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Do Wise Choices Translate Into Cost Savings and Improved Outcomes?

Patients today are largely reliant on agents when making health care decisions: their physicians, their insurance carriers (including state and federal government agencies), their families, and often on professional societies and other assemblies of experts. In a simple market theory, producers and consumers are responsible for making their own decisions. In complex market reality, however, a great many resources are allocated as a result of indirect or delegated decision making. One individual (the principal) entrusts another (the agent) with responsibility for making decisions which are intended to yield benefits to the former. In return, the agent receives remuneration from the principle. Shareholders of a large private company, for example, typically pay a general manager to make the day-to-day operating decisions for their enterprise. As a result of the manager’s decisions, they hope to receive dividends from their investment. The manager, in return, will devolve more specific decisions to other specialist employees within the enterprise. By substituting “patient” for “principal” or “shareholders” and substituting “health” for “benefits” or “dividends” in the above paragraph, we roughly describe today’s allocation system for health care services. Defining “agent,” however, is more complex: is the agent (who has indirect or delegated decision making) the oncologist and their team, is the agent the third party payer, the Federal or state health benefits program, or is the agent somebody else? Practicing oncologists commonly encounter the potential principal versus agent conflict in the form of the question, “Doctor, if this were you or your wife, what would you do?” Disentangling the complex interests of the various agents, and attempting to align the agent’s incentives with the interests of the principal, is behind many of the recent changes in health care finance. As examples, establishment of the Medicare Program in 1965 made an agency of the federal government the purchasing agent for medical care for the elderly and disabled. Further modifications, including the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA), imputed to the oncologist (acting as an agent) incentives to prescribe potentially unnecessary chemotherapy that was not beneficial to the principal, and reduced this perceived incentive to prescribe chemotherapy by lowering reimbursement for office-based chemotherapy administration. In contrast, the voluntary, from-the-ground-up effort, which addresses the potential principal versus agent conflict, is the Choosing Wisely (CW) program. Choosing Wisely was established by the American Board of Internal Medicine Foundation as a response to a challenge posed to organized medicine to be better stewards of society’s resources. ASCO and other professional societies developed lists of care processes that were selected as providing little value to patients and were commonly used by physicians within the specialty. Candidates for ASCO’s Top Five low-value care processes were nominated by more than 200 oncologists. The choices were vetted by patient groups and pharmaceutical industry representatives. An oversight panel made the final choices, gathered supporting evidence, and wrote the manuscript, which was then approved by the ASCO Board of Directors. The processes were chosen without objective cost data, and without objective data on the frequency of their use. The oversight panel did not select processes that oncologists should “never do,” but rather chose processes that should be less frequently applied in practice. Our selections were truly meant to spur both a societal and an individual patient physician conversation about the choices being made by patients and their agents. In the article that accompanies this Commentary, Ramsey et al report a study which suggests that the selections were wisely chosen. Their study is one of the first to explicitly explore adherence to the CW measures, and to associate lower cost of care with adherence to nonrecommended care processes. Ramsey et al identified patients with cancer from the SEER registry in western Washington State and linked their insurance claims filed with a commercial insurance carrier for their analytic data set. The authors then developed algorithms to identify care processes that they defined as “adherent” or “nonadherent” to the five care processes selected in the first round of the ASCO CW list. Because much of the care was delivered before the publication of the CW measures, Ramsey et al’s results are best considered a baseline, rather than the results of publication or implementation of the CW measures. What they do not show is whether adherence changed over time (particularly after publication of the CW measures in 2012); whether the measures as chosen are commonly applied; and when care is adherent to the measures, whether there are improved outcomes, either in patient survival and/reduced morbidity, or most important, in outcomes important to individual patients. In order to facilitate replication of the Ramsey study by other investigators, three methodologically relevant points should be made: (1) The CW recommendations, reflecting the clinical trial evidence on which they were built, use the TNM staging system to identify patients. SEER classifies cases at the time of Focus on Quality