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‘Choosing Wisely’ has been disappointing

February 18, 2021

Topics: Quote of the Day

By John N. Mafi, M.D., M.P.H.; Rachel O. Reid, M.D., M.S.; Lesley H. Baseman, B.A.; Scot Hickey, M.S.; Mark Totten, M.S.; Denis Agniel, Ph.D.; A. Mark Fendrick, M.D.; Catherine Sarkisian, M.D., M.S.P.H.; Cheryl L. Damberg, Ph.D.
JAMA Network Open, February 16, 2021

Key Points

Question: Have low-value care use and spending decreased over time with increasing focus on reducing waste in the US health care system?

Findings: In this cross-sectional study of more than 21 million individuals with fee-for-service Medicare, the percentage receiving any of 32 measured low-value services decreased marginally from 2014 to 2018. Claim line–level spending on low-value care per 1000 individuals did not decrease substantially over this period.

Meaning: This study found that among individuals with fee-for-service Medicare receiving any of 32 measured services, low-value care use and spending decreased marginally from 2014 to 2018, despite a national education campaign to address low-value care and increased attention on reducing health care waste.



By Don McCanne, M.D.

It is disappointing, but not surprising, that programs such as “Choosing Wisely” have not had much impact on reducing low-value care, but that is the nature of medicine. Only a relatively small percentage of care produces major improvement in outcomes, and much of the rest is of marginal benefit. Some is of no value and may be harmful, but other factors play a role such as in this study showing opioid use for back pain and antibiotic use for upper respiratory viruses actually increased, sometimes to the detriment of the patient.

What do we do about it? Care that is of no value or even detrimental simply should not be covered. Care that is of low-value but not of no value is much more difficult since it may have some value for some individuals. Perhaps low-value care should be paid at rates so low that the benefit of serving the patient would be the primary reward, whereas care that has such a low benefit that it is not worth the time or effort might preferentially be avoided.

The authors suggest ACOs or capitation as possible solutions. Those issues are more complex and other considerations may outweigh those approaches. Under a fee-for-service system low prices or no price seems more appropriate.

Of course, research to identify best practices will provide the continuing guidance that we need for higher value care. If you think back through the decades, medicine has changed and mostly for the better.

What about single payer Medicare for All? It would change the financing from catering to the medical-industrial complex to a system that caters primarily to the patient instead. Just introducing that attitude would give us a great restart in improving our management of low value care.

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About the Commentator, Don McCanne

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Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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