Medical group fights against unnecessary tests

Posted: April 04, 2012

The patient suffers from headaches and wants to undergo the dull roar of an MRI machine to make sure everything is all right. Good idea?

Probably not.

How about the drip-drip of chemo for the cancer patient who is near death? A CT scan for someone who has fainted but shows no neurological symptoms? Or an annual electrocardiogram for a person with low risk of heart disease?

No, no and no.

These are among dozens of recommendations that nine medical societies are announcing Wednesday, in an effort led by the ABIM Foundation, an affiliate of the American Board of Internal Medicine, based in Philadelphia.

With governments and insurers bemoaning the soaring costs of health care, the medical profession is increasingly offering its own solutions. The new campaign, dubbed Choosing Wisely, is not the first such effort but is among the most comprehensive.

Now comes the tricky part: getting patients and doctors to go along with it.

Various estimates have pegged spending on unnecessary tests at $200 billion to $250 billion each year in the United States, a phenomenon blamed on such factors as overcautious doctors who seek to avoid malpractice claims and patients who don't realize how much their treatments cost.

Organizers of Choosing Wisely say the goal is not cutting costs, strictly speaking, but achieving the best value and the best care. If an expensive test is necessary, then full steam ahead. Conversely, some tests are cheap but still should not be done because they can subject the patient to needless anxiety and risky follow-up procedures that turn out to be unnecessary, the groups say.

The campaign is not about rationing or withholding proper care, said Christine K. Cassel, president and chief executive officer of the ABIM Foundation. On the contrary; if waste is not reduced, there will be less money for the care that is necessary, she said.

"If we don't as a community collectively address this cost issue, then there's a whole lot of people that aren't going to get the care that they need," Cassel said.

Each of the nine medical groups contributed a top-five list of tests or procedures that they determined were often unnecessary in their own fields, for a total of 45, though a few tests showed up more than once. They represent such specialties as family medicine, cardiology, radiology and oncology.

Health-policy experts said the effort was a good way to launch a conversation about the topic. But one University of Pennsylvania economist said it might be hard to get insured patients to question the need for tests if they do not have to pay for them directly.

"The way to get them to do it is to give them a stake in the outcome," said Mark Pauly, a health economist at Penn's Wharton School.

More employers are moving to high-deductible health insurance plans, under which patients pay more costs up front, but such coverage is not the norm.

Cost aside, it can be tough for a patient to speak up, even when the patient himself is a physician.

Take the case of internist Steven E. Weinberger, chief executive officer of the Philadelphia-based American College of Physicians, one of the nine Choosing Wisely groups.

When Weinberger had arthroscopic knee surgery a year and a half ago at the Hospital of the University of Pennsylvania, the doctor's secretary told him he needed to schedule preoperative testing. That included a chest X-ray, an electrocardiogram and blood work, none of which was medically necessary, Weinberger said.

Yet despite his medical expertise, he went along with it.

"I should have been the person to say no, but you don't like to argue with the person who's providing your care," Weinberger said. "You don't want to be seen as the difficult patient."

Preoperative chest X-rays made his group's top-five list of unnecessary tests. Also not recommended: CT scans and MRIs for patients with non-specific lower-back pain.

Public and private insurers have started to address spiraling costs by cutting reimbursements, but Weinberger called that a "nonspecific" approach.

Better to have physicians identify procedures that are wasteful and maintain the tests that are needed, a process that will lead to more acceptance than if solutions are imposed from outside, he said.

As for gaining patient acceptance, a key will be to explain the reality behind misleading "survivor stories," said H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy & Clinical Practice.

"This is the person who has something found early and is doing well, and the presumption is that person has benefited," he said.

In fact, many abnormalities that are detected early - such as a small cancerous nodule - may never progress far enough to harm the patient, or they may even go away entirely, said Welch, author of Overdiagnosed: Making People Sick in the Pursuit of Health.

Yet when such things are detected early, the patient and doctor feel compelled to take action - resulting in biopsies and even surgery that can lead to harm, he said.

"The best medicine isn't the most medicine," Welch said, "even if you had all the money in the world."


Contact staff writer Tom Avril at 215-854-2430 or tavril@phillynews.com

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