I always thought I was an informed patient, favoring conservative treatment and helping to save Medicare and the health system money; but when push came to shove, I was a coward that did not speak up when unnecessary tests were ordered.
I think my reaction says something about the limits that even informed patients have in their ability to save the system money and ultimately raises questions about the usefulness of practice guidelines, “choosing wisely,” and evidence-based medicine to do the same. This isn’t an attack on these crucial efforts to bring more science to the practice of medicine. It is a plea for them to be more effective.
As a personal example, when my eye doctor and I agreed it was time for cataract surgery, I signed up with a well-known, large-volume surgeon at his practice in Northern Virginia. In the middle of the elaborate, pricey process, I was given a pre- and post-surgical package. It included a form that required that before surgery the practice should receive a statement from my primary care physician with the results of a timely blood analysis and an EKG, even though I do not display any obvious morbidity warning signs—my blood pressure, BMI, and so forth are all very good.
When I saw the form, I remembered—vaguely—that Cochrane and other advocates of evidence-based medicine had stated that most of the time those tests (and their costs) were not necessary pre-cataract surgery. But I didn’t say anything to the eye surgeon, despite knowing this information. I thought of my wife: She never sends food back at a restaurant for fear of being a troublemaker. Troublemakers do not get good service. I wondered if I should become a troublemaker to this surgeon, but ultimately I went along with his request.
Not wasting time by requiring preoperative tests for patients not at major risk of complications is the first item in the American Academy of Ophthalmology’s “Choosing Wisely” campaign. The tests also are unnecessary according to the Cochrane Library literature reviews. However, the recommendation to generally not test is clearly very widely ignored—and has been for a very long time. There was a 2015 study that noted “…since 2002, guidelines from multiple specialty societies have deemed routine preoperative testing necessary…. Our [study] results showed no difference in the prevalence of testing as compared with 20 years ago….. [Our] data underscore the fact that publishing evidence-based guidelines alone does not necessarily change individual physician behavior.” The paper found that about 53 percent of those getting cataract surgery get some generally unnecessary tests—at a cost to society of millions of dollars. Yet as I experienced, a prominent medical practice in one of the nation’s best-educated counties was routinely insisting on the tests. What is the point in having guidelines if they are ignored?
As a member of the board of directors of the National Committee to Preserve Social Security and Medicare, I believe one way to “preserve” Medicare is to stop paying for unnecessary care: Instead, we should Choose Wisely. I am a member of Consumers United for Evidence-based Healthcare, the US consumer arm of the Cochrane Collaboration, and I’ve participated as a patient representative on four or five practice guideline development panels. Yet despite all of this, I said nothing to my physician about the unnecessary testing I was ordered to undergo. How many other patients would have the information I had? How many would be troublemakers and resist? Not many, I bet.
There are a few ways to address unnecessary testing and its associated costs. However, I don’t think it would be fair to further shift costs to patients by giving them an Advance Beneficiary Notice of Noncoverage (a warning that Medicare may not pay for a procedure and the burden will be on the patient), as some have suggested. One in seven people older than age 65 are below the supplemental poverty measure level (which looks at medical out-of-pocket expenses). I volunteer as a State Health Insurance Program Medicare counselor, and from what patients tell me, the popular Capitol Hill movement to cost-shift to patients is simply unsustainable. Members of Congress should more deeply consider the costs already facing many seniors and those with disabilities.
One solution might be for routine tests (such as the one I experienced) ordered within a month of a cataract surgery bill to result in an off-setting reduction in the total payment to the doctor ordering the tests. Of course, there should be exceptions: as the Choosing Wisely campaign states, “An EKG should be ordered if patients have heart disease. A blood glucose test should be ordered if patients have diabetes. A potassium test should be ordered if patients are on diuretics.”
A second solution might be broader-reaching. I believe the Choosing Wisely program is very important, and I am not singling out eye surgeons. The April 2017 issue of Health Affairs has an article by Arthur S. Hong and colleagues in which they urge the health community to “consider further efforts to reduce the burden of low-value imaging.” The problem of slow or weak adherence to Choosing Wisely consensus-savings is not just in cataracts: It is probably an across-the-board problem. To alleviate this, Medicare could propose over the next several years a program or demonstration where at least one (and over a longer period, perhaps two or three) of the items listed in each specialty’s Choosing Wisely list is no longer reimbursed by Medicare except for in some special cases.
A third solution would be to address malpractice, as several people I have spoken to believe the eye doctor in my case ordered the tests as a protection against malpractice litigation. I disagree, although malpractice deterrence is probably a hindrance to sensible guideline use. To address that issue, stakeholders need to agree to form a system where competently following an accepted specialty guideline is a prime facie defense that can result in protection against huge verdicts. This could encourage the growth and use of guidelines, but with language that ensures that guideline compliance is not just an item to be checked off.
My experience convinces me that as much as I’ve enjoyed being a patient representative on guideline panels, it is a very academic exercise and largely removed from actual patient experience. The costs—and crisis—in our health care system are too urgently in need of attention for continued academic discussions that do not result in action. Let’s find a way to take real action.
Making Practice Guidelines And ‘Choosing Wisely’ More Effective posted first on http://ift.tt/2lsdBiI
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