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Choose Wisely 

Doctors and patients are teaming up to reduce unnecessary treatments — and to improve outcomes

click to enlarge ALI BLACKWOOD ILLUSTRATION
  • Ali Blackwood illustration

The congestion, coughing and sore throat just won't go away. You have to stay home from work, and you're losing sleep. You schedule a visit with your doctor, thinking you have an upper respiratory infection and hoping to get some antibiotics for some relief at last.

But your doctor says no. Antibiotics, the doctor explains, are unlikely to help. Not only could an unnecessary prescription be potentially harmful, but it will also cost money and increase the threat of resistance to antibiotics. You get it. Antibiotics aren't the answer this time. Leaving the clinic, you have a better understanding of what to do to get better and what to do in the future. In short, you're now an empowered patient.

This is how the Choosing Wisely campaign should work. The campaign is a national initiative of the American Board of Internal Medicine that encourages physicians and patients to discuss necessary treatment based on evidence-based recommendations. The goal is for patients to get the best value out of health care spending, a balancing act that should lead to the most effective treatment to achieve the best possible quality of life, while creating the fewest negative side effects and complications, all at the best price.

Educating patients is key, but it takes time. "It turns out there's a bunch of studies showing that if you provide information to patients, in the context of having empathy, then patients are satisfied without receiving those services," says Matt Handley, chairman of the Washington state Choosing Wisely Task Force.

Handley says experts have known for years that there's too much "low-value" care. The Washington Health Alliance sought to reduce overuses several years ago, and when the Choosing Wisely campaign launched, Washington Health Alliance became one of the few grantees in the nation to promote it in 2015. Handley, who's also a medical director for quality for Group Health, says the state is seeing results, and that Group Health has reduced the use of antibiotics for upper respiratory infections by 50 percent, with no change in patient satisfaction.

But there's another push in the movement for quality over quantity in health care: physicians are now actually being paid for the value of the care they deliver, instead of payment based on the number of tests ordered or patient visits.

Combined with the shared decision making in the Choosing Wisely campaign, it's led to a changing landscape in health care for both for patients and physicians. To reduce health care costs, and achieve better outcomes, both patient choices and physician reimbursement will need to be transformed. "If you're trying to improve value," Handley says, "you've got to do both."

SHARED DECISIONS

Choosing Wisely recommends a number of ways to cut down on patient visits and reduce the cost of health care for patients. In addition to cutting antibiotic prescriptions when evidence shows they aren't likely to be helpful — theoretically also cutting down on patient visits — the campaign recommends that certain procedures be conducted more sparingly.

Carl Olden, a physician at Pacific Crest Family Medicine in Yakima, says that the common practice in the past has been for women to get a Pap smear every year until women turned 65. But women don't need a Pap smear every year, according to a recommendation from the American Academy of Family Physicians and Consumer Reports. Since it takes 10 to 20 years for cervical cancer to develop, Choosing Wisely recommends that women in their 20s only get a Pap smear every three years. For women 30 to 65, it's generally every five years, along with an HPV test.

"Most women are happy to hear that," Olden says.

But while a recent national survey showed that many primary care physicians find Choosing Wisely recommendations easy for them to follow, doctors are wary that their patients will resist following the guidelines. The Journal of General Internal Medicine surveyed 2,000 primary care physicians and 2,500 primary care providers at the Department of Veterans Affairs about recommendations on four diagnostic tests, screening tests and medications that are likely to cause harm if overused. Of those who responded, 80 percent said advice on avoiding overscreening, or testing for colon cancer or cardiac problems, would not be difficult. But the study also found that physicians most consistently considered some recommendations difficult for patients to accept. Those included limiting the use of antibiotics for sinusitis, avoiding imaging for low back pain, and not prescribing sedative-hypnotics to treat insomnia, agitation or delirium in older adults.

This is why it's important for physicians to educate patients, says Olden, who adds that his patients understand that they may have to wait longer to see him because he spends more time discussing decisions with patients. He says physicians must talk to patients in a way that's respectful and provides education, because it will ultimately lead to better outcomes in value and cost.

Reducing unnecessary treatment, says Olden, will clearly reduce costs.

Yet there's one sometimes overwhelming barrier in convincing patients to avoid a treatment they may not need. What if there's even a 1 percent chance they do need it? What if, even though Choosing Wisely recommends against most CT scans for a headache, that CT scan ends up revealing something serious that otherwise would have been ignored?

"That takes a long time to have that discussion. It's easier to say, 'Let's go ahead and get it,'" Olden says. "We have to fight against that."

It's tough for a physician. Patients have ideas about what they want, and the system is designed around the idea that satisfied patients become repeat customers. If a patient doesn't come back, doctors lose revenue. That's why Olden says that health care reimbursement will need to change so doctors have incentives to value quality, evidence-based practices over quantity of visits.

"That's wishful thinking," Olden says. "But that's where we need to get if we want to bend cost curves and improve outcomes."

MORE INCENTIVE

Physicians generally don't object to Choosing Wisely recommendations, says Kelly Stanford, Group Health's vice president of clinical operations and market integration. It supports the way they'd like to work every day anyway, she says.

"The challenge is the gap between getting from one payment methodology to another," she says.

Right now, Stanford explains, physicians largely are compensated every time they do something — perform a procedure or order a test — a "fee-for-service" system. But for the amount of money we're spending nationally on health care, the results of the current system are lacking, she says.

According to a 2015 analysis by the Commonwealth Fund, the U.S. spent almost 50 percent more on health care as a percentage of GDP than the next highest spender, France, and almost twice as much as the United Kingdom. But the report notes, "Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions."

"We need to fundamentally change the system to align what people are paid for and what they're working on," Stanford says.

That means moving toward support of a value-based health care system, where physicians are compensated for the value of care provided to patients. Defining and quantifying health care "value" can be a challenge, but it is crucial. In 2013, Bill Gates had this to say: "I have been struck by how important measurement is to improving the human condition. You can achieve incredible progress if you set a clear goal and find a measure that will drive progress toward that goal."

Broadly, health care "value" can be understood as a simple equation: health outcomes divided by the cost of delivering care. Health outcomes include things like whether the patient survived, any disabilities they may face in the future, how long it took patients to recover enough to resume their regular lives, how long the improvement in health will last, and whether long-term side effects of treatment might be anticipated.

Stanford says that Group Health, soon to be part of Kaiser Permanente, a nonprofit that refers to itself as an "integrated managed care consortium," has always paid attention to health care value because it operates under a system in which care is integrated with the patient's coverage.

It works a bit differently in other health care systems. Gary Knox, chief medical officer for Rockwood Clinic and a member of the Washington Choosing Wisely Task Force, says Rockwood physicians still mostly rely on a fee-for-service model. But they are given incentive pay if they meet certain quality metrics or demonstrate they are following Choosing Wisely recommendations. For example, Rockwood tries not to treat sore throats with antibiotics without first conducting a test for strep throat. Rockwood can check if physicians are meeting the threshold. If so, the doctor receives a bonus, Knox says.

Knox says that in most health care organizations he's aware of, those kinds of bonuses make up about 10 to 20 percent of physician compensation. That's enough to effect some change in how physicians behave, Knox says. However, moving even further toward a pay-per-value system most likely would not happen quickly. And it brings up a thorny issue: Will a value-based payment system ultimately mean less overall pay for physicians?

"I don't know the answer to that yet," Knox says. "It could be that physician salaries will go down. But I don't really know. It's not something we want to happen, and we're not planning to do that in our system."

POWER TO THE PATIENT

The Choosing Wisely campaign and a value-based approach both ultimately depend on patient cooperation. "I think it's key in making this shift to value-based care," Stanford says. "You have to have the patient engaged and involved." If patients know they have some control in making decisions, they may take more ownership and be better informed.

But the shift may take a while. According to a study from the Journal of the American Medical Association released in October, the number of some unnecessary medical treatments — like antibiotics for the flu or bronchitis — actually increased from 2002 to 2013, around the time Choosing Wisely was launched. In response to the study, Elizabeth McGlynn, vice president at Kaiser Permanente Research, told NBC News that "the take-home message for patients is that they should take an active role in identifying the important components of their care and advocating for themselves — being actively engaged is important."

For Robin Shapiro, president of Seattle-based Allied Health Advocates, the Choosing Wisely campaign is a good thing. It means that health care organizations will need to be more transparent about how much medical care will cost, and providers may be more willing to talk to patients about the cost of a surgery because of the campaign.

"That campaign has done a really nice job of making the discussion about things that really matter to patients in a way that patients understand," Shapiro says.

Handley, chairman of the Choosing Wisely task force, says the campaign is more aligned with patient preferences. As a side effect, care will get safer. He says that using evidence-based medicine and shared-decision making is important, and Choosing Wisely marries those two things.

"We think this is about patient empowerment," Handley says. "Let's get patients more empowered, so they can make decisions with their health care." ♦

To learn more, visit choosingwisely.org.

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