Covered California Choosing Wisely Against Defensive Medicine

Part of Covered California’s mission is to improve health care quality and lower costs. In an attempt to meet these goals they announced a partnership with the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely initiative. The Choosing Wisely initiative seeks to encourage better dialog between patients and physicians to reduce duplicative tests based on evidence when charting the most effective course of treatment.

Download Choosing Wisely initiative overview [wpdm_file id=77]

Covered California trying to harness health care costs

One of the main drivers of escalating health care costs are redundant and expensive tests often ordered by doctors practicing defensive medicine and at the request of patients. Anthem Blue Cross recently released their assessment of the roots to rising costs. They determined that new medical technology such as expensive diagnostic tests like MRIs and CT scans account for an estimated one-half to two-thirds of the growth in health care spending. The question boils down to if these tests really necessary?

What 5 things should doctors and patients discuss to reduce costs

The Choosing Wisely initiative has developed Lists for different medical specialties centered on Five Things Physicians and Patients Should Question. Here are a sampling of the five questions from two of the 26 medical specialty lists. From The American College of Obstetricians and Gynecologist the five recommended topics to avoid unnecessary tests and procedures include –

1. Scheduling elective non-medically indicative inductions of labor or Cesareans before 39 weeks.
2. Scheduling of elective, non-medically indicated inductions of labor between 39 and 41 weeks.
3. Performing routine Pap tests in women ages 30 – 65.
4. Treating mild dysplasia less than two years in duration.
5. Screening for ovarian cancer in asymptomatic women of average risk.

From the American College of Cardiology the five recommended discussion topics are –

1. Performing stress cardiac imaging at initial evaluations on patients without cardiac symptoms.
2. Performing annual stress cardiac imaging as part of a routine follow-up visit.
3. Performing stress cardiac imaging as a pre-operative assessment in low-risk patients.
4. Performing echocardiography as routine follow-up for mild native valve disease.
5. Performing stenting in certain stable patients with non-culprit lesions.

Is the test necessary?

The big push is to get patients to ask if a recommended test is necessary and to get physicians to review the necessity of certain tests with patients. When you read through the five things physicians and patients should consider it’s clear that some of these tests and procedures require lots of layman explanation.

My doctor says I need…

By default, the patient will defer to the physician’s judgment. It requires extra time on the part of the doctor to explain why the test may or may not be necessary. Consequently, if the imaging equipment is available and the patient doesn’t object, the test is routinely ordered and this has led to an increase in costs for both patient and insurance company.

Patient advocacy questions are less technical

Fortunately on the Choosing Wisely Lists page is a far more patient friendly description of procedures and tests developed in cooperation with Consumer Reports. The Patient-Friendly resource on Bone-density test discusses when you need them and when you don’t. They discuss in plain English why the test isn’t necessary in younger people without risk factors, the risks of treatment and the relative costs of the test. While the Lists are side by side, it isn’t readily apparent which medical specialty list corresponds to the patient friendly list. It would be nice if they could combine the lists so on one page it spoke to the physician and also included questions for the patients to ask.

Is cost reduction a bridge too far for insurance companies?

It is a noble goal for both health insurance companies and Covered California to move forward with strategies and initiatives to reduce the cost of health care. The big hurdle is that insurance companies can’t and shouldn’t dictate the health care procedures. Short of denying experimental or treatments with a low probability for a positive outcome, any interference by the insurance company and the doctor-patient relationship is strictly forbidden.

Tests and providers are choice of patient and doctor, not insurance

Not only can’t insurance companies discourage duplicative tests, they can’t dictate that a patient go to a network provider that might perform the test for less cost. Often times there is an out-patient clinic that can perform an imaging test for one-third to one-half the cost of a hospital. But if the doctor schedules the test at the more expensive hospital setting, both the patient and insurance company incur the greater expense.

Will Covered California provide patient advocates

It’s great that Covered California is taking the lead to initiate the discussion between physicians and patients about unnecessary and redundant tests and procedures to reduce health care costs. I’m just not sure how they are going to do it. The discussion really needs to be started on the doctor side of the table and Covered California, or any health insurance company, doesn’t really have any incentives to make the doctor start the conversation. If Covered California was able to assign a patient advocate to each person seeking medical treatment to ask pointed questions of the doctor, that might have some impact on lowering expensive tests.

Less expensive vs. no test

Another form of reducing costs is offering less expensive and invasive testing methods. Men over 50 should get tested for colorectal cancer. Under the provisions of the ACA the colonoscopy is no charge. But getting men to schedule a time, let alone even consider the procedure is a challenge. Kaiser Permanente has been sending out the far less invasive fecal immunochemical testing kits to men.

They found men were far more likely to send in a simple stool sample for testing as opposed to scheduling a colonoscopy. The Kaiser approach is successful in getting more men screened for colorectal cancer. When a test is returned positive for certain indicators of cancer, the men readily set up the more expensive and time consuming colonoscopy.

Hospital investment in high-tech toys

There is also the sticky issue of hospitals that have invested millions of dollars in high technology medical imaging and other equipment that they don’t want to see unused. Hospitals and outpatient clinics have based their acquisition of this high-tech equipment on forecasted utilization of the machines and reimbursements rates from health insurance companies.

If Choosing Wisely is successful and puts a serious dent in expensive imaging tests, won’t the hospitals move to increase the rates they charge to make up for the lower demand? There is also the little wrinkle of doctors being owners of outpatient clinics that perform the tests. Does anyone really think a doctor is going to reduce the ordering of expensive tests to the clinics he or she might be a part owner in and risk the capital investment?

Costs are reduce when patients ask questions

Health care reform and initiatives like Choosing Wisely seek to radically change the landscape of health care expenses and utilization. As much as we would like to think a few well positioned laws may make the difference in escalating costs, both Anthem Blue Cross and the ABIM Foundation realize the power to drive down costs rests between the patient and physician.

News Release from Covered California about Choosing Wisely partnership

COVERED CALIFORNIA JOINS PARTNERSHIP AIMED AT REDUCING UNNECESSARY MEDICAL CARE

“Choosing Wisely” Helps Doctors and Patients Make Better Choices, Cuts Waste, and Makes Health Care More Affordable

SACRAMENTO, Calif. — Covered California™ will partner with “Choosing Wisely,” a partnership of the American Board of Internal Medicine (ABIM) Foundation, Consumer Reports, and leading national medical societies to encourage discussions between patients and their physicians about unnecessary procedures and treatments that are driving up health care costs and often causing harm.

At its May 23 meeting, the Covered California board approved a resolution to join the Choosing Wisely Consumer Partnership, a shared-decision-making initiative launched to help doctors and patients make effective choices.

Peter V. Lee, Executive Director of Covered California, said, “Choosing Wisely provides specific, evidence-based recommendations to help physicians and patients make wise decisions about appropriate care based on individual situations. The campaign reduces duplication and waste and makes sure each patient gets the right care for them.”

The campaign fits in with the mission of the newly created insurance exchange to streamline health care delivery, control costs and encourage more people to get the health care they need. “Choosing Wisely is a prime example of engaging consumers directly in decisions about their care,” Lee said.

The ABIM Foundation reports that up to 30 percent of medical screenings and treatments are duplicative or unneeded and may not improve people’s health.

Twenty-five medical specialty societies, representing more than 725,000 physicians, listed more than 130 tests and procedures that are commonly ordered, not always necessary, and could cause undue harm, according to the foundation.

The procedures include labor induction and cesarean deliveries, feeding tubes for patients with advanced dementia, CT scans of children’s minor head injuries, electroencephalograms (EEGs) performed on patients with recurrent headaches, and procedures for treating infants with acid reflux.

The lists are being distributed to physicians and are reaching millions of patients nationally through consumer and advocacy partners, including Consumer Reports, the world’s largest independent product-testing organization. These groups are supporting the project with programs aimed at educating the public about unnecessary tests or treatments.

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