Donald M. Berwick, MD: "Choosing Wisely": Physicians Step to the Front in Health Care Reform

The war-torn landscape of health care policy debate has left much of the public confused and frightened. At the center has been the Affordable Care Act, promising broader coverage for the uninsured and a better deal for people who have insurance, but under continuing barrage in Congress, the courts, and the media. Combined with the certain knowledge that health costs are far too high, this conflict leaves average people wondering what they will lose, and when.

Silver linings are in short supply, but one appeared last week in the form of a new initiative called "Choosing Wisely," catalyzed by the American Board of Internal Medicine Foundation. Its goal is to identify medical interventions -- like tests, procedures, drugs, and even surgery -- that are often overused without benefit to patients, and, in their words, "whose necessity should be questioned and discussed" between physicians and their patients. For this initiative, the ABIM Foundation worked with specialty societies, such as the American College of Cardiology and the American College of Radiology -- nine societies so far and more to come -- to identify "Five Things Physicians and Patients Should Question" in each specialty. For example, the American College of Radiology included, "Don't do imaging for uncomplicated headache," in its list; the cardiologists included, "Don't perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present."

Blunt, unfeeling cuts in health care benefits, coverage, or payments are one way to bring health care costs under control, but they are not the right way. Far better is to identify the many ways in which health care wastes money doing things that do not help patients and, too often, hurt them. But, public officials or payers are not trusted to point that out; when they try to call attention to harmful overuse of care, they are tarred as favoring "rationing," even when their motives are to help patients and the science is strong.

But, "Choosing Wisely" is a game-changer. The advice comes not from payers or politicos, but from pedigreed physician groups. The specialty societies are not guessing; their lists of procedures contain copious scientific citations supporting the claims of overuse. Their advice earns further trust because, in many cases, by suggesting that physicians and patients think twice before using certain tests and treatments, the specialty societies are speaking against their own economic self-interest, which in fee-for-service payment attaches income to volume. The American College of Gastroenterology, for example, recommends certain limits on colonoscopy frequency, even though more colonoscopies mean more income.

As one would predict and hope, the organizations carefully couch their recommendations in terms that leave room for doctors and patients to customize care to individual circumstances; they are, correctly, suggestions, not handcuffs. Payers, even while they celebrate this step of professional leadership, should exercise restraint in converting these lists into hard-wired payment rules.

However, these lists do no good if they remain on paper, only. The ABIM Foundation, these forward-thinking specialty societies, and many other professional groups should now help physicians, nurses, and other clinicians take concrete, local steps to reduce harmful overuse of ineffective care. And, equally important, these same physician-leaders ought to let the American public know boldly, repeatedly, and through every possible channel that asking questions about the need for and effectiveness of these practices is in each person's self-interest. If physicians and nurses explain it, the public can come to understand that avoiding unhelpful care is not rationing, but rational. It is a way to make sure that all Americans can get all of the care that helps them; avoiding care that hurts makes American health care more affordable. Happily, Consumer Reports, AARP, and other organizations representing the lay public are connecting tightly to "Choosing Wisely."

We are witnessing a horse race between those who would simply cut care and those, like me, who believe firmly that we can improve our way out of unsustainable costs. Overuse of unhelpful care is just one category of costs we ought not to agree to, but it is a fine place to start.

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