Think Twice Before Choosing Wisely

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Commentary — March 2015 

By Bob Lanier, MD

The Choosing Wisely campaign is a media stunt gone mainstream to prepare for single-payer rationing. Sorry, but I think it's a major political mistake with unintended consequences, and the rah-rah support of the Texas Medical Association makes me nervous.

I first became aware of Choosing Wisely when, as executive medical director for a 5,000-member national specialty society, I was contacted for endorsement by the American Board of Internal Medicine (ABIM). The original task requested of our executive committee was to identify the five most "abused or overused tests" ordered by physicians in our specialty either through ignorance or for personal profit. I, of course, began to look for how this information was to be used and what the implications of the program might be. I found the Choosing Wisely concept was the brainchild of the National Physicians Alliance (NPA), whose activities in the past few years included Support for Taxes on Soda and Sugary Drinks (August 2013); Support of Comprehensive Health Workforce Reform to Improve Access, Quality, and Cost-Effectiveness of Healthcare (July 2013); Gun Violence — A Public Health Issue (February 2013); and Health Savings Accounts Harm Patients' Health (September 2007). 

The political agenda of NPA is pretty straightforward, as this group was formed to advocate a national single-payer plan for medicine. Unable to get traction with the concept initially, NPA teamed with Consumers Reports and spun the concept into an exposé on the "Five Tests patients should refuse when your doctor suggests them." 

That exposé got traction and attracted political parties interested in reducing laboratory tests and x-rays because the major political theory circulating is that if unnecessary testing were eliminated, there would be no need for rationing with the advent of single-payer passage. The Robert Wood Johnson Foundation took up the cause and put their money behind it. With huge grant monies from Robert Wood Johnson, the ABIM Foundation began contacting the specialty and state societies to redistribute these monies as grants. ABIM was pleasantly surprised at how easy the concept was sold to the leadership of state and specialty societies, especially when dangling grant monies in front of them. TMA bought into the program as one of five states that got the grants. 

The concept of Choosing Wisely slowly morphed from a tabloid media-based project of reducing "five abused or overused tests" into a program against diagnostic testing — period. You may not understand that, so let me repeat — there are folks who believe that diagnostic testing as a concept is profit-driven, unnecessary, and greedy. They want to severely limit your diagnostic abilities. 

The guru of the movement is Dr. Gilbert Welch from the Dartmouth Institute for Health Policy and Clinical Practice. His book, Overdiagnosed: Making People Sick in Pursuit of Health, with foreword by Ralph Nader, is truly the bible of the Choosing Wisely movement, and interested doctors should review it to see what is really coming next for a program that sounds so apple pie and reasonable. In one particularly entertaining passage, he relates the personal decision by a clinical oncologist friend to have prostate surgery as irrational. He related that he (Dr. Welch) would never have to make those decisions "because I will never be tested." 

Dr. Welch regularly visits media outlets preaching the gospel of single payer and no testing. It worked! Consider this Choosing Wisely recommendation from the American Academy of Family Practice: Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam. 

Wow — with the stroke of a pen we have eliminated most prostate cancer expenses; aren't we smart? How did a few papers trump the collective experience of urologists? Other executive boards polished that up a bit and suggest no screening on men with less than a 10-year life survival expectation. (As the average life expectancy is 74+, you folks entering into Medicare better get your stuff done, pronto.) Perhaps I am more sensitive to this than most because I am 70 years old and sitting, literally, on a Gleeson 7, biopsy+ prostate. I wonder how long it will be before I am forced to "choose unwisely" based on the opinions of a panel inspired by Dr. Welch and this new quasimedical movement. Should I jump the gun for surgery now, knowing that my age may restrict me in the future more than my cancer? 

The issue of "testing harm" needs further examination before the cherished skills learned from decades of practice are arbitrarily rejected. If you make no money off a throat culture, and it is your instinct that you need one, why should you be subjected to insurance panel review based on compliance to negative opinion-based political guidelines? That's coming – you will be rated on how much unnecessary lab and images you order as dictated by these political committees. It's ironic that the "no testing" movement is being championed by diagnostic internists. 

Despite statements in the December issue of Texas Medicine that the lists for this program are "evidence-based" (a mantra that elicits good feelings from people in the know but has no extrinsic definition) — the truth is with few exceptions the lists were put together with minimal consideration other than the opinions of a handful of executive committees representing each organization — they were political and not academic. I respect my executive committee greatly, but their opinions are not a substitute for practice parameters and guidelines. As time goes by, a mad rush will occur to save money for the system by doing less for the patient based on the latest cost-savings study done by an insurer or physician employed by a health or academic system. The classic example in the latest issue of Texas Medicine was that the executive committee from the American College of Cardiology had to reverse its stand stating that unblocking only the culprit occluded coronary artery was enough and that unblocking all the arteries was costly and unnecessary. Those greedy cardiologists looking at all the other blocked arteries were proven correct. 

No one truly knows the number of "unnecessary tests" for anything except by extrapolation of a relatively small set of vague data generated by health systems and insurers to reduce their expenses. "If we don't restrict tests, the insurers will" is the common rebuttal. I am not so sure. 

Choosing Wisely is a platform for insurance coverage, measurement, and payment based on reverse guidelines — period. Let us pray that these new dumbed-down negative guidelines don't restrict the fleeting liberties we have always enjoyed in our patient advocacy. 

Let us hope TMA isn't hoodwinked in incremental programs leading to single-payer rationing. 

Bob Lanier, MD, is executive medical director of the American College of Allergy Asthma and Immunology and past president of the TMA Foundation and the Tarrant County Medical Society.

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