Choosing Wisely: Less dogmatic language is needed

When the American College of Emergency Physicians (ACEP) decided not to join the Choosing Wisely campaign, I was among those who expressed disappointment with this decision, in part because I have long been a proponent of efforts to encourage more cost-effective care in the ED.   In fact I had already independently done a significant amount of work in the development of such strategies.

I recognized that there were legitimate concerns about participation in this campaign, but felt that overall ACEP had an obligation to become ‘part of the solution’ to the unsustainable growth in health care expenditures in our Country.  When ACEP’s Board reversed itself on Choosing Wisely, I thought this was a thoughtful and appropriate decision, and still do.  That being said, I do have concerns about the language that most of the medical specialty societies participating in Choosing Wisely are using in their cost-effective care recommendations.  Using a “do this” or “don’t do that” format is too prescriptive, and more importantly, this format lends itself to misuse by third party payers as justification for denial of coverage.

The CW campaign states that the effort is “focused on encouraging physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary”.  This is a valid patient-centric approach that relies on shared medical decision-making “to help make wise decisions about the most appropriate care based on a patients’ individual situation”.  It also implies that these recommendations are just that: recommendations, not absolute dogma.  Mr. John Held, from the ABIM Foundation, has indicated that these lists “do not all need to be in the do this or don’t do that format, however most of them are.  It should also be noted they are not ‘never do’ events, and are backed by evidence and guidelines when such tests or procedures should be used.”

Clearly, ABIM recognizes the possibility that third party payers could use these lists and the evidence behind them to deny coverage and payment.  By claiming that CW does not intend for these recommendations be considered ‘never-do events’, and that they are based on guidelines; it appears that ABIM hopes to deter the linkage of these lists to payment denials. Unfortunately, the inflexible language used in most of these CW recommendations makes it that much easier for payers to do just that.

I still strongly support the effort, but I am very concerned that the dogmatic “do this, don’t do that” language used in these recommendations will effectively hand over the keys to medical decision making to government and third party payers.  The typical approach used in these Choosing Wisely recommendations looks like this one, from the American College of Physicians:  “Don’t obtain imaging studies in patients with non-specific low back pain.”

I would have preferred language like, “Imaging studies are not generally indicated in patients with non-specific low back pain.”   The latter leaves more room for clinical decision-making, the former invites payers to deny coverage first, and dispute the decision later, especially when the test is negative.  Even though ACP does go on to define non-specific low back pain as, “pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination”, it is sometimes difficult to attribute low back pain to a specific disease or spinal abnormality without imaging, especially in patients who are elderly, or are demented, or have other seemingly unrelated conditions, like diabetes.

Some physicians may feel that using this alternative, more elastic language is hedging, and that using the more directive language might give physicians liability cover when they decide not to order a test, or might provide physicians with stronger moral suasion in promoting a cost-effective care approach with patients or family.   There may be some validity to these arguments, but I am not persuaded.  I don’t believe that dogmatic mandates for care provide any significant protection from malpractice liability.  Getting sued for malpractice is a function of poor outcomes, bad luck, and negligence, and a good plaintiff’s attorney can spin these situations their way no matter how the recommendation, guideline, or mandate is worded.  I do believe that shared decision-making is a good thing, but that physicians generally do not need to rely on inflexible mandates to help patients arrive at the best decision:  guidelines will suffice.  What I do not want to see is physicians having to say, “since CW says ‘don’t do that test’ your insurance plan is not likely to pay for it”.   In my mind, that is not persuasion, it is coercion.

I also believe that physicians would be more willing to adopt a recommendation that advises them of best evidence rather than one that delivers a medical edict.  For the CW campaign to succeed, it is not necessary to completely eliminate any use of these tests and treatments when indications for them are questionable.  A significant reduction in their use would go a long way towards solving the current health care financing crisis.  Furthermore, the development of these lists is predicated on best evidence, not on scientific certainty.  How many Level A guidelines that have been adopted in one decade are abandoned the next?  Using  “do this, don’t do that” language turns a recommendation into a directive; and leaves less room for the uncertainties in the art of medicine, or the nuances in the application of exceptions to the rule or the clinical decision tools that are built into many of the strategies in the CW lists.  These clinical decision tools are never absolute:  they inevitably rely on clinical judgment.

Using less dogmatic language in the Choosing Wisely recommendations may not dissuade payers from attempting to use these lists to deny coverage or exert undue influence on these decisions; but it will allow physicians and specialty societies more leeway to object to these denials, and keep these payers from beating us, and our patients, over the head with our own best evidence.   The CW campaign may wish to reconsider its use of overly prescriptive language, especially as payers and employers begin to use these lists to justify denial of coverage when the decisions made by physicians and their patients appear to run contrary to CW recommendations.

I believe CW will soon be incorporated not just into pre-authorization criteria for elective tests and procedures, but also into benefit design, and eventually into retrospective medical necessity determinations.    Don’t be surprised to see code-modifiers developed to indicate when a test is performed at the insistence of the patient, leading to higher co-insurance payments or retrospective denials applied by payers or employers.  Perhaps my concerns are overblown, but there are already pretty clear indications that this is exactly what employer funded, commercial, and government insurance plans intend to do.

Myles Riner is an emergency physician who blogs at The Fickle Finger.

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  • Guest2

    “I believe CW will soon be incorporated not just into pre-authorization criteria for elective tests and procedures, but also into benefit
    design, and eventually into retrospective medical necessity
    determinations. Don’t be surprised to see code-modifiers developed to indicate when a test is performed at the insistence of the patient, leading to higher co-insurance payments or retrospective denials applied by payers or employers.”

    Choosing Wisely is basically code for Do Less, which is why the big for-profit insurance companies are so enthusiastic about pushing it. They would deny EVERYTHING if given half a chance. And Obama himself is fully behind helping his corporatist insurance one percenter buddies making more money by denying care. “. . .Maybe you’re better off not having the surgery but taking the pain pill.” If insurance companies are given free rein, “choosing wisely” will soon mean “terminal sedation and withholding of food and water” for anyone deemed too expensive to treat, America’s own Liverpool Death Pathway.

    If America really wanted to control health costs they’d implement tort reform ….. but once again, that would involve running up agaist Obama’s well-heeled buddies and donors, this time in the personal injury/malpractice scam.

    • PCPMD

      The bottom line is that we in the U.S. consume far more healthcare resources than we could possibly afford (and we’re now making our children and grandchildren pay for our largess instead). Even if every single test, procedure or drug that was used to placate our voracious healthcare appetite was completely appropriate and legitimate, the fact remains that we still couldn’t afford it. That much of what we consume is frivolous or to placate our anxieties, is sadder still.

      Furthermore, individual entreatments to “consume less” at the healthcare trough fail, because when its our turn, we want “everything done, no stone un-turned” (all the while asking someone else to pay for it, of course).

      If we make the assumption that all individuals should have access to the same level of healthcare, whether they can afford it or not, and we accept that our ability to pay for this is finite, then the logical conclusion is that healthcare consumption must be rationed. Every nation that’s implemented some form of universal healthcare understands this, so why is this so taboo for us?

      The idea that we can do everything possible, for everyone, at any cost, without restriction, and do so affordably is a politically convenient lie.

      • http://www.twitter.com/alicearobertson Alice Robertson

        I think you are overall right, but gosh I wish people would stop looking to socialized medicine as some kind of French Revolution against the rich who will always get better care no matter what country they live in. Remove the capitalistic aspect and just about everyone will suffer on some level.

        • PCPMD

          Philosophically, I’m completely opposed to pretty much anything the government mandates/coerces or otherwise forces to be. I think that a large part of our runaway healthcare consumption has been enabled by the development of tax-payer funded medicare, which in turn establishes the norm for healthcare overall (i.e. do everything possible for everyone about everything, cost be damned – and do it again for good measure if you didn’t get what you wanted the first time).

          Had the recipients been asked to pay for this exuberance out of their own pocket (either individually or as a senior collective), the costs would have been contained from the get-go, and expectations about the limitations (and cost) of medicine would’ve more or less paired with reality.

          Instead, we’ve created a population who’s expectations and consumption are unsustainable, unfunded, and unrealistic; and a parasitic healthcare-industrial complex that siphons off 18% of our GDP.

          The problem is, we’ve actively reared, nursed and brought into existence a Beast that now threatens to consume us with its limitless appetite. How do we deal with this? Kill it (i.e. reinvent healthcare) or tame it (regulate healthcare)? As much as I think the solution should be the former, I think we as a nation cannot stomach this, and will either accept the latter, or impotently hurl epletives at “The System”, or “The Man” as our healthcare conglomerate collapses under its own weight.

          Regarding capitalism, we really haven’t had a true capitalistic approach to healthcare for almost a century. When unlimited tax-payer dollars are available for consumption by the populace via market-based insurance and health-care systems, is it any surprise that this has lead to a hybridized monstrosity with an equally voracious appetite to consume them?True capitalism would have enforced a degree of self regulation, discipline and self-rationing, which would have also helped evolve efficiencies in the market to lower cost and improve quality. Instead, we have high cost, unrealistic expectations, and high degrees of dissatisfaction.

          • http://www.twitter.com/alicearobertson Alice Robertson

            I tend to overall agree with you, but I had to stop at the “True capitalism” sentence because surely BigPharma has given any type of capitalism a bad name. But, then again, government dollars got mixed in with that too…so in the big picture you are right. We have an entitlement society that thinks CEO’s are the problem while rarely looking in the mirror to see exactly what you described has happened and ultimately a whole lot of people are going to suffer because of their attitude and lack of any sort of accountability on their lifestyle, worldview, or pocketbook (which means even a copay is considered sacrilegious:). We are confusing “rights” with “responsibility”. And I intend to just keep talking until I
            am blue in the face because after living in the UK and seeing firsthand the travesty there I am defiant in this regard. It’s so bad there this was in the Telegraph recently; “Fears about standards care for terminally ill people in the NHS
            are fueling support for the legalisation of assisted suicide, a study
            suggests. More than a third of those who said they support a change in
            the law cited a belief that dying people cannot expect to receive
            “decent” care at the end of their lives among their reasons.”

            and have the firsthand knowledge that I don’t want that kind of care.

          • Mandy

            “When unlimited tax-payer dollars are available for consumption by the
            populace via market-based insurance and health-care systems, is it any surprise that this has lead to a hybridized monstrosity with an equally
            voracious appetite to consume them?True capitalism would have enforced a
            degree of self regulation, discipline and self-rationing, which would
            have also helped evolve efficiencies in the market to lower cost and
            improve quality. Instead, we have high cost, unrealistic expectations,
            and high degrees of dissatisfaction.”

            I agree, PCMD, I think you’ve put it very well there.

  • doc99

    Linking Choosing Wisely to Med Mal Reform would have been universally hailed by all docs in the trenches. As it stands now, this remains a serious wedge issue.

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  • http://www.twitter.com/alicearobertson Alice Robertson

    *This is a valid patient-centric approach that relies on shared medical decision-making** I understand the intent of these decisions, but I fail to see that it is patient first or center. It is money first, and then some patient safety from tests thrown in, and not wasting resources. Ultimately, some patients will die under this type of decision making…and I imagine some will be saved along with resources and money. My take on this is a bit different than most because we suffered from this type of dogma without a face ideal that is being pushed today (understandably so, but I’m a mom and one of the few who were hurt by it.. A specialist at Cleveland Clinic took this stance and cancer spread in my daughter’s lymphs while I waited on him to “listen” to my complaints…..his responses felt dogmatic not personal….ultimately, the doctor used up the doc talk type of mantra and said my complaints were hurting my daughter psychologically. The test showed cancer had spread in the interim). So tread lightly….and while extolling the virtues of policy be sure to listen intently to a patient who is pleading for a test that will either soothe their heart, or help them heal.

    • http://www.facebook.com/people/Myles-Riner/100000936260954 Myles Riner

      I am so sorry to hear about your daughter’s distressing experience. I can assure you that many physicians have concerns about just the kind of issue you highlighted, and have had such concerns ever since capitation as an incentive to limit care to pre-paid health plan enrollees (putting physicians in risk-sharing positions alongside insurance companies) began to be rolled out in the ’70s. It is never easy to strike the right balance between appropriate care and unnecessary care, but I am certain that dogmatic cost-effective care ‘mandates’ are not the right tools, whereas evidence based guidelines applied by thoughtful and caring providers could work. We all must pay attention to the cost of care crisis that our country faces, and work very hard to find strategies that put quality health care services first, in order to limit outcomes like the one your daughter experienced; and encourage cost-effectiveness second.

      • http://www.twitter.com/alicearobertson Alice Robertson

        It’s really good to have conversations like this. I really do worry though about cost first because people have a false sense of government being a great caretaker of their needs as a false sense of security. But you are right….there is so much room for waste and fraud to get tidied up, but I sorta fear the “cost” factor becoming utmost in doctor’s minds. Sometimes it feels like the blending of the old school doc mindset with the new school mindset doc and somewhere amidst all the dialogue there is a resounding truth that can be captured by those who care enough to listen.

  • SBornfeld

    I have to wonder if acquiescence to the CW campaign by the specialty academies was seen as the only way to have a voice in the process. As it is, I hear the voice of the USPSTF loud and clear here, and precious little from the specialty organizations, when I listen to the CW campaign.