Not Choosing Very Wisely

A new study by the ABIM Foundation -- the sponsors of the Choosing Wisely campaign that aims to reduce the incidence of unnecessary services -- found that nearly three-fourths of physicians think that unnecessary tests and procedures are a serious problem for our health care system, and about the same percent say the average physician orders those at least once a week.

No kidding.

The physicians seem to put a lot of the blame on patient demands, with 47% reporting they get such requests at least once a week.  The physicians overwhelming (87%) claim they always/almost always try to talk patients out of unnecessary tests, and that patients usually (70%) follow their advice, but most (53%) admit they likely would give in if a patient was insistent, even if the physician knew the test or procedure was unnecessary.  Given all those unnecessary ones that still happen, there must be a lot of insistent patients.

The tests and procedures may or may not have potential adverse health impacts on patients, but they certainly have cost implications.  Still, 57% of physicians reported talking about costs of tests and procedures half of the time or less.  19% never discuss costs at all, which was about the same as those who claim to always/almost always do so.  That's disappointing -- but not surprising.

The physicians do see themselves as being in the best position to address the problem of reducing unnecessary services (58%, compared to only 15% for the next highest party, the government), which leads one to wonder why they are not doing so already.

Maybe they're just not paying attention.  Heck, only 21% of the physicians have even heard about the Choosing Wisely initiative (at least unaided -- after being read a short description a whopping 38% thought they knew something about it).

I wrote about a similar issue a year ago (It Was Those Other Guys), when a JAMA study found that physicians cited everyone other than themselves for being responsible for rising costs.  There's a certain head-in-the-sand aspect of all this that I just have to shake my head at.  

Maybe handling demands for those unnecessary tests help explain results of another new study.  Guilherme Del Fiol and colleagues did a meta-analysis of studies that looked at clinical questions raised during patient care -- and found that clinicians only followed up on the questions only 51% of the time.  To be fair, when they did pursue the questions, they found answers 78% of the time, but I'll bet patients wouldn't be too happy if they knew it was only 50/50 (well, 51/49) that their clinician will follow-up on their own clinical questions.

I like to believe that the open questions were ones that, in the scheme of things, were just not considered important, rather than ones that simply fell through the cracks.  In any event, it makes me wish patients were more insistent about getting those questions answered instead of insisting on those pesky unneeded tests and procedures.


Dr. Del Fiol's study suggested that perhaps technology could help clinicians track and ensure follow-up on such questions, and I hope they're right.  Of course, a recent RAND report found that, while they like EHRs in principle, physicians are often dissatisfied with certain aspects, including the difficulty of data entry.  So I wouldn't hold my breath for better documentation of those clinical questions.

The unnecessary tests and open clinical questions certainly are a problem, but I fear we're making poor choices on a broader, more structural level that may haunt us for a long time.  A new study on market consolidation caught my attention due to its important (although unsurprising) results.  Laurence Baker and his Stanford colleagues found that hospital ownership of physician practices does increase hospital prices and spending.  Prices went up 2-3% for every time market share increased by one standard deviation.

The data for the study was from 2001-2007, and may not reflect "newer" strategies such as shared savings models, but still suggest that there is a difference between vertical integration designed to wring out supply chain savings (think Walmart or Amazon) and vertical integration aimed at knocking out competition.

Dr. Baker's study did find that some looser forms of integration, such as PHOs or IPAs, did not appear to have quite the same increase in spending, but those don't seem as preferred as outright acquisitions

This is not the first time these kind of results have been found (see, for example, last fall's Hospitals, Market Share and Consolidation by Cutler and Morton), but the results add to the warnings about what we're getting ourselves into with these acquisitions and other types of consolidation efforts.  I have to wonder why the community leaders -- including the board members of the non-profit health systems and the largest local purchasers -- are not raising harder questions about these consolidations. 

While economists are still studying the issue, health systems are busy acting: hospital mergers and acquisitions continue their dizzying pace, up 51% in 2013 relative to 2010.  Acquisition of physician practices also has continued.


The FTC is starting to wake up about the problem, especially if the health system in question is named St. Luke's (e.g., the Boise and Toledo cases).  As Deborah Feinstein, the director of the bureau of competition for the FTC, told The Washington Post, "We have seen, over the last couple of years, hospital-doctor combinations that are troubling to us.  And we are looking at it."

I feel better already.

I can't think about provider consolidation without thinking about ACOs.  One doesn't necessarily imply the other, but it'd be foolish to ignore the potential connection.  According to consulting firm Oliver Wyman, there are now 522 ACOs -- more than double a year ago -- which serve some 17% of all Americans.  Two-thirds of Americans live in an area served by an ACO, although only 40% live in an area served by two or more. 

For ACOs to be successful, they require partnership not only between hospitals and physicians, as well as other providers, but also between the ACO and payors.  They're not starting off on great footing for the latter.  ReviveHealth's 2014 Payor Survey found that on a scale of 0-100, hospitals' trust in payors scored 53.2, which would be an "F" in most grading situations.  The highest rated payor -- Cigna -- only scored 63.1, which is still at best a "D."

United Healthcare drew the lowest ratings on virtually every aspect, even though the Blues tended to pay even less.  The Blues were seen as most trusted by consumers and most honest in contract negotiations.

Despite the lack of trust for payors, hospitals are drinking the Kool-Aid about joining narrow networks, with 47% reporting they are already in the works to be in one and another 13% planning to do so.  They may be hoping they can consolidate their market enough so that they are the narrow network.

I've expressed my skepticism about narrow networks previously (It's a Narrow World After All).  They may appear less expensive in the short term but it's hard for me to believe that they are best for patients in the longer term.

With CMS pressing the accelerator for ACOs and FTC putting on the brakes for consolidation, many are wondering where federal government is driving the health system.  As Robert Field, a law and health policy professor at Drexel University in Philadelphia, told the Post, “The federal government has a schizophrenic attitude toward provider consolidation.”

Maybe schizophrenia explains why we're not making better choices.