Wednesday, August 13, 2014

What would happen if Choosing Wisely became the medical "law of the land"?

Choosing Wisely (CW) is an initiative or campaign lead by the American Board of Internal Medicine Foundation (ABIMF) to change the thinking of physicians and patients so that the choice of  medical tests and treatments are chosen  wisely in such a way as to greatly reduce waste of resources and harm to the patient.

It began as an apparent low-key program to simply have the physician and her patient sit down together and have conversation about what needed to be done in a particular patient's case and it continues in part to be marketed as such. So, if for example that a given test, e.g. MR of the lumbar spine,might not be ordered if it were the case that an MR in that stylized scenario had not been shown to be helpful.The patient would be subject to possibly harm of a false positive tests and the possible cascade of more testing,etc etc.

However in the two years since the launching of CW ( at the time of this writing) several policy experts and wonks have envisioned a much more full bodied, authoritative and coercive role  for the pronouncements announced under the CW brand.  It is this expanded role for CW that I refer to as the medical law of the land.. From simply reducing waste and  harm a second wave of CW is to reducing "low value" services,however that may be defined

So based on some of these experts' recommendations, what would the medical landscape look in the era in which the decisions of Choosing Wisely ,would be much more than the suggestions or recommendations,which is how they are sometimes presented  and  instead be  determinative in regard to the reimbursements of third party payers, private and public as well being used in decisions regarding maintenance of certification and other mechanisms to decrease medical costs.

Consider the comments of Dr Robert Benson Jr.,President Emeritus of the ABIM and ABIMF  writing on the ABIMF blog with bolding of words added by me:

" CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations."...ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC."

So, a candidate for ABIM certification would have to properly quote the Choosing Wisely rules recommendations before he even gets to take the certification ofrMOC examination.

This recent commentary by Dr N.E. Morden and her co-authors from Yale and Harvard tells the same story.

"..physician-endorsed low-value labels will probably be leveraged to these purposes. [cost containment and quality measures]...We believe that if such efforts are designed and applied carefully they should be embraced as a promising method for reducing low-value services."

...linking the lists ( of tests and procedures not to do ) to specialty specific maintenance of certification act activities such as practice audits and improvement tasks could also advance their dissemination and uptake at very low cost."

"...Choosing Wisely items should also be incorporated into quality-measurement efforts such as Center for Medicare and Medicaid Services Physician Quality Reporting  ...linking low value service use to financial incentives ( translate penalties )  .. should accelerate ...into practice changes."

So payment for physician services,quality ratings,and maintenance of board certification are linked to adherence to the "recommendations" of  CW.

In this proposed choosing wisely world the deciders at CW assume a very powerful position.Various special interest groups stake holders would have great incentive to lobby the CW leaders,to do what they could to direct the "recommendations". Physicians would have to follow the CW guidance or risk loosing certification let alone payment for services. As bound as physicians would be to the  dictates of the CW authority how much trust could a patient have that his physician is acting in his ( the patient's) best interests .Making CW the medical law of the land would be a giant step toward the collectivization of medicine and destruction of the traditional physician patient relationship.

Of course, all of those sky-is-falling comments are in stark contrast to what one would read on the websites promoting the CW campaign.. There we hear  marketing phrases such as "ensuring the right care at the right time" and doing reasonable, sensible things and involving the patients in the decision process. Mom and apple pie with ice cream on the pie is the image floating above  the CW advertising efforts, but when one reads the comments of Benson and Morden et al  that outlines what they want to do,a different, darker side of CW is visible.So what is it: an idealized physician-patient collaborative effort or advocacy for  an alarming  level of medical care hegemony lead by select members of the higher echelons of the progressive medical elite who seem to believe that carrots are not enough .The ABIMF and the Robert Wood Johnson Foundation are spending millions of dollars convincing the public and members of the medical profession that Choosing Wisely is a collaborative,thoughtful movement that just wants to ensure that patients get the right care at the right time while the President Emeritus of ABIM(F) and some policy wonks from Yale and Harvard talk a markedly different game.

Today's trial balloons may well become tomorrow's policies and governing rules about how medicine is practiced and it will not be all about the right treatment at the right time.It will be about the most cost effective means of achieving quality adjusted life years as that is valued by someone other than those trying to live those years.



Addendum: Minor changes in grammar and style made on 10/8/14

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