Nine medical societies, in a campaign dubbed Choosing Wisely, have identified 45 common medical tests and procedures that they are encouraging doctors to use less often, and patients to demand less often. The societies say these tests are frequently unnecessary and can, in some cases, cause more harm than good.
Some health experts estimate that overprescribed tests, procedures and treatments cost up to $250 billion every year. They range from EKGs, MRIs and brain scans to Pap smears, bone scans and the overuse of some antibiotics and cancer drugs.
The specialty groups, under the auspices of the American Board of Internal Medicine Foundation, have no objections to tests and procedures that are deemed appropriate; their target is those that are wasteful or are ordered by doctors mainly because they have a financial stake in their usage.
While some health care participants have voiced concern that these recommendations will lead to rationing of health care and new limitations on the ability of consumers to make health care choices, others applaud the move as long overdue. “To some extent, physicians are trying to move in the direction of showing concern about the costliness of the tests they recommend as well as the medical appropriateness of them,” says Wharton health care management professor Mark V. Pauly, an economist. “The idea not only of questioning your doctor about these tests, but questioning your doctor about everything, is what I would advise the sensible consumer to do.”
Yet Pauly is concerned that the specialty groups’ advice may be ignored by many Americans. Most of them, he says, have health insurance and therefore don’t directly shoulder the cost of these tests, which, if managed properly, “won’t do you harm. They just won’t do much good.” More consumers would question the need for tests, he suggests, if they “have an economic stake in the outcome.”
Attempts to change patient cost sharing have been one approach to creating such a stake. “The easiest way to talk about this is to say — and this has actually happened — that certain procedures everybody agrees are super high-value ought to be free, like pediatric immunizations. The mirror image of that, which people don’t like to talk about, is that some tests provide, not zero benefit, but just a very small benefit for a very high cost.” One example, Pauly says, is a dexa scan to test for bone density. “It’s a fairly rare condition,” but because many consumers have insurance to cover the test’s cost, they will opt to have it done. “Using cost sharing to guide people towards the things of high value and away from the things of low value seems like common sense. I think there is some movement in that direction, although there could be more.”
As to whether physicians are reluctant to cut back on testing if they have a financial investment in the testing procedures, Pauly notes that this question applies whether one is talking about “physicians or auto mechanics…. If they are recommending a test or a procedure that they are going to perform themselves, you’re not sure their motives are totally pure.” Most of the time, he adds, he is confident that physicians make recommendations “based on their medical judgment alone.”
Mark Duggan, Wharton professor of business and public policy, also applauds the Choosing Wisely campaign, noting that some physicians are finally coming forward and identifying certain procedures where overuse is especially prevalent. “To the extent that you are going to shine the light anywhere in the health care system, these 45 tests and procedures are a good place to start.” Overuse is no surprise, he adds, given that “often a person pays nothing to get a procedure, and the person doing the procedure gets more income.”
Duggan cites three ways in which the specialty boards’ recommendations could lead to a reduction of low-value, no-value or negative value tests. One: Doctors would realize that for every five times they order a test, perhaps one of those times wasn’t necessary. Two: Patients would see these recommendations and be more skeptical about agreeing to certain tests. Three: Insurers would have “a powerful rationale for introducing slightly different co pays for these kinds of services.” Insurers “could say that for a particular type of treatment, we are going to raise our co-pay,” says Duggan. “Inevitably, whenever that happens, there is a concern it will harm access or reduce necessary care. You have to keep that in mind…. But it is so abundantly clear that in the years ahead, with the aging of the baby boom generation and anemic job growth, something needs to be done.”
Besides raising co pays, insurers can raise co-insurance, which means, for example, that consumers pay a percentage of the cost of individual procedures. “Maybe then, people would have an incentive to go to providers who offer a test, such as an MRI, for a lower cost” than a competing service, Duggan says, adding that the hundreds of thousands of physicians in the U.S. “are doing their best to provide good care.”
He emphasizes that the specialty groups’ recommendations do not prohibit people from getting certain tests. “It’s just saying that if you want to have them, you will need to pay a little more because medical evidence shows that these tests deliver benefits that are far below their costs.”
At some level, Duggan notes, “physicians need to make a more compelling case to themselves and their patients that a particular test is really needed, or isn’t needed. I don’t think it will lead to a sea change in American medicine, because there is so much wasteful spending in the health care system. [I see] this as one tiny step in the direction of trying to make it more efficient.”