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Payment Incentives May Be Key to Dropping Unneeded Procedures

By John Reichard, CQ HealthBeat Editor

April 4, 2012 -- Nine medical societies recently named a total of 45 medical procedures they say are often not necessary, with eight more specialty groups scheduled to release their own lists this fall.

It's a big step toward reducing unnecessary medical spending but the way doctors are paid is also key, analysts say.

Unnecessary medical spending is a big problem in the U.S. Experts say up to one-third of nation's health care tab is for wasteful care.

Reducing that spending is tough, partly because government attempts to cut out certain types of treatments lead to charges that medical care is being rationed. But with doctors themselves urging the changes, the rationing charge is one less obstacle to overcome.

There are others, however, particularly the reluctance of doctors to change their ways and the lack of payment incentives for them to do so.

The Choosing Wisely Campaign announcement last week represents an ambitious beginning because it names dozens of commonly used procedures and treatments that these groups say are ineffective or that doctors and patients should question. They include the use of antibiotics for most types of sinusitis, repeating colorectal cancer screening less than 10 years after a negative test except in certain cases, ordering a pre-operative chest x-ray for outpatient surgery and imaging for low back pain in the first six weeks.

Others include screening women under 65 for osteoporosis with DEXA (dual energy x-ray absorptiometry) scans, giving stress tests in annual checkups to healthy patients without cardiac symptoms and giving routine cancer screening tests to dialysis patients with limited life expectancies and no signs or symptoms of cancer.

Sponsored by the non-partisan ABIM Foundation, the campaign relies on Consumer Reports to help educate patients about the need to question their doctors about the procedures. AARP and eight other organizations, each with the potential to reach at least a million consumers, will help with the consumer education efforts.

Robert Berenson, a senior fellow with the Urban Institute, said that it takes doctors a long time to adopt best practices.

"When I started my medical training hormone replacement therapy was recommended, then it was not recommended, then it was recommended, and now it's not recommended except a recent study suggests well, maybe it should be, at least for some women. So there is conservatism with is partly warranted," Berenson said.

Nevertheless, Berenson does not dispute that a substantial part of medical treatment is wasteful. But he says the issues facing physicians when they make treatment decisions often are not black and white but fall into a gray area. And in the gray area, "payment incentives matter a lot" in terms of whether or not a doctor performs a test or service. That speaks to the importance of moving away from fee-for-service payment that rewards doctors for doing more rather than for doing what is appropriate, Berenson said.

Berenson, said, for example, that stent placement for stable chronic coronary disease hasn't fallen off despite recommendations by the cardiology specialty society that in many instances other approaches should be used instead. "So relying just on what specialty societies [recommend] may not be enough to actually change behavior when you've got financial incentives that cut the other way," Berenson said.
Daniel Wolfson, chief operating officer of the ABIM Foundation, said payment "is a big issue and Bob, as always, is right."

But payment incentives are not the immediate focus of the campaign. "We're asking the specialty societies to do the right thing and to be good stewards of physician resources," Wolfson said. The societies "are the most influential individuals to talk about unnecessary tests."

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