Low-value services within Choosing Wisely often revenue neutral for recommending societies
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A new study on Choosing Wisely showed the campaign’s recommendations had strengths and opportunities for improvement, one of the study’s authors said.
The Choosing Wisely campaign was launched in 2012 by the American Board of Internal Medicine Foundation and Consumer Reports. It was founded on the principle of avoiding services with “no or minimal benefit to patients in specific clinical situations," and "is also a public education campaign in which professional societies create lists of low-value services that that physicians should avoid," Ishani Ganguli, MD, MPH, an internist and associate professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, told Healio.
The campaign also sought to reduce unnecessary care and engage physicians in conversations about overuse, according to Daniel B. Wolfson, the executive vice president and chief operating officer of the ABIM Foundation.
“As part of this effort, we asked our partner societies to focus on tests and treatments that were done frequently and/or carried a significant cost to patients — such as imaging for low back pain or preoperative ECGs for low-risk patients — that were within the control of their own members, and for which there was significant evidence of overuse,” he told Healio.
Despite the substantial reach of the campaign, “low-value services are still commonly used,” Ganguli said. “This may be due, in part, to the types of recommendations that are included in the lists.”
“Some have worried that professional societies may not necessarily pick the highest-impact low-value services for their lists, for example by avoiding ervices that benefit their own bottom lines,” Ganguli said.
According to Wolfson, the societies were asked “to consider patient safety primarily, and not the impact on their members’ revenue when they were choosing recommendations.”
To understand the potential impact of the recommendations on patients and on physicians, Ganguli and colleagues conducted what they called the “first longitudinal content analysis” of all 626 U.S. Choosing Wisely recommendations.
According to the findings, published in JAMA Internal Medicine, Choosing Wisely recommendations were usually either imaging studies (26.8%), laboratory tests (24.9%), medications (22.7%) or clinical procedures (17.9%).
Ganguli and colleagues found that most of the low-value services in the recommendations — 64.2% — were revenue neutral for members of the recommending society, “meaning physicians who employed one or more of these services was not likely to make any money by conducting the service,” Ganguli said. Meanwhile, 33.4% of the low-value services generated revenue for the recommending society and 2.4% were low-value services that represented lost revenue.
“More promisingly, nearly half of recommendations [44.7%] warned against low-value services with high direct harm potential and 62% of the recommendations named services that were likely to lead to additional medical services down the road of uncertain value, so following these recommendations may prevent both direct and downstream harms,” Ganguli said.
In addition, 45.4% of recommendations were for services that cost fewer than $200 (deemed “low-cost” by researchers), 37.9% were for services that cost between $200 and $2,000 (considered “moderate-cost”) and 16.8% were for services that cost more than $2,000 (considered “high-cost”), according to the researchers.
They also reported that “the share of recommendations representing low-cost services increased over time (1.2%, P = .001) such that there was a 1.2 percentage point increase in the proportion of low-cost services for each additional year” during the study period.
Study limitations include not analyzing the current prevalence of the low-value services and using classifications that were “inherently subjective, not externally validated and may not be reproducible,” the researchers wrote.
The study results “point to the successes of Choosing Wisely to date,” according to the researchers. However, the Choosing Wisely recommendations “are only useful if they are acted on,” Ganguli said.
“Any efforts to reduce low-value care should prioritize high-impact, low-value services — ones that cause the most spending across populations, direct harms, and the likelihood of leading to additional medical services of unclear value,” she added.
Wolfson said that the study findings “demonstrate that the Choosing Wisely recommendations have improved patient safety and quality, in full accord with the spirit of the campaign.”
“We also believe that the vast majority of the clinical recommendations in the campaign advanced the campaign’s mission of promoting conversations between clinicians and patients about reducing overuse,” he said.
In a related editorial, Niloofar Latifi, MD, an assistant professor of medicine at Johns Hopkins Medicine, and colleagues said there are many factors that “drive use of low-value care, such as a culture that highly values testing and procedures, even without evidence of benefit, and a predominantly fee-for-service payment mechanism.”
“Thus, we do not believe that better lists are likely to be associated with decreased low-value services or reduced costs of medical care,” they wrote.
Latifi and colleagues added that “the time is now” for the health care community to move away from a fee-for-service model and onto value-based care, which will likely require “multipronged interventions and implementation strategies.”
“Audits, feedback and clinical decision support may be helpful, but we also believe that health systems should make it difficult for physicians to provide low-value care by removing low-value tests from order panels, requiring justification for low-value tests and procedures, and providing financial incentives for physicians who provide high-value care,” they wrote.
References
Ganguli I, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.6911.
Latifi N, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.6908.
Perspective
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Leonard Feldman, MD
Ganguli and colleagues do a nice job of assessing more than 600 Choosing Wisely recommendations. There are a few instances that I disagree with Ganguli’s team on the interpretation of a Choosing Wisely recommendation, but no one will ever completely agree 100% when more than 600 recommendations are assessed. Overall, I am a big fan of the Choosing Wisely campaign.
Could the ABIM, creators of Choosing Wisely, when they introduced it years ago, have started with the five criteria that Ganguli and colleagues developed: the cost of the topic(s), the prevalence of the topic(s), the cascade effect of the topic(s), the direct harms of the topic(s) and the effects on revenue(s)? Yes, they could have, but Choosing Wisely was a proof of concept when it began. I experience this with the Choosing Wisely: Things We Do For No Reason column I co-edit in the Journal of Hospital Medicine. The objective of our column aligns with that of Choosing Wisely; but we try to cover topics that Choosing Wisely has not. With this high-value care work, we did not know what impact we were going to have when we started. I assume the ABIM would say the same thing.
Moving forward, as medical societies consider new recommendations for Choosing Wisely, they need to take the next step in the evolution of this campaign and only include recommendations that have a high impact by choosing ones that meet multiple criteria as set forth in this article. The concept has been proven. It is now time for all of us to become a little more discerning about the future recommendations we include in Choosing Wisely or the Things We Do For No Reason column.
Associate professor of internal medicine and pediatrics,
Johns Hopkins University School of Medicine
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