June 10, 2015

The “Less Is More” Medical Campaign – Part 2

Some people do the darnest things.  Dallas Mavericks owner Mark Cuban did a good one when he tweeted to his followers to have their blood tested "for everything available" every three months.  Naturally the media had a field day and jumped all over it saying that this could result in false positives, further testing, unneeded treatment, stress, and considerable costs.

The medical community did expose their true feelings when they described the "less is more" movement as a discussion to reduce overuse of "low-value" services.  They say that low-value services are screening, diagnostic tests, or treatments that are unlikely to help patients and post the risk of harm.

In general, they are referring to all screening which means much of the preventive care advocated by the Centers for Medicare and Medicaid Services (CMS).  Researchers have suggested the cost of wasted healthcare dollars, including from overuse of low-value services, makes up a third of the nation's $2.8 trillion healthcare bill.

The less in more campaign has been in the background over the last decade, but has gained a healthy traction with the 2012 Choosing Wisely campaign by the American Board of Internal Medicine (ABIM) Foundation.  The campaign enlisted clinician groups to help promote change by naming an evidence-based top 5 list of tests and procedures that physicians and patients should question because they offer little or no benefit and may cause harm.  Consumer Reports and other consumer groups have also signed on to help educate patients about how more medicine can be harmful.

In addition, some of the prominent diabetes organizations have adopted positions not friendly to those of us with type 2 diabetes.  I will admit that this has me upset and very much against the Society of General Internal Medicine (SGIM) for their stand on this - "Don't recommend daily home finger glucose testing in patients with Type 2 diabetes mellitus not using insulin."  It is not that the American Association of Clinical Endocrinologists did much better, they didn't.

But in an analysis reported last year, researchers at Dartmouth and Harvard pointed out that most of the tests and procedures selected by medical groups, especially "proceduralist societies," for their top 5 lists are either rarely done or are typically performed by clinicians in other fields.  One of the interpretations of this was that specialty societies weren't choosing things that affected their own revenue streams, they were choosing things that affected others' revenue streams.  This is how convoluted Choosing Wisely has become.

Moving away from payment systems that reward volume to those that reward value -- which is what Medicare is rolling out in the post-SGR era, may also help accelerate investment in clinical decision support linked to EHRs to reduce low-value care.  Right now, there is no financial reason for a physician group to invest in that kind of technology.  Risk-sharing arrangements such as accountable care organizations may create a kick in the pants for physician organizations to put things in place like what Cedars-Sinai is doing, providing financial reasons to invest, on top of the motivation to improve quality of care.

Whatever changes are needed to move the less-is-more movement forward, the idea
has staked its claim in the culture of medicine.  What's been accomplished is a cultural sea change, a cultural wave around safety issues and a cultural wave about overuse.  If this is true, why haven't we seen a dramatic decrease in adverse events, medical errors and hospital infections?  I think everything at present is lip service in hopes that the situation will improve.  That is another reason that the catchy phrases are not accomplishing anything, but giving the medical community a warm fuzzy.  It is time for actions to speak louder than catchy phrases.

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