive and generally do not provide much benefit.
Nancy Morioka-Douglas, MD, MPH, a clinical professor of medicine/community and family medicine at the Stanford University Medical School, and a member of the NPA, agrees that doctors must take control of costs, especially needless procedures.
Referring to Brody’s plan, Morioka-Douglas seeks a “call to action” among each medical specialty to generate lists of at least the top five commonly ordered diagnostic tests or treatments that provide “care of low value to patients, specifically if it carries risk that outweighs benefits.”
The NPA convened a Good Stewardship Working Group to identify overused clinical activities across three primary care specialties, internal medicine, and family practice.
The working group homed in on seven areas of overuse, with specific cost savings in several cases:
1. Statins. Low-cost generic statins should be prescribed when initiating cholesterol-lowering treatment rather than high cost, brand-name drugs, saving $5.8 million annually.
2. Sinusitis. Antibiotics are prescribed in more than 80% of outpatient visits for acute sinusitis—accounting for 16 million physician office visits annually—but most cases are due to viral infection that will resolve on its own.
3. Imaging. Lumbar spine imaging for lower back pain before six weeks does not improve outcomes but increases costs. Back pain is the fifth most common reason for physician visits.
4. Electrocardiogram screening. Potential harms of annual ECG screening exceed potential benefits, Morioka-Douglas says. ECGs or other cardiac screening should not be performed annually for asymptomatic, low-risk patients.
5. Pap tests. They “don’t show much in women who’ve had a total hysterectomy for benign disease, and there is poor evidence for improved outcomes,” Morioka-Douglas says.
6. DEXA screening. Bone-density screening for osteoporosis is not cost-effective in younger, low-risk patients. Bone density testing in women under age 65 accounts for $527 million in annual costs.
7. Blood chemistry panels. It’s not necessary to order basic metabolic panels or urinalysis for screening in asymptomatic, healthy adults. When complete panels are performed on asymptomatic patients, only lipid screening yields significant numbers of positive results. Orders of complete blood counts for general medical examinations were associated with $40.8 million in costs.
This list is not comprehensive, Morioka-Douglas says. There could be many variations of lists, with other procedures added. “We challenge other physician groups to come up with a comparable list of goals,” she adds.
Weinberger, of the American College of Physicians, says his organization is also forming a checklist for publication soon. “We’re identifying areas of misuses and talking very much about what the National Physicians Alliance is doing,” he says.
But your organization doesn’t need to wait for a national program. Physicians can use the NPA checklist or adapt it to their own needs to ferret out waste.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
