Reduce health waste through deregulation and free market principles

Emergency Physicians Monthly has an important debate between ACEP President David Seaberg and EP Monthly founder Mark Plaster about the “Choosing Wisely” program.

Choosing Wisely is being pushed by the ABIM Foundation as a way to get specialty societies to label certain tests as “unnecessary” or of questionable benefit.

I side with Dr. Seaberg in this argument.

I disagree with the concept some people advance that we need to essentially “do it to ourselves before someone else does it to us” (see the comment to Dr. Seaberg’s position). Reasoning like this is how physicians and patients have lost much of the control of the house of medicine. Read through the news and look at the emphasis on reducing the amount of “unnecessary” care.

Recently, the Washington Times published an article about how the Institute of Medicine stated that we waste $750 billion each year in health care. How could anyone disagree with reducing that which is “unnecessary”? It’s a great sound bite. But as Dr. Plaster notes in his article, the devil is in the details.

How do we define “unnecessary”? A pregnancy test in a male patient is “unnecessary.” No way to justify its use. But other tests which seem to have little clinical utility may be deemed “necessary” for non-clinical reasons. A CT scan may only infrequently show the etiology of a patient’s syncope, but some doctors may believe the CT scans are “necessary” to avoid accusations of improperly evaluating a patient or to prevent being sued for missing a rare neurologic cause of a patient’s syncope. If we want to decrease the amount of “unnecessary” testing, we need to address all of the reasons that such testing is performed. Why doesn’t Choosing Wisely change the preamble of its campaign to include: “The following tests are medically unnecessary and no type of professional or legal liability should ever be imposed upon physicians for failing to order or perform them …”?

I question whether the ties that several ABIM foundation trustees have to the Obama administration (via A Line of Sight) will affect the mission of this project.

Finally, many of the groups listing “unnecessary” testing in the Choosing Wisely campaign are making their directives at other specialties. Radiologists are telling emergency physicians not to order so many CT scans. Neurologists are telling emergency physicians not to order CT scans for migraine headaches. Unless those specialists are going to come to the emergency department, evaluate the patients, and follow their own recommendations, they have no business telling other specialties what to do. Easy to point fingers when you have no skin in the game.

We need to reduce the amount of testing performed in this country, but I still think that the best way to do so is through deregulation and free market principles. If patients want to pay for a test with little clinical validity, they should be able to do so. They should be able to have the test done ten times if they want to pay for it.

Patients should be able to make an educated decision as to whether they want a have a test performed. And physicians should function as advisers to the patients in this regard, not gatekeepers who deny testing.

In this respect, I predict that Choosing Wisely just won’t work for its intended purpose and it will likely be used as a first step toward rationing care – especially care that ends up with “normal” results.

“WhiteCoat” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.

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  • Michael Hein

    I think that preferable term is”low utility” exams, rather than “unnecessary” exams. As you point out “unnecessary” is in the eye of the beholder, if you will. However, “low utility” acknowledges that we not uncommonly order tests that are unlikely to contribute to diagnosis or rule out diagnosis. It’s important to remember that ordering low utility tests results in real downstream harm for some and a cascade of additional costs as clinicians frequently chase “abnormalities” found on these low utility exams, like chasing the proverbial rabbit down the bunny hole. It’s expensive, wasteful, and harmful.

  • Kathleen (Kathie) Clohessy

    Following your logic, “educated” patients should also be able to demand surgery and medication if they want it, too. And if health care were a commodity that consumers could buy at the grocery that logic would hold true. But it is not.

  • Marc Frager

    The ABIM neglects to mention the test that is the biggest waste of money, its own Maintenance of Certification. This monstrosity is just another way to assume control over and reap massive profits from physicians despite never being demonstrated to have any significant value, and not any better than much cheaper self-assessment tools available elsewhere.

  • W Joseph Ketcherside, MD

    I disagree with this author. The way to reduce the amount of testing and treatment that does not benefit the patient is for the doctor to stop ordering tests and prescribing treatments that are not necessary. There is more than enough literature to answer this question on many issues. In my own specialty of neurosurgery, we have known who should not have a back operation for decades and yet we still see many of those patients get cut.

    Doctor, you can’t change the world, and I assure you that you will not personally alter the entire economic model of US health care. But you can do the right thing for every patient that YOU see, and you can teach that judgment at your local medical school in a variety of roles. And you can support the professional organizations that are trying to make us think about what we are doing in the case of tests and procedures that are clearly abused.

  • Homeless

    “Patients should be able to make an educated decision as to whether they want a have a test performed. And physicians should function as advisers to the patients in this regard, not gatekeepers who deny testing.”

    Hear, hear!

    Let patients have control. Why stop at tests? Why not let patients decide if they need medication? We can save money from all those unnecessary doctor visits if patients could buy drugs OTC. If I don’t need advice, why should I be required to pay for it?

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