The former acting head of the Centers for Medicare & Medicaid Services lauds efforts such as the Choosing Wisely campaign, which aim to reduce medical interventions "for which the risks outweigh the benefits."
At the American Hospital Association's Leadership Summit last week, Don Berwick, MD, called out the "11 scary monsters" lurking under the healthcare industry's bed. Can you guess which one he says is the worst one of all, the Godzilla thwarting improvements to quality care?
Pat yourself on the back if you said "excess," or "overtreatment." These are drugs, tests, or procedures that "don't help, but subject people to risk." Berwick, former acting administrator of the Centers for Medicare & Medicaid Services, says spending on American healthcare is 40% more than it needs to be.
See Also: Berwick Names 11 Monsters Facing Hospital Industry
But if he had his audience trembling in their seats, worried about their jobs, Berwick may have scared a few listeners even more by talking about "the courage" he's seen in three efforts underway to slay those beasts.
The first, he said, is that "The ABIM (American Board of Internal Medicine) Foundation has been sponsoring the Choosing Wisely campaign."
The second, "Shannon Brownlee and Dr. [Vikas] Saini [of the Lown Institute] have been doing the important work…They're taking a closer look at overtreatment and it will be scary what they find." [Note: Berwick is a volunteer member of the Lown Institute Advisory Council.]
And third, he said, "I'm thrilled that Rich [Umbdenstock, president and chief executive officer of the American Hospital Association] is now telling me that the AHA is taking on the agenda of appropriateness [of care]. That's now on the AHA agenda."
So the AHA is trying to slay its dragon from within. That's very cool.
I wanted to dig in deeper to each of these efforts to see where they began, how far they've come, and what they accomplish in coming years. Here's what I found:
Choosing Wisely Expanding
Daniel Wolfson, the ABIM Foundation's executive vice president and COO, explains that the Choosing Wisely campaign began in 2001 with the simple premise that "physicians should be good stewards of resources."
With a small ABIM Foundation grant, the National Physician Alliance came up with five types of procedures or practices in primary care "for which the risks outweigh the benefits."
That was followed by a 2010 article in the New England Journal of Medicine. by Howard Brody, MD, director of the Institute for the Medical Humanities at the University of Texas. Against a backdrop of Congressional wailing about the out-of-control spiral of healthcare costs, author Brody suggested that physicians couldn't pretend to be blameless bystanders helplessly watching the system explode.
Rather, the enormous variation in healthcare costs across the country was evidence that physicians, the ones ordering tests, drugs, and procedures, were failing to conform to evidence when they urged some expensive and sometimes harmful for their patients. Doctors needed to clean their own house.
Brody suggested that every physician specialty group develop a "blue ribbon committee" to agree on "five diagnostic tests or treatments" commonly ordered by that specialty that are among the most expensive, and which had not been shown to not provide meaningful benefit to major categories of patients.
Each physician group's "Top Five would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit," Brody wrote. He suggested that arthroscopic surgery for knee osteoarthritis and many common uses of CT scans, should start the list.
Nine specialty groups' lists launched the project in April, 2012 with their selection of 45 procedures, tests, or drugs that patients and their doctors should seriously question before undergoing because of the potential for needless cost, waste, and harm.
In March, the ABIM Foundation grew that list from nine specialty groups to 26, and from 45 procedures, drugs and tests to 130, some of which groups felt so strongly about, they duplicated.
But there's more, Wolfson says. Later this month and through the fall, The ABIM Foundation will grow that list again, adding another 30 specialty groups' top fives, for a total of 250 procedures and tests that doctors and patients should avoid.
The ABIM Foundation collaborates with Consumer Reports to take the message to patients as well, to reassure them that they are not necessarily getting poor or no care when they don't receive worthless or harmful treatments.
"We've elevated the conversation and made it legitimate to talk about, and get away from the hysteria that this is about rationing and death panels," Wolfson says. He points to this week's New York Times article about efforts to stop calling certain benign conditions "cancer," such as ductal carcinoma in situ.
The Lown Institute Tackles "Inculturation"
President Vikas Saini, MD, tells me the institute is tackling the problem from another angle, that of the habits and "inculturation," engrained in physicians to influence their overtreatment of patients starting in medical school.
It's also focusing on the institutional barriers, such as poor bench-to-bedside translation of evidence, gaps in physician knowledge, defensive medicine practices, and patient misunderstandings that result in treatment trajectories the patient never would have wanted.
"The real issue is conflict of interest," Saini says. "What it means to be a healthcare professional is that you take your special knowledge and skill and put it at the service of the patient." But conflicts of interest "have proliferated, and not just with industry support, but much more broadly.
"There's so much money in the system and the money seems to have taken over." An institute survey on physician and hospital overuse is in the planning stages.
AHA to Address 'Appropriateness'
Though Umbdenstock was excited enough about the AHA project to tell Berwick about it, the AHA is "not ready to share details at this time," a spokeswoman wrote me in an e-mail.
So I was left to ask others what a "Choosing Wisely-" like campaign aimed at reducing "excess," "overtreatment," or "inappropriate" services within acute care institutions might look like.
And I am left to imagine where those efforts could go. This could be a tough one for some struggling organizations, because apart from bundled or global payment arrangements or accountable care contracts, saying "no" to acute setting tests and procedures will impact a hospital's bottom line.
Wolfson recalls that when he had a detached retina requiring surgical repair, he was told that he couldn't have the procedure without first having an EKG test. "When I questioned that, they said to me that the anesthesiologist required it because it was protocol. It was department system policy. That's an example of many policies that suggest it's a system change that needs to occur," he says.
Hospitals can tackle policies and procedures that require extra or more frequent imaging without any medical necessity. Wolfson says that Cedars Sinai Medical Center in Los Angeles has embedded 120 decision support points into its electronic medical record system.
Hospitals can institute more "hard stops," such as those being launched at many hospitals to reduce medically unnecessary, elective C-sections and inductions prior to 39 weeks of pregnancy, no matter the physician or patient's request.
There could be hard stops that prompt panel reviews of procedures for some cardiology conditions which have not reached clinically significant thresholds.
And these decision support points can trigger reviews of physician staff privileges, pointing out outliers who may appear to be doing too many procedures.
I eagerly await what the AHA will roll out for its own Choosing Wisely version of this effort.