The Choice is Yours

Of late there has been increasing concern over the ever-rising costs of health care in America. Some have attributed these rises, in part, to an overconsumption of medical resources – imaging studies, lab tests, procedures – both through clinician recommendation and patient demand. As such, efforts have been made to made to cut back on this “waste” and to educate both patients and doctors about the effectiveness and value of health care. 

Choosing Wisely was one such campaign, one of the most widely disseminated of its kind, sharing recommendations to reduce unnecessary medical services among both doctors and patients. In theory, doctors would order fewer tests knowing they were inefficient; patients would understand which tests weren’t worth spending their healthcare dollars. The thinking was that patients with more to lose, those under consumer-directed health plans who were paying more out of pocket for healthcare, would push to get the most bang for their buck. Makes sense. But did it work?

A recent article explored the apparent impact this campaign has had on reducing low-yield testing, seeking to examine whether this type of intervention is worth pursuing further, and, if so, where emphasis should be placed: the clinician or the consumer. 

There was indeed a noticeable decline (4%) in the number of tests ordered since April 2012, and there were indicators that linked this change to the Choosing Wisely campaign. Although the numbers were smaller than were anticipated, the data demonstrated that Choosing Wisely has met some level of success. Consumer pushback, however, did not seem to be a driving force in this decline, at least based on the population studied in this article. 

With these mixed results, the question becomes: Is this the right path to reduce spending? The answer appears, to me, that it cannot be the only path we try. Choosing Wisely will help, slowly, but additional pressures must be applied elsewhere in the healthcare system to truly turn the tide of rising costs.  

This Policy Prescriptions® review is written by Vedika Agrawal as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where she is a medical student.

Abstract

Choosing Wisely was launched by the American Board of Internal Medicine in April 2012 as a patient- and clinician-targeted campaign to reduce potentially unnecessary “low-value” medical services. The campaign’s impact on low- and high-value care beyond its first year is unknown; furthermore, it is unknown whether some patients such as members of consumer-directed health plans and people residing in different US regions have responded more than others. To evaluate the impact of Choosing Wisely, we used commercial insurance claims to track changes in the use of low-value imaging (x-ray, computed tomography, and magnetic resonance imaging) for back pain before and after the campaign began, a period running from 2010 to 2014. We selected back pain imaging because it is a prominent target of Choosing Wisely, which considers it low value except in a minority of cases, because of its relatively high out-of-pocket expense, and the large volume of low back pain visits nationally. We found only a 4 percent relative reduction in low-value back imaging 2.5 years after the start of the campaign and some differences in regional trends, but no differences associated with enrollment in consumer-directed health plans. Our findings highlight the ongoing challenge of reducing unnecessary medical care, even when patients have “skin in the game” under consumer-directed health plans.

PMID: 28373333

Hong, AS, et al. Health Affairs. 2017; 36(4): 671-679.

The full list on recommendations by Choosing Wisely can be found here: http://www.choosingwisely.org/getting-started/lists/