In a recent article in the NEJM, by Nancy Morden and others, titled “Choosing Wisely — The Politics and Economics of Labeling Low-Value Services” the authors have reviewed the outputs of the Choosing Wisely campaign. The campaign engages professional medical societies (nine) in listing tests and treatments that should be discussed with patients because they are of “low value” – there may be better treatment choices, with lower risks and lower costs.
The authors note that the American Academy of Orthopedic Surgeons did not identify any major procedures, the source of their members income, but did include an over the counter supplement, items of medical equipment and one rarely used procedure. Work by the Dartmouth Institute has documented wide variations in use of some orthopedic procedures, e.g. elective knee replacement and arthroscopy, among medicare patients suggesting that some commonly used procedures could have been included in the list. Despite Jack Wennberg’s work in Vermont in the early 70’s identifying the enormous geographic variation in tonsillectomies and the recognised dearth of strong evidence for the procedure – the procedure didn’t make it onto the list of the American Academy of Otolaryngology.
They also noted that participating societies generally named other specialty’s services as being low value, and particularly targeting investigations, rather than their own revenue generating services. Their were a couple of honorable exceptions with the Society of General Medicine identifying annual physical exams and the American Gastroenterological Association listing specific indications for endoscopy.
So the authors suggest that payors and the new ACOs will see an opportunity to align financial incentives with the use of high value services avoid the use of those services labelled as low value.
But is it all about money and doctor’s financial self-interest? When you look outside of the USA the evidence suggests that it isn’t simple as that.
The Dartmouth Institute have documented the wide levels of variation in treatment of Medicare patients through their Atlas but equally high levels of variation are seen in the UK NHS as reported by Right Care in a system which doesn’t have the same drivers. Similar levels of variation have been reported in other european health systems.
Doctors and other clinicians who recommend treatment, nurses, physiotherapists etc., have complex and different motivations beyond the financial. For example:
- They want to exercise their skills to help and “cure” patients
- They believe in and want to demonstrate the value of their profession or specialty
- They want to enhance their personal professional reputations by providing new or different treatments
- They enjoy performing and want to improve their competence in a particular procedure
So if it isn’t just about money then the authors’ proposal to address the problem through financial incentives may not be as effective as they expect. One would need a more comprehensive approach to changing behaviour that addressed some of the other causes of variation in clinical practice.