There are two ways to change your course when things aren’t going the way you want them to: Add stuff or remove stuff. As the U.S. National Health Expenditure approaches $3.5 Trillion and quality continues to lag other developing nations in key categories, it’s safe to say that things aren’t going the way we want them to. We’ve certainly tried the path of adding stuff; think ACA, MACRA, MIPS, ACO, PCMH and the rest of the usual acronym suspects (UAS). I’m sure some of these initiatives will help, but it’s always wise to ask the question:

 What should we stop doing?

Since 2012, the ABIM Foundation has been pushing the narrative of “less is more” through the Choosing Wisely campaign. From their site:

Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations of “Things Providers and Patients Should Question.” More than 70 specialty society partners have released recommendations with the intention of facilitating wise decisions about the most appropriate care based on a patients’ individual situation.

The campaign provides guidance to clinicians in the form of lists that include items like:

The campaign also provides patient-friendly resources from specialty societies and Consumer Reports like this one: Treatments and Tests Your Baby May Not Need in the Hospital.

What Do The Doctors Think?

A recent study supported by The Commonwealth Fund attempted to gauge physician awareness of the Choosing Wisely Campaign and learn more about their perspectives on the drivers of over treatment. It also attempted to understand clinician views on their role in financial stewardship. Should they be aware of costs and consider them in their patient’s treatment path?

The study can be found here: Physician Perceptions of Choosing Wisely and Drivers of Overuse.

The study is limited in that it was focused on clinicians from a single organization (Atrius Health: the largest ambulatory care provider in Massachusetts). Still, with 584 clinician responses, the findings are a good place to start a conversation. Here are some highlights:

  • Primary care physicians reported significantly greater awareness of Choosing Wisely (47.2%) than medical specialists (37.4%) and surgical specialists (27%). 
  • Approximately one-third felt it unfair to ask physicians to be both cost-conscious and concerned with welfare, thought too much emphasis was placed on costs, and thought doctors were too busy to worry about costs. 
  • Specialists were more concerned about malpractice, whereas primary care physicians reported feeling significantly more pressure from patients for tests and procedures. 

The authors offered the following takeaways:

  • Initiatives aimed at improving financial stewardship may benefit from efforts targeted at supporting clinicians in dealing with the uncertainty that comes with conservative management. Physicians may be more willing to forgo or delay low-value care if they have appropriate support that addresses patient demand, malpractice concerns, and other drivers of overuse. 
  • There is receptivity to more support for physicians to consider costs when recommending testing or treatment regimens. Ideally, decision support would be combined with information on price to address the significant knowledge gap around costs expressed in our survey.

The transition to value-based care will provide incentive to follow these types of guidelines and consider cost, but what do we do in the meantime. Most care is still delivered on a fee-for-service basis and will continue to be for years to come. We can’t wait around for the feds to make it better. Let’s employ tools, processes and training to enable clinicians and patients to engage in a deeper dialogue about what treatment is best for the patient today. To be successful, our solution must take into account the cost of care to the patient (including what their insurer pays). Just as importantly, we must account for the fact that clinicians are running a business and need to stay solvent.

On Wednesday, May 25th we’ll discuss the Choosing Wisely campaign and the role of clinicians as financial stewards in the 15th installment of The Business of Healthcare chat and blab (#hcbiz).

12:00 PM EST — Tweet Chat

The tweetchat begins at 12:00 PM EST and will ask 3 questions in 30 minutes:

Q1: Should doctors be expected to know and consider the costs of care when treating patients?

Q2: What tools/techniques can clinicians use to deal with patient demands for medically unnecessary or low value treatments, procedures and tests?

Q3: What tools/techniques can clinicians use to enable the extended dialogue while still operating under the time/volume constraints of fee for service?

(Follow the #hcbiz hashtag on Twitter or use an app like to join the conversation).

12:30 PM EST — Blab

Then at 12:30 PM EST, the #hcbiz Show will dive deeper with a live 1-hour panel.