April 21, 2018
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Too much health care? How a patient-doctor conversation might cut back on the excess

A screenshot from a video distributed by the Choosing Wisely campaign. Penobscot Community Health Care is one of four health care sites in Maine participating in the national initiative that encourages doctors to be more prudent in ordering common medical tests and procedures.


While growth in health care spending in the U.S. is starting to slow, the rapid growth that has been customary in recent decades largely wiped out any income gains the average American family experienced in that time.

Fortunately, the conversation has shifted in recent years to focus on better patient outcomes at a lower cost. And since health care spending is so high in the U.S. and especially Maine, there’s plenty of room for improvement.

Of the total amount spent on health care in the U.S., between a third and a half is unneeded, doing nothing to improve patient health. Often, the excess care exposes patients to unnecessary risk. And this waste starts in the exam room.

In Maine, a small initiative is underway aimed at forcing doctors to think twice before ordering that MRI for low back pain or prescribing antibiotics for sinus infections. Four sites in Maine — Penobscot Bay Medical Center in Rockport, Winthrop Family Medicine, Oxford Hills Family Practice in Norway and Bangor’s Penobscot Community Health Care — are piloting “Choosing Wisely.”

It’s a national initiative that has brought together evidence-based recommendations from professional societies that represent more than 60 types of medical specialties. Their recommendations are part of a campaign focused on both patient awareness — influenced by Consumer Reports’ involvement — and doctor training.

Each professional society involved — from the American Academy of Family Physicians to the American Academy of Allergy, Asthma and Immunology — has developed a list of five common tests, procedures and prescriptions that are especially prone to overuse and aren’t shown by research to be effective. The lists encourage doctors and patients to question those practices.

The patient awareness campaign — through posters on exam room walls and other means — is meant to give patients a tool to ask their doctors questions about the right course of treatment. For doctors, the training involved in Choosing Wisely is meant to give them the tools to explain why they might not, for example, order a bone density test for a young female patient.

It’s encouraging to see doctors, through their professional associations, take a role in combating excess spending in health care. Their primary lobbying organization, the American Medical Association, which isn’t involved in Choosing Wisely, has famously resisted major reform efforts throughout its history.

Doctors “are not only stewards of the wellness of their patients, they’re stewards of the resources that we have as a society to deliver that care,” said Dr. Noah Nesin, chief quality officer at Penobscot Community Health Care. “We can’t make our decisions in a financial vacuum.”

It seems simplistic, but patient-doctor conversations — often de-emphasized in a system in which physicians are pressed for time and can’t necessarily bill for conversations — can pay off in the form of higher patient satisfaction, better health outcomes and even a lesser likelihood of medical malpractice lawsuits.

While Choosing Wisely emphasizes evidence-based medicine and effective patient-doctor interaction, it’s unlikely to have a major effect — even if widely implemented — without other health system changes to back it up.

Since the medical system reacts to incentives, chief among those changes is the transition to a payment system that rewards medical providers for keeping patients healthy rather than ordering more tests and procedures. That change is starting to happen, both for patients with public (Medicare and Medicaid) and private insurance. Other measures aimed at making providers accountable for patient health and the quality of care also are starting to take hold.

Another incentive for doctors to provide excess care is to guard against the potential for medical malpractice lawsuits. That’s why states should consider basing their malpractice laws on the same evidence-based practices emphasized by the professional medical associations involved in Choosing Wisely.

In effect, that change would defend doctors who use the research to inform their practice.

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