Reducing overuse and misuse in medical care

On March 31, 2017, at ACP's annual meeting in San Diego, California, internal medicine society leaders from over 30 nations, including those from the European Federation of Internal Medicine (EFIM) and the International Society of Internal Medicine (ISIM), and several key opinion leaders (KOLs) convened as part of the ACP International Forum to consider the worldwide problem of overuse of medical services and failure to provide high-value care, defined as health care that balances clinical benefit with costs and harms, with the goal of improving patient outcomes. All the participants agreed that inappropriate testing, unnecessary procedures and interventions, and other low-value services have resulted in a serious, international problem of rising cost of medical care, in addition to the potential harm to which our patients may be exposed. None of the participants doubted the importance of this problem that in the United States is considered to account for approximately 30%, or $700 billion of that nation's total annual health expenditures. This report, the proceedings of the 2017 ACP International Forum on Reducing Overuse and Misuse in Medical Care, summarizes the discussion and identifies the elements the participants agreed should be included in any nation's strategy to address this problem.

Systems of health care, of course, vary greatly from nation to nation. Some are largely publicly funded and others more privately funded, while the majority of health care systems are a combination of the two. Nations vary as well in terms of the level of their economies, and each has its own level of medical resources as well as its own culture. Nonetheless, the participants identified much more similarities than differences as they considered the roots of the problem of overuse and wasteful use of medical interventions. These roots include but are not limited to misaligned financial incentives encouraging physicians to do more tests and procedures, while encouraging hospitals to promote services associated with higher levels of reimbursement. This theme of rewarding volume, not value, was identified as a problem by a clear consensus of participants.

Other important causes of wasteful use of health care resources that the participants agreed upon were uncoordinated systems of care, including lack of interoperability of electronic medical records; lack of availability of, and commitment to, primary care (which takes different forms in different nations) versus subspecialty care; undue practice variation and failure to follow guidelines and issues pertaining to quality of care; failure to educate key stakeholders, including the public, the medical practice community, policymakers and health administrators; inappropriately strong roles for for-profit companies that influence physician decision-making and health policy overall; and a paucity of research data, including comparative effectiveness research. Of these identified causes of ineffective or wasteful medical care, consensus was reached that misaligned incentives, specialty versus primary care, and failure to engage all stakeholders in solutions were considered most important.

Similarly, consensus was reached on the merit of large-scale, forward-thinking initiatives designed to encourage high-value care. These include the Choosing Wisely campaign launched by the American Board of Internal Medicine Foundation (ABIMF) and supported by ACP, EFIM, and other organizations worldwide; ACP's High Value Care initiative; and the Global Ratings Scales introduced in the United Kingdom to improve quality and limit practice variation.

Given the diversity of health systems represented in the Forum, the complexity of the problem of irrational use of resources, and the importance of national culture and local resources, it was clear that no single approach would likely succeed worldwide, nor was there any attempt by the attendees to devise a one-size-fits-all solution. Nonetheless, there emerged a clear and shared vision of the elements that could be considered essential components of any nation's plan to address the problem of wasteful care. Elements of this shared vision include the following:

• Realign incentives to favor value, not volume. This pertains to physician compensation for procedures, hospital-based reimbursement for diagnostic and invasive procedures, and for-profit industry-driven use of pharmaceuticals and devices that are not associated with benefit commensurate with cost.
• Strengthen primary care. Only with a robust internal medicine workforce will care proceed within a model that supports cost-effective, comprehensive, and continuous care, where patients can avoid unnecessary hospitalization, emergency visits, procedures, and interventions. Subspecialty care is, of course, essential, and no patient should be denied access to the best care medicine can provide. However, that care should occur within a system dedicated to wellness, prevention, and avoidance of unnecessary cost.
• Educate all stakeholders on the importance of high-value care. This includes physicians, patients, hospital and insurance administrators, policymakers, and leaders of the pharmaceutical and medical device industries. No single group deserves the “blame” for the current crisis of wasteful care, but all must be part of the solution.
• Appreciate that cost reduction must be driven by data. This includes data on comparative effectiveness, quality, performance, and outcomes. Care must be based upon best evidence but also be individualized, accounting for quality of life and patient choice. Difficult decisions are best made when reliable data can support compassionate options.
• Communication and interoperability among clinical data systems are essential. This includes electronic medical records with appropriate connectivity and systems that support high-value decision making and reduce duplication. Absent that, care will continue to be fragmented, redundant, and less than safe.
• Eliminate, or at least minimize, the influence of for-profit corporations. The last several decades have seen remarkable advances in pharmaceuticals, imaging, and medical device capability. But the next several decades must provide a more cost-effective, value-driven collaboration wherein quality of care advances as unnecessary cost is contained. All stakeholders, including the medical and corporate communities, must take on this important ethical challenge.

The International Forum concluded with all participants appreciating the ubiquity and complexity of the problem of wasteful care and the importance of local culture and resources, as well as agreeing on the key elements of any nation's strategy to address this important problem. No single group is solely responsible for this problem, and all must be part of the solution. Internal medicine must maintain a watchful eye and a strong and unified voice regarding the problem of wasteful care. The 2017 ACP International Forum can be regarded as an important first step.

Participants

American College of Physicians (ACP)

ACP Alberta Chapter

ACP Mexico Chapter

Academy of Medicine of Malaysia

Academy of Medicine, Singapore

Bangladesh Society of Internal Medicine

Buenos Aires Society of Internal Medicine

College of Physicians, Singapore

Colombian Association of Internal Medicine

Consulting Physicians of South Africa

Costa Rican Association of Internal Medicine

Czech Society of Internal Medicine

Dutch Society of Internal Medicine

European Federation of Internal Medicine

Hamad Medical Corporation

Hong Kong Academy of Medicine

Indonesian Society of Internal Medicine

Internal Medicine Society of the Dominican Republic

International Society of Internal Medicine

Israel Society of Internal Medicine

Japanese Society of Internal Medicine

Korean Society of Internal Medicine

Latin American Society of Internal Medicine

Mexican College of Internal Medicine

Panamanian Society of Internal Medicine

Paraguayan Society of Internal Medicine

Peruvian Society of Internal Medicine

Philippine College of Physicians

Portuguese Society of Internal Medicine

The Royal Australasian College of Physicians

Royal College of Physicians of London

Royal College of Physicians of Thailand

Serbian Association of Internal Medicine

Swiss Society of General Internal Medicine

Taiwan Society of Internal Medicine