Do “Choosing Wisely” Lists Protect Physician Income?

Kaiser Health News and the Chicago Tribune recently collaborated on a story that led with the following observation: “When America’s joint surgeons were challenged to come up with a list of unnecessary procedures in their field, their selections shared one thing: none significantly impacted their incomes.”

The comment refers to the five items on the AAOS-approved Choosing Wisely list of orthopaedic-related procedures that physicians and patients should discuss and question (see the related OrthoBuzz item from Feb. 26, 2014).

Orthopaedists are not alone in this allegedly income-protecting tactic: “Some of the largest medical associations selected rare services or ones that are done by practitioners in other fields and will not affect their earnings,” the article stated.

For example, the Choosing Wisely list developed by the North American Spine Society (NASS) does not include spinal fusion, a controversial but lucrative procedure. “What we did when we made up the list was to start with more straightforward situations and hopefully expand that later,” said NASS board member F. Todd Wetzel in the article. That explanation makes some sense, considering that the evidence base for many tests and procedures—orthopaedic and otherwise—is equivocal.

Ultimately, the best decisions are made on a patient-by-patient basis, and the patient’s role in the Choosing Wisely campaign can’t be overemphasized. It’s about having a rational and respectful two-way conversation when a patient insists on having a certain test because his or her friend with the same symptoms had that test—or when a physician strongly recommends a certain procedure, the risks and benefits of which the patient doesn’t understand.

While it’s hard not to agree with Morden et al. in their NEJM Perspective piece (Feb. 13, 2014) that “more numerous and more courageous lists should be developed,” patient-education efforts must be ramped up because culling out low-value tests and procedures from the health care system should not and cannot solely be the responsibility of physicians.