Supercommittee Cuts

Posted on Nov 1, 2011 in Practice Management | 0 comments

When Less Is Better, Safer, and Less Expensive

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The congressional Joint Select Committee on Deficit Reduction (Supercommittee) has been charged with finding ways to decrease federal budget deficits by at least $1.2 trillion over the next 10 years, and there is broad recognition among policy makers that savings in Medicare should be part of the solution. On October 19, 2011, a panel was convened to present new ideas for Saving Money and Improving Patient Care in Medicine. The panel included representatives from the journal Health Affairs, the California HealthCare Foundation, the American Board of Internal Medicine (ABIM) Foundation, and the Foundation for Informed Decision Making.

The goals of the panel were to—

• Allow Medicare to make better coverage decisions that will contribute to improved health outcomes for beneficiaries.
• Discourage the provision of unnecessary care that adds costs and doesn’t benefit—and could—harm patients.
• Encourage more shared decision-making between doctors, other healthcare providers and patients, especially in important decisions about end-of-life care.

Much of the panel’s testimony was based on recommendations from the National Physicians Alliance Good Stewardship project that identified the five top activities in three primary care specialties—family medicine, internal medicine, and pediatrics—where quality of care could be improved. Published initially in the Archives of Internal Medicine,[1] the project identified seven discrete activities among family and internal medicine that could improve care and cut costs. These included—

1. Stop using imaging in patients who have had low back pain for fewer than six weeks. According to one panelist, Nancy Morioka-Douglas, MD, “Low back pain is the fifth most common reason that patients visit a primary care doctor; however, imaging before six weeks doesn’t improve outcomes, but it does increase costs.”
2. Stop giving antibiotics for sinusitis. Sinus pain accounts for 16 million office visits each year and $5.8 billion in annual healthcare costs. Unfortunately, the underlying cause is generally viral rather than bacterial and will likely resolve on its own. According to Morioka-Douglas, 80% of sinusitis office visits end with a prescription for antibiotics, which can lead to the additional problem of antibiotic resistance.
3. Stop ordering an electrocardiogram (ECG) or other cardiac screening for low-risk patients. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low risk for coronary heart disease improves health outcomes.[2]
4. Stop performing a Pap test in women who have already undergone a total hysterectomy for benign disease. Most dysplasia in adolescents regresses spontaneously; therefore, screening Pap tests done in this age group can lead to unnecessary anxiety, morbidity, and cost. Pap tests have low yield in women after hysterectomy (for benign disease), and there is poor evidence for improved outcomes
5. Stop ordering bone density scans for women younger than 65 years, or men younger than 70 years, who have no risk factors. Risk factors include, but are not limited to, fractures after age 50 years, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking, alcoholism, and thin and small build.
6. Stop obtaining a blood chemistry panel or urinalysis for asymptomatic, healthy adult patients. The exception would be asymptomatic adults with hypertension who should be screened for type 2 diabetes.
7. Start prescribing brand-name statins instead of generics. Doctors should always start with generic statins, and only switch to a brand-name drug if there’s an adverse reaction or if the patient doesn’t achieve LDL goals, said Morioka-Douglas.

According to additional published data,[2] adoption of the Top 5 Lists in Primary Care would generate an annual savings of $6.76 billion; the largest annual dollar savings ($5.8 billion) would be achieved by prescribing low-cost generic statins when initiating cholesterol-lowering treatment rather than higher cost, brand name drugs.

The total cost saving estimate of $6.76 billion is conservative, the methodology used by the authors could not capture the cost savings for all items on the Top 5 lists in primary care. The pediatric items related to treatment of mild-to-moderate sinusitis, avoidance of early referral of serous otitis media to ENT, and using corticosteroids to control asthma in children; the adult items related to not doing Pap smears on women who have had a hysterectomy for benign reasons, and DEXA scans on men younger than 70 years old were not included in the cost saving figures. Thus, the total cost savings would be larger than the $7 billion estimate.[2]

The National Physicians Alliance has received a second round of funding from the ABIM Foundation that will enable the Top 5 lists to be put into practice.[3] Demonstration practices are being recruited to showcase implementation and the project is producing training videos to help clinicians communicate with their patients about treatment plans consistent with the Top 5 list recommendations. A version of the videos is also being produced to be shown to patients in waiting rooms.

These videos will be shared with other specialty societies embarking on their own efforts to generate Top 5 lists in their respective fields.

 

Jill Shuman, MS, ELS
Published October 27, 2011

References

1. Good Stewardship Working Group. The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-1390.
2. Kale MS, Bishop TF, Federman AD, Keyhani S. “Top 5” lists top $5 billion. Arch Intern Med. 2011; Oct 13. [Epub ahead of print].
3. National Physicians Alliance. “Top 5” lists top $5 billion in potential savings. http://npalliance.org/wp-content/uploads/Top-5-Tops-5-Billion.pdf. October 5, 2011. Accessed October 26, 2011.