‘Choosing Wisely’ initiative may be a tipping point for costs and ethics

I’ve heard speakers at countless recent meetings call for stemming the rising costs of health care. But none inspired the response I heard from last week’s Birnbaum Lecture with former Medicare chief, Dr. Don Berwick.

As one Group Health clinical leader told me, “This is the first time I’ve really understood why controlling costs is an issue of professional ethics.”

And at the ensuing HMO Research Network (HMORN) conference, the lecture sparked some solid ideas for next steps in research.

Why this momentum? Some might credit Dr. Berwick’s stunning candor and humility recounting a medical error during his pediatric residency—a blood transfusion gone wrong, harming a newborn in his care. With the wisdom of 38 years of hindsight, Dr. Berwick told us what the incident taught him about himself and the potential for health care to do harm—and to prevent it. He convinced our hushed audience of 1,000: Health professionals and their leaders have a moral duty to ensure their patients’ safety, personally and through system improvement.

Then the lecture took a surprising turn as Dr. Berwick began talking about inefficiency and wasted resources.

Costs don’t involve “a baby lying helpless at night waiting for a blood transfusion,” he said. Yet like safety, stabilizing cost is an ethical duty. Health care spending is swallowing wages, business vitality, our investments in education, infrastructure, and public safety through our government’s growing inability to serve its citizens, he explained.

“Without changes now, millions of people face imminent harm,” he said. “Our schools totter, our bridges decay, our generosity to the poor wavers, our assistance to the disabled pales, our arts languish, our standard of living and our children’s standard of living hang in the balance.”

Turning to solutions, Dr. Berwick surprised us again. Instead of focusing solely on health economics, he borrowed from global warming: Just as solving our environmental crisis requires many factors (fuel efficiency, solar power, home insulation, carbon sequestration, etc.), stabilizing our nation’s health care economy will take several concurrent improvements.

Dr. Berwick and RAND researcher Andrew Hackbarth described those changes in the Journal of the American Medical Association last month. Eliminating six major categories of waste (overtreatment, failures in care coordination and in execution of care processes, excess administrative costs and prices, and fraud and abuse) could free up at least one fifth of our nation’s total health care spending. That alone could make our health care system sustainable—avoiding potential harm from proposed cuts in provider payments, health care benefits, and eligibility for coverage.

Dr. Berwick also endorsed an initiative called “Choosing Wisely,” which is gaining ground among national medical specialty societies, including cardiologists and radiologists. Sponsored by the American Board of Internal Medicine Foundation with support from Consumer Reports, the initiative promotes conversations among physicians and their patients to improve care and eliminate unnecessary tests and treatments. To date, nine specialty societies, representing 374,000 physicians, have each developed a list of “Five Things Physicians and Patients Should Question.” Examples include antibiotics for early sinus infections, advanced imaging for short-term back pain, and routine EKGs or stress tests for low-risk patients without symptoms of heart disease. Even more specialty societies are on board, now developing their own lists of five "don'ts".

 The Choosing Wisely initiative is remarkable because doctors’ professional advocacy groups are making recommendations that are often counter to their own economic interests. By recognizing elimination of unnecessary care as a matter of professional ethics, medical professionals in a broad range of specialties may be signaling that we're reaching a tipping point toward solving America’s health care cost crisis.

As the HMORN Annual Conference attendees buzzed about Choosing Wisely last week, many of our researchers were excited to study such movement within our Network’s health care systems. Group Health researchers have already been partnering with our Group Health care-delivery colleagues on initiatives to reduce harmful overuse of opioids for non-cancer pain and curb use of unnecessary high-end imaging. Picture researchers throughout the HMORN collaborating to evaluate whether patient and provider education to reduce waste in health care can make a real and lasting difference to costs and the economy locally and nationwide.

I thank Don Berwick for his eloquent and compelling call to action. As professionals we should now understand we cannot sit on the sidelines. It’s time to use our resources as a learning health care system to reduce the harm of overuse, overtreatment and inefficiency. We must. It’s our moral obligation.

—Eric