Thursday, April 09, 2015

The Choosing Wisely recommendations: tools or rules?

This post by Retired Doc is from a few months ago but it it is important and especially timely now in light of all the questions swirling around what the ABIM Foundation is up to. 

The Choosing Wisely (hereafter CW) recommendations were compiled from submissions by leaders of various specialties and are, hence, suggestion based as opposed to evidence based. They were initially promulgated as tools to help clinicians deliver high value care.   But, as Retired Doc pointed out, another agenda is at play:

However in the two years since the launching of CW ( at the time of this writing) several policy experts and wonks have envisioned a much more full bodied, authoritative and coercive role  for the pronouncements announced under the CW brand.  It is this expanded role for CW that I refer to as the medical law of the land...

So based on some of these experts' recommendations, what would the medical landscape look in the era in which the decisions of Choosing Wisely would be much more than the suggestions or recommendations,which is how they are sometimes presented  and  instead be  determinative in regard to the reimbursements of third party payers, private and public as well being used in decisions regarding medical specialty certification  and maintenance of certification and other mechanisms to decrease medical costs.

He quoted these proposed uses of CW from the ABIMF blog:

ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC.

ACP could grade use of resources through MKSAP questions.

CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations.

He quoted other policy leaders proposing a similar agenda and then went on:

Physicians would have to follow the CW guidance or risk loosing certification let alone payment for services. As bound as physicians would be to the  dictates of the CW authority how much trust could a patient have that his physician is acting in his ( the patient's) best interests .Making CW the medical law of the land would be a giant step toward the collectivization of medicine and destruction of the traditional physician patient relationship.

As such it would also mean the destruction of evidence based medicine as I once noted in a post in which I outlined EBM's history, intended purpose and definition:

Two of the interviews are with David Sackett, widely known as one of EBM's main apologists. He talked about the beginnings of the movement and emphasized that it is not merely a collection and critical appraisal (a term the EBM founders coined) of evidence. Rather, it goes beyond that to encompass the judgment of the individual clinician and the preferences and values of the individual patient. Those two elements often get left out of the discussion. Because the individual patient is a key element of EBM, proponents of medicine done by central planning can never claim to advocate for evidence based medicine. Along the same lines Dr. Gordon Guyatt remarked that there is no clinical decision that doesn't have the individual patient's preferences and values attached to it. As a corollary, evidence alone cannot inform a clinical decision.

Clearly those who would leverage central authority to impose CW dogma on medical care are opposed to EBM whether they admit it or not. 

1 comment:

james gaulte said...

Thanks for the discussion.I wish I had used the "tools or rules" phrase.(and I probably will). The anti-EMB aspect of Choosing Wisely is a strong insight and well worth emphasis.