Some components of Choosing Wisely could be encouraged among health system- and hospital-employed physicians without causing financial losses, such as replacing more brand-name drugs with generic alternatives.

Oct. 24—As more hospitals shift to value-based payment, more have an incentive to discourage use of low-quality services—the focus of the Choosing Wisely campaign.

The campaign, cosponsored by the ABIM Foundation and Consumer Reports, was designed to spark conversations among physicians, patients, payers, and purchasers about the overuse of tests and procedures, and to support physician efforts to help patients make smart and effective care choices. But five years after the campaign’s launch, both the shift toward value-based payment and the reduction of low-value services remain slow, leading researchers said at a Washington D.C. meeting on the initiative.

“If your business model is purely a model of doing more [volume], some of these [Choosing Wisely] things are probably not going to work,” said Michael Chernew, PhD, a professor of healthcare policy at Harvard Medical School. “It is the case that in a fee-for-service world you have a tension, potentially, [when trying to cut back on] some of these particular things.” 

For example, encouraging physicians to reduce the use of preoperative testing and imaging for lower back pain—two commonly used services that are focal points of the Choosing Wisely campaign—might have a negative financial impact on their hospital employers.

But hospitals that are shifting to value-based payment—where they are financially rewarded for providing cost-effective care and not just more care of dubious efficacy—can use the campaign’s initiatives to boost performance.

“The justification for moving [forward on Choosing Wisely initiatives] is that it makes these financial incentives and the value initiatives align,” Chernew said in an interview.

However, hospital movement to value-based payment is still not far along, according to recent data. For example, an Ernst & Young LLP Advisory Health survey in June found that about 67 percent of small hospitals and health systems ($100 million to $500 million in revenue) planned no value-based payment initiatives in 2017. Similarly, 61 percent of hospitals and health systems with revenue of $500 million to $999 million planned no such initiatives. In contrast, value-based initiatives were planned by all but 23 percent among those earning from $1 billion to $2.49 billion, 14 percent among those earning $2.5 billion to $4.99 billion, and 8 percent of those earning at least $5 billion.

Echoing those survey results, researchers said larger integrated health systems and hospitals that are more invested in alternative payment models have had more success implementing some of the Choosing Wisely goals.

“If you’re a fee-for-service system, it is going to be harder to reduce overuse—not impossible,” John Mafi, MD, assistant professor of Medicine at the University of California, Los Angeles and a researcher of low-value service utilization. “In more-capitated payment systems, like accountable care organizations (ACOs) and HMOs, you’re going to have an easier time reducing these services.”

Eve Kerr, MD, director at the Veterans Affairs (VA) Center for Clinical Management Research and a professor at the University of Michigan Medical School, said the capitated VA system has less use of low-value care, although it still occurs there.

“There’s tremendous variation at the facility level, and we haven’t drilled down to the individual provider level, but I think if we did we’d see that there as well,” Kerr said. 

The modest movement to value-based payment has mirrored the modest effects of the adoption of Choosing Wisely initiatives.

For example, research published in April in Health Affairsfound only a 4 percent relative reduction in low-value back imaging two and half years after the start of the campaign. Earlier research found that the campaign resulted in declines over several years among two low-value services, increases in two others, and no change in three others.

“The changes we have seen have been small; I think it’s easy to come to a conclusion that we haven’t moved the ball a lot,” Chernew said. “The impact is clearer if the targeted effects at specific organizations are examined.”

For example, USC Medical Center used the Choosing Wisely approach to reduce its use of preoperative surgical imaging for patients receiving cataract surgery. The resulting 80 percent drop in preoperative visits was credited with reducing the median cataract surgery wait time from 245 days to 64 days, said Eric Wei, MD, interim chief quality officer for the hospital.

More Opportunity

The opportunity for hospitals and health systems to encourage physician avoidance of low-quality care has increased with the substantial rise in their employment of physicians in recent years, researchers said. The share of physicians who work in a practice with at least some hospital ownership or who are direct hospital employees reached 32.8 percent in 2016 after years of steady increases, according to a regular report by the American Medical Association.

But getting employed physicians to pursue value-improvement initiatives like Choosing Wisely will require leadership from the top of the organization.

“Our CEO [at the University of Michigan Medical School] has basically said, ‘I understand that this may reduce unnecessary care. It may mean a decrease in income for some areas for a short period of time, but it’s the right thing to do,’” Kerr said.

Financial Wins

Some components of Choosing Wisely could be encouraged on behalf of health system- and hospital-employed physicians without causing financial losses, including replacing more brand-name drugs with generic alternatives, Chernew said.

Additionally, hospitals that get their physicians to reduce utilization of low-value services may not have to reduce their overall volume of—or revenue from—other services.

“It reduces the use of those services to make room for other services; hopefully those services are necessary and high-value, but that’s something that needs to be studied too,” Mafi said in an interview.

Hospitals also may face pressure from enrollees in high-deductible health plans (HDHPs) to obtain some of the cost savings offered by avoiding low-value services as identified by the campaign.

Kellie Slate Vitcavage, program director for Maine Quality Counts, which encourages and educates patients on the Choosing Wisely initiatives on low-value care to avoid, said her organization plans partnerships with employers to help workers who are covered by HDHPs “make smart choices.”

Chernew said the campaign also could serve as one more push to get hospitals to move toward value-based care.

“One reason it is important that they get the financial incentives right is because then these [Choosing Wisely initiatives] become winners, not losers,” Chernew said.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, October 24, 2017