This summer, the organization representing 130,000 internists will publish of a series of papers that will tell America's doctors what they should and should not order in diagnostic tests and therapies, a guideline that strives to lower cost while it eliminates unnecessary care.
"We feel it's our responsibility to be developing some recommendations as to what our physicians should be doing to keep costs down," says Steven Weinberger, MD, deputy executive vice president of the American College of Physicians. While the organization will be looking at diagnostics as well as therapies, its first target will be the former.
First up, Weinberger says, will be a paper examining the needless yet expensive tests such as magnetic resonance and CT scans ordered for simple low back pain when simpler and much less expensive x-rays would suffice.
"If we look at the things that are overused and misused, there's a fairly large amount of low-hanging fruit," Weinberger says. "There are patients who get much more in the way of MR or CT scans (tests that cost thousands of dollars) than are needed or indicated, or follow-up scans that should be done as x-rays. And we're going to say to our physicians, these are the ways to practice medicine most effectively."
That low-hanging fruit may yield huge savings, he says.
"Look at the numbers that are so very high: [PricewaterhouseCoopers] says it's $210 billion and the Congressional Budget Office put the number at $700 billion – that's annual spending on unnecessary care," care that doesn't improve outcomes.
The ACP is calling its effort "High-Value, Cost-Conscious Care Initiative," a series of recommendations that will be published starting sometime this summer after they are thoroughly vetted and peer reviewed in the Annals of Internal Medicine, the ACP's bi-weekly medical journal. The initiative was announced on Sunday, the last day of the organization's annual three-day meeting, which this year was held in Toronto.
The ACP says it is the largest medical-specialty organization and second-largest physician group in the United States, so presumably its recommendations will carry some weight.
Weinberger, executive vice chair of the department of medicine at Beth Israel Deaconess Medical Center in Boston, says part of the ACP's goal is to break the bad habits some doctors get into.
"There's plenty of things that physicians do when there is really no evidence they should do it, but it's become part of the culture," he says. But he adds, "This is not rationing," but if strategies like this aren't initiated to reduce unnecessary, expensive procedures, rationing of those medical interventions that are necessary may become more likely when money really does start to run out.
Another aspect of the effort will involve educating patients and educating physicians how to say no to patients who ask for tests and treatments that aren't really indicated. Doctors may point out that the test doesn't do any good, but too often they don't want to, nor do they try to fight their patients on the issue. In the end, the physician gives in. That's the type of practice Weinberger says should stop. American Medical Association President J. James Rohack, M.D. Is on board with the idea. "Physicians need tools to help them identify and provide appropriate medical care. In many cases, the needed tools will be used across settings and by many different specialties, and the AMA-convened Physician Consortium for Performance Improvement has developed a cross-cutting process for developing measures on coordination of care and appropriate use."
Weinberger, a pulmonologist, says he sees many patients undergoing lung function tests prior to surgery, on orders from their physicians, "when they don't have lung disease, and there's no reason for them to have these tests. But it's part of that physician habit."
Another example, he says, is the excessive ordering of magnetic resonance image tests for patients' joints before operations "when there's no need to get those done."
Weinberger was asked if the ACP is prepared for criticism from other providers, such as radiologists, who may perceive the guidelines as an effort to take business away from them, or perhaps insinuating themselves into areas where they have no expertise.
But Weinberger replies that's not the ACP's worry. "Our first responsibility is to patients and society, to provide the best possible care that keeps costs in line. We have no interest in cutting down those procedures or tests that should be done and done appropriately."
And, he added "there will still be plenty of business for the radiologists—plenty of appropriate diagnostic work that needs to be done."
Other areas that are ripe for the initiative's scrutiny include cardiology studies that include exercise testing, some of which include imaging studies. Also included will be numerous blood tests that are done routinely prior to surgical operations. "Some may be indicated, but some may not be," he says.
The use of certain drugs may be unnecessary, but are prescribed by doctors out of habit, he says. Take the tuberculosis drug Isoniazid. When patients are taking that medication, Weinberger says, their doctors usually order liver function tests routinely, "when they don't necessarily need to be done routinely in all patients."
The ACP also will be recommending numerous ways in which physicians communicate with their patients other than through an office visit, such as greater use of e-mail, "which may indicate you don't need to have the patient come in for an office visit after all." More physicians will be working with payment models that involve "the patient centered medical home," rather than relying on income from those patient visits.
How does he think physicians will take these recommendations, especially if they challenge or question decades' worth of practice? Weinberger says he feels confident they will understand and do the right thing once they see the evidence.
"I'm not sure there is going to be that much controversy," he says. "The physicians we've spoken to agree that there's a lot of overuse and misuse of care. And the overwhelming sentiment is that it really is the responsibility of physicians to address this and take control of this. It's a lot better if we do it than if the insurance industry does it, or any other third-party payer."