• The politics and economics of Choosing Wisely

    NEJM published an interesting Perspective on the politics and economics of labeling services as “low value” by Nancy Morden and colleagues. It’s not quite as damning of Choosing Wisely as the following quote suggests, but I’m trying to provoke you to read the whole thing. (It’s ungated.)

    Participating societies generally named other specialties’ services as low-value. […] Cognitive specialists name very few of their own revenue-generating services. The notable exception is the Society of General Internal Medicine, whose list includes the annual physical, a common visit type for primary care physicians. Most proceduralists, like the orthopedists, include few of their own operative services. The American Academy of Otolaryngology—Head and Neck Surgery, for example, lists three imaging tests and two uses of antibiotics but no procedures, despite decades of literature on wide variation and overuse of tonsillectomy and tympanostomy-tube placement. The American Gastroenterological Association stands out among proceduralist societies in listing specific uses of endoscopy as three of its “Top Five”; this list has potential to meaningfully reduce low-value care — and revenue for gastroenterologists.

    My view is that it’s foolish to think individuals of any profession or sub-field thereof would act strongly against their financial interests. I’m not expert enough to evaluate the low-value items selected by medical societies for inclusion on the Choosing Wisely list, but I’ve heard it said that they’re mostly uncontroversial services and not the bigger-ticket (but still overused) ones. This is about what I’d expect. In JAMA Internal MedicineDeborah Grady, Rita Redberg, and William Mallon suggest that many contributions stem from opaque methodology, another disappointment.

    This sounds one step away from calling Choosing Wisely useless. It isn’t useless. Accepting the fact that it’s very hard to take money out of people’s pockets—let alone to expect them to voluntarily relinquish some of their pie—we should support even modest steps toward decreasing waste. Sure, it’d be nice to lop out that wasteful 30% (or whatever it is) all at once. That’s just not going to happen. But if we can carve out 1% here, 3% there, and build on that, in time we’ll be in a better place than we otherwise would have been.

    Choosing Wisely, like all things, has disappointing limitations. But it’s still a small step worth taking toward a more efficient health care system. The real disaster isn’t that the first step is small, it’s if it is our last.

    UPDATE: Reference to the JAMA Internal Medicine editorial added. H/t Adrianna.


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