Choosing Wisely takes aim at waste

February 1, 2014

The medical community is using checklists to voluntarily cut costs

Momentum is growing for the Choosing Wisely program. The initiative, which has challenged national medical organizations to identify five tests or procedures commonly used in their field whose necessity should be questioned, is being embraced by a growing number of professional societies and is being incorporated into clinical settings in an effort to cut unnecessary medical waste in the United States.

It’s a welcome development for payers-organizations that have long been at the table of stakeholders advocating for real-world cost reduction in the system overall.

When Choosing Wisely rolled out in 2012, it had the support of nine organizations, but now boasts 60 participating medical societies, according to Richard J.  Baron, chief executive officer and president of the American Board of Internal Medicine (ABIM) and the ABIM Foundation, who launched the initiative.

"It's been going wonderfully well in any direction you could name," Baron says.

The ABIM Foundation funds some of the administrative functions of the initiative such as branding and trade marking, but Baron says the majority of funding comes from those organizations who participate in the effort.

Society checklists

Each society has developed its own list of recommendations derived from concrete, evidence-based studies to guide physicians practicing in the field. For example, the American College of Radiology suggests not doing imaging for uncomplicated headaches, avoiding admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exams and not doing a computed tomography (CT) for children suspected of appendicitis until an ultrasound is considered.

Experts say the Choosing Wisely recommendations carry greater weight with physicians because they were developed by their own professional societies and aren't dictated by payers for the purpose of reducing costs.

"The drivers are quality and what's right for the patient and the key person in charge is actually the front-line workers who are delivering care," says Kulleni Gebreyes, MD, a director with PricewaterhouseCoopers' health industries practice.

Joseph Flood, MD, FACR, president of the American College of Rheumatology (ACR), says the ACR went through a thorough process to identify key tests or procedures that may be overused or needing re-evaluation, including a recommendation not to use anti-nuclear antibody (ANA ) subserologies without a positive ANA test first.

"Those expensive tests were thought by us to be really low hanging fruit where we could save the system a lot of money by suggesting that," says Flood, who also practices at the Columbus Arthritis Center in Ohio.

Quick adoption

Since the initiative rolled out, Gebreyes says that they've seen academic medical centers and multihospital health systems use Choosing Wisely as a springboard when developing their own clinical initiatives to reduce costs and improve the quality of care.

"We particularly see it used with systems that are investing heavily in population health management and are involved in risk sharing contracts," she says.

Baron says Cedars-Sinai incorporated 120 Choosing Wisely recommendations into the decision-support engine of its electronic health record system and the Anne Arundel Medical Center in Maryland also incorporated the campaign into its electronic medical records system to improve awareness among consumers and medical staff.

Data are limited about the effect the campaign has had on utilization but Gebreyes says the most significant cost implications of the campaign will likely be from reductions in hospital stays.

"On the inpatient side, I think reducing the number of tests may not reduce your costs in a significant way but what we have found is the coordination and the communication that goes around a campaign that also improves appropriate utilization decreases length of stay," she says.

While payers are not directly involved with Choosing Wisely-its recommendations must have a clinical basis and must come solely from the medical community-some have worked to boost awareness of the campaign among providers. Paul Kasuba, MD, chief medical officer for Massachusetts-based Tufts Health Plan, says it has held forums around Choosing Wisely to help promote its implementation in the community.

"We've got a community here who understands that there is inefficiency and waste in the system and are looking for effective ways of taking that out and part of it is by being better-educated orderers of tests and also consumers of healthcare," he says.

Collegial environment

Baron says payers haven't been directly involved with the effort because the campaign's focus is centered on the best patient care practices from a medical perspective.

"The idea behind the initiative is really professionalism in action, and we don't advocate for these things to be hard coded into prior authorization rules," he says.

While 60 medical societies have developed their own lists of five recommendations, experts say the recommendations that have been garnering the most attention and utilization are those related to oncology, hematology, and radiology.

Emergency room physicians were among the later joiners of the effort because they were concerned about some of the liability risk unique to the emergency room setting, according to Baron. When they did decide to join the campaign, they also voiced a desire to see medical liability reform as well.

While the Choosing Wisely initiative continues to gain momentum across the country and abroad, Baron says one of the next focuses for the ABIM Foundation will be help continue the culture shift within the medical education space.