Whenever I give a talk on the sorry state of the United States health care system, somebody inevitably asks me what we should do to reduce our spending. My first comment is always along the lines of “if we knew what to do, we’d be doing it already”. But if I’m pushed, I'll usually note that the best first step might be for us to stop doing things that don’t work. There's an organization dedicated just to that, it's called Choosing Wisely; and, it's also the topic of this week's Healthcare Triage.
 
(Intro)
 
Reducing spending without negatively affecting quality is not entirely straightforward, however, there are numerous processes of care that we know are wasteful. They have been shown be research and analyses not to improve quality - sometimes they even result in harm. Regardless they increase spending. By identifying and eliminating these wasteful processes we can meet the goals of accountable care without unintended consequences. And, if we do these things writ large it could result in an improved financial outlook for the entire healthcare system. 
 
A 2012 paper in JAMA explicitly singled out waste as a better way to reduce healthcare spending in the United States. In this table from the manuscript you can see that a reasonable estimate of waste in the US healthcare system could be more than 900 billion dollars a year, 300 billion dollars of which is spent by Medicare and Medicaid alone. The over-treatment category alone accounts for somewhere between 158 to 226 billion dollars each year. Focusing solely on this area could still result in large savings. 
 
With that in mind it's worth talking about Choosing Wisely; it's an initiative of the ABIM foundation that, and I'm quoting, "aims to promote conversations between physicians and patients by helping patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary." They first made news in 2012 when they had nine specialty societies release lists of five things physicians and patients should question. Basically, they came up with lists of things we shouldn't do when practicing medicine. They identified over-treatment as waste. 
 
I've been somewhat skeptical of these efforts in the past, partly that's because without coupling these ideas to payment reform the financial incentive to continue doing them remains. Additionally I felt that the scope of some of the recommendations was limited. As a pediatrician for instance, I couldn't help noticing that none of the original recommendations really focused on children. But, in the coming years and months Choosing Wisely has addressed some of my concerns. They along with 17 leading medical societies have come-out with many, many more newer tests, procedures or therapies that are common - but, likely unnecessary. Pediatrics is well represented among them. Here are the recommendations made by the American Academy of Pediatrics:
 
Antibiotic should not be used for apparent viral respiratory illnesses (like sinusitis, pharyngitis, or bronchitis).
 
Cough and cold medicines should not be prescribed or recommended for respiratory illnesses in children under four years of age.
 
Computerized tomography (or CT) scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated.
 
Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure.
 
And, CT scans are not necessary in the routine evaluation of abdominal pain.    
 
And here are some other highlights from various other specialties, for instance: 
 
Don't schedule non-medically indicated inductions of labor or C-sections before 39 weeks. (That comes from the American College of Obstetricians and Gynecologists, and American Academy of Family Physicians)
 
Avoid doing stress tests using echocardiographic images to assess cardiovascular risk in persons who have no symptoms and a low risk of having coronary disease.
 
When prescribing medication for most people age 65 and older with type 2 diabetes, avoid attempting to achieve tight glycemic control.
 
Don't routinely treat acid reflux in infants with acid suppression therapy. 
 
These recommendations cover a wide swath of care options for problems that are both common and expensive. If we listen to them we'd save a HUGE amount of money. We'd also do a fair amount of good; people often forget that these tests and treatments carry potential harms. When you do them and achieve no benefit you are potential hurting quality. 
 
When I really think about it I'm forced to admit my skepticism comes from a place of cynicism. I wish that wasn't the case, but it is. Some doctors fear lawsuits, this won't change that. Some doctors see a subset of patients that aren't representative of the general population, and are conditioned to believe that more tests are necessary than really are. This won't change that either. And I still believe that as long as we continue to pay for this stuff it's gonna get performed far too often. Financial incentives drive behavior, even when they're aligned in the wrong direction. I'm more than happy to be proven wrong, but I think it's unlikely. 
 
But really, I'm all for this; I think it's great. We just have to have a little perspective. None of these recommendations are news to those of us who practice medicine and follow the medical literature. Seriously, try and find a physician who doesn't know that overuse of antibiotics for sinusitis is a problem. The real issue as I've discussed before isn't that doctors don't have access to evidence. You can say that mammograms should be used less often, but when enough physicians call that "crazy" and "unethical" and label the USPSTF idiots - then it's all sort of moot. 
 
But Choosing Wisely continues to give us lots of good ideas to work with. I encourage you to go explore their website, links below, to see some of the many, many things we shouldn't be doing. We should also think about giving their efforts teeth by tying Choosing Wisely's efforts to payment reform.