The ‘Choosing Wisely’ Campaign is the Wrong Vehicle for ACEP’s Reform Efforts.
A campaign called Choosing Wisely has gotten some attention of late because of its stated goal of reducing health care costs by eliminating tests and procedures that are not “necessary.” Since ‘Choosing Wisely’ launched, nine medical specialty organizations have offered up their top five items for the chopping block. These range from CT scans for fainting from the American College of Physicians to antibiotics for chronic sinusitis from the American Academy of Allergy, Asthma and Immunology.
ACEP was asked to join the campaign in 2011, and after extensive review and discussion at the Committee level, ACEP declined. There are several reasons for our initial response:
Emergency physicians have no right of refusal with our patients and often pick up the slack for other members of our esteemed profession. A recent member poll showed that 97% of us report seeing patients on a daily basis who are sent to the emergency department by their primary care physician. Many of these patients have been sent in with expressed instructions from the family physician to have this or that test ordered either because their office practice is swamped, the office is closed, or they lack the facilities to perform these tests.
ABIM, the organization sponsoring the campaign, refused to allow any discussion of liability reform as a component of the Choosing Wisely campaign. To quote from the letter ACEP Past President Dr. Sandy Schneider sent to Daniel Wolfson, ABIM’s Executive VP and COO: “This is a significant issue in emergency medicine and a critical factor as to why emergency physicians order the number of tests and procedures they do. Unlike primary care physicians, emergency physicians are not chosen by their patients, who have a greater tendency to sue for any perceived untoward event. In addition, we often lack prior care information. It is simply not possible for emergency physicians to talk about reducing ‘unnecessary’ testing without including messages about the need for medical liability reform.”
Emergency physicians approach our patients with the goal of eliminating anything life threatening. We cannot afford to miss anything, even something that seems like a long-shot. The consequences may be life or death for our patients. A test that is unnecessary for 99 patients may save the life of patient number 100.
Emergency medical care constitutes just 2 percent of all health care spending in the United States, no doubt in part because so much of the care we deliver is uncompensated. We are masters of efficiency and improvisation but there is only so far a dollar can be stretched. Emergency departments have been closing at an alarming rate across the country because so much care isn’t paid for. This is not the place to cut costs any further.
Lastly, should ACEP participate in this campaign, it very well may assure that emergency physicians will not receive reimbursement for the five identified procedures or tests.
ACEP is dedicated to advancing emergency care and promoting evidence-based quality improvement measures for its patients. To that end, we are reevaluating our response to the Choosing Wisely campaign by developing a workgroup, comprised of members from the Reimbursement, Medical-Legal, EM Practice, Clinical Policies, Quality and Performance, and Public Relations Committees to examine the issue and prepare a proposal for ACEP Board consideration.
This article originally appeared on the blog The Central Line on May 8, 2012
Q&A: 15 Minutes with Dr. Seaberg
EPM: Walk us through the timeline of being presented with the Choosing Wisely campaign, and how ACEP ultimately chose to not participate.
Dr. David Seaberg: This came to ACEP when Sandy Schneider was president. She formed a committee to look at whether ACEP should participate, and there were a lot of concerns. Identifying five procedures that could be deemed “unnecessary” was problematic for our members. They decided to not participate. It came up again during my presidency. Since this was catching wind from other organizations, about six months ago, I formed a second workgroup to look at whether ACEP should participate. It was a different workgroup, but they came up with the same conclusions that while cost control is important, the Choosing Wisely campaign was not the right vehicle. We had a backlash from the academic community, so we formed a third taskforce to look at this. All three taskforces agreed that this was an important concept, but that Choosing Wisely was not the right vehicle. After the third workgroup declined to join Choosing Wisely, I formed a cost effective emergency care taskforce. This group looks not only at the things we do that maybe we shouldn’t, but also what are some of the more cost-effective practices that we should do.
EPM: The Choosing Wisely web site describes the task as: “identifying five tests or procedures commonly used in their field, whose necessity should be questioned and discussed.” Isn’t this open, broad language?
Seaberg: It may sound clear and open, but if you Google the Choosing Wisely campaign, you will find the term “unnecessary tests” in all of the first page entries. Here is the issue. We have other groups who are now, through the campaign, telling us how to practice emergency medicine. The issue is that these are going to be deemed unnecessary tests and in emergency medicine, that is not so black and white. What will happen – the concern that many of our members express – is that if we list five things, CMS will eventually use them to not pay us. Again, there are certain circumstances, particularly in emergency medicine, where we don’t know the patients as well, and where these “unnecessary tests” may be necessary.
The problem is that this is merely a PR campaign, but CMS might still use it to stop payment. That was the concern of many members. We had about an equal number of people who wanted us to join the campaign and didn’t want us to join. We felt that the best move for ACEP would be to form a comprehensive cost-effectiveness task force, and not be limited by five tests that were part of the Choosing Wisely campaign.
EPM: So you feel that the Choosing Wisely campaign is a slippery slope?
Seaberg: Choosing Wisely is very much a slippery slope. There are certain members of ACEP who felt that if we put out five tests, we will never again get paid for those, and there are certain instances where these tests may be necessary.
EPM: What kind of push-back have you received from the academic community?
Seaberg: They wanted us to participate. I even got a letter today. In the American College of Neurology, in their list of five, two of them were telling emergency physicians what to do. That was not the purpose of the campaign. It’s about telling what your own specialty should be doing, not telling other people what to do. So, in this regard, there may have been some benefit from being in the Choosing Wisely campaign, but these groups are sending their guidelines to us, and we’re going to say, ‘this probably shouldn’t be one of your five because it really should just involve your specialty.’ That’s the danger with some of these guidelines. Just because a family medicine doctor knows the patient and has all their records and thinks a test is unnecessary, that might get spread over into the emergency department. And that is not how we should be practicing medicine. Clearly cost control is going to be critical in the future of medicine. We understand that this is a critical issue. We just want to have a better means for coming up with what we think will be solutions.
EPM: Will this question come up again for the next ACEP president?
Seaberg: Dr. Sama has been very involved in this discussion and he has been very much on board. Again, we have this cost-effective emergency care taskforce that’s working. It’s got very bright people. We’re going to be putting out a survey to ask our members what are some of the things that you think should be on this. Then we’re going to refine that survey and put it in our new survey tool called the Emergency Medicine Practice Research Network. Then we’re setting up a delphi panel after that to further refine our areas. Again, it may not just be tests, it may be practices that we should be doing. So, we’re going to take a much more comprehensive look at cost effectiveness than many of these other specialties are doing.
David Seaberg, MD is President of the American College of Emergency Physicians (ACEP)