Avoiding Avoidable Care

By Joanne Conroy, MD

I attended a meeting last week in Boston titled “Avoiding Avoidable Care,” organized by the Lown Cardiovascular Research Foundation and the New America Foundation. The meeting focused on proposing solutions to the problem of avoidable care in all areas of medicine. The ultimate goal is facilitating the transformation of the American health care culture from one focused on volume and quantity to one centered on value and quality.

Most of the meeting was very valuable. Although the room was definitely filled with the “believers,” there was good discussion about the fact that a significant amount of care is delivered in the United States without sufficient evidence to support its use. Every intervention or drug has a risk–benefit equation. If there is no benefit, the risks of avoidable care are obviously, well, avoidable.

There were excellent case studies and great panels about the role of medical journals and the social responsibility of physicians. Three Boston-area CEOs talked about the challenge of managing the transition between paying for volume to paying for value. There was a spirited debate about fee for service and other payment mechanisms and whether they have adversely affected the culture of medicine.

We discussed the ABIM Foundation’s Choosing Wisely campaign: a series of top five things physician specialty groups advocate forgoing because the evidence does not support current use in clinical practice. The recommendations include things like:

  • Do patients need CTs or MRIs after fainting if it is simple syncope?
  • Do healthy patients need stress imaging for annual checkups if they have no cardiac symptoms?
  • Do patients need CT scans or antibiotics for chronic sinusitis?

Unfortunately, I am not sure the panel got their arms around next steps. Everyone agrees that there are better ways to use our limited resources. The challenge is identifying the institutional prevalence of avoidable care in low-risk populations in addition to creating checks and balances to monitor and reward reductions in unnecessary care. There are two major stakeholders in health care — hospitals and insurers — that are probably in the best position to effectively intervene: They are submitting or paying the claims for this care. However, there seemed to be an aversion at the meeting to discussing how to make both of these stakeholders partners rather than adversaries in this initiative. I see this as a missed opportunity.

I asked one of the speakers if he could recommend five to ten things that every hospital CEO should do tomorrow to have the greatest impact on reducing avoidable care. Instead of answering, he responded that he could not see why a hospital would be interested in doing that. Newsflash! Many hospitals are committed to addressing unnecessary care and have mechanisms to maintain continued improvement.

One other troubling issue was that there was no panel on medical education, even though several speakers noted that the solution to utilizing limited resources lay in transforming the undergraduate and graduate medical education system. This was another missed opportunity to discuss the current advances in medical education and bring another group of stakeholders in as part of the solution. Most of the physician participants had spent their careers in academic medicine, so we all own the problem.  Is medical education a key component of this type of change?  It is necessary, but not sufficient, to achieve the speed and scope of change in medical practice that is really required. We need to engage hospitals, practitioners, insurers, and regulators to create sustainable change.

Some bright spots:

Dr. Bernard Lown spoke. His personal and professional life choices are really inspirational. His blog is worth adding to your blog roll and describes many of his achievements and his personal journey. It would be a great read for medical students. There was also a young resident from the Brigham, Dr. Neel Shah, who has started a site so resident and students can better understand the financial implications of their care choices. His career path is worth following!

—Joanne Conroy, MD, is Chief Health Care Officer at the Association of American Medical Colleges. She can be reached at jconroy@aamc.org. Follow her on Twitter @joanneconroymd

0 thoughts on “Avoiding Avoidable Care

  1. I am amazed that some bureaucrat has not yet thought about avoidable care organizations, ACOs, in which specialist physicians would be paid not to deliver care. If they were paid less than they make in practice, we could save a large amount. Furthermore, by not delivering care we would cut medical errors.

  2. Unfortunately, the Choosing Wisely campaign is missing a couple of key points. Most community hospitals and private physicians would not find “delivering less care” a viable business model today, and this won’t change overnight. There is no mechanism to “hold harmless” a physician who orders fewer tests, and misses or delays a patient’s diagnosis. Without tort reform, physicians need to protect themselves with thoroughness. Finally, the new push to tie physician payments to patient satisfaction does not necessarily correlate with fewer tests or treatments; patients often push to have tests for reassurance, and may feel insulted or neglected if treatment options are not pursued.
    Karen Sibert MD
    Associate Professor of Anesthesiology
    Cedars-Sinai Medical Center, Los Angeles