Top 45 Ways to Cut Health Care Costs, According to Medical Groups
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Health care costs are currently eating up just over 17 percent of the American economy. And while there has been some slowing of this in some quarters, health policy experts project that if something isn’t done to hold it down, costs will devour nearly one quarter of the economy in just a few short years.
So it’s quite an event when the very doctors who stand to make more money by ordering expensive routine tests like MRIs and CT scans — or often perform them to avoid malpractice lawsuits — are recommending that 45 procedures no longer be performed on patients unless there is a sound medical reason to do them. (See the full list below.)
Behind today’s announcement are nine of the nation’s top medical specialty societies,
the American Board of Internal Medicine Foundation and Consumer Reports.
As their “Choosing Wisely” campaign points out, the latest projections from the Congressional Budget Office indicate that up to 30 percent of care delivered in the United States goes toward tests, procedures, doctor visits, hospital stays and other services that may be unnecessary or harmful to the health of patients.
Among their recommendations: re-think the use of antibiotics for non-bacterial or minor sinus infections; avoid X-rays for lower back pain unless “red flags” indicate a potentially serious disease; choose an ultrasound over a CT scan for children with appendicitis; restrict colonoscopies to once a decade for patients who have low to average risk of colon cancer; and perhaps most controversially, scale back on chemotherapy for patients who are near death.
Not only do they advise that this list of 45 tests and procedures be given more thought before being performed, they are also telling consumers to ask their doctors more questions about when and why to order them.
Today’s announcement comes on the heels of great pressure being exerted on medical professionals to hold down costs. Both insurance companies and other providers have been shifting the cost of health care to doctors and hospitals in the form of lower reimbursements and programs to pay doctors based on quality — not quantity — of care.
These recommendations also follow two others that created controversy. The first was in 2009, from an independent panel of doctors known as the U.S. Preventative Services Task Force which advised women between 40 and 49 to get fewer mammograms. Then, last year, the same group recommended fewer PSA screenings for prostate cancer.
Both of those set off a flurry of criticism about whether the federal government was trying to control Americans’ health care and ration care under the guise of health care reform.
Today’s announcement gives those critics more ammunition. But it’s also a strong, clear voice from some of the country’s leading doctors warning that some of these tests are not only unnecessary but may be harmful to patients.
Read their full list below and share your own feelings on these recommendations in the comments section.
Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.
Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.
Don’t routinely do diagnostic testing in patients with chronic urticaria.
Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.
- Don’t diagnose or manage asthma without spirometry.
Don’t do imaging for low back pain within the first six weeks, unless red flags are present.
Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.
Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.
Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.
- Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.
Don’t perform stress cardiac imaging or advanced non-invasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present.
Don’t perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients.
Don’t perform stress cardiac imaging or advanced non-invasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery.
Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.
- Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI).
Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.
Don’t obtain imaging studies in patients with non-specific low back pain.
In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).
In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.
- Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
Don’t do imaging for uncomplicated headache.
Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.
Avoid admission or preoperative chest x-rays for ambulatory patients with unremarkable history and physical exam.
Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.
- Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.
For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without highgrade dysplasia, completely removed via a high-quality colonoscopy.
For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines.
- For a patient with functional abdominal pain syndrome (as per ROME III criteria) computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.
Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis.
Don’t perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
Don’t perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
- Don’t use white cell stimulating factors for primary prevention of febrile neutropenia for patients with less than 20 percent risk for this complication.
Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.
Don’t administer erythropoiesis-stimulating agents (ESAs) to chronic kidney disease (CKD) patients with hemoglobin levels greater than or equal to 10 g/dL without symptoms of anemia.
Avoid nonsteroidal anti-inflammatory drugs (NSAIDS) in individuals with hypertension or heart failure or CKD of all causes, including diabetes.
Don’t place peripherally inserted central catheters (PICC) in stage III-V CKD patients without consulting nephrology.
- Don’t initiate chronic dialysis without ensuring a shared decision-making process between patients, their families, and their physicians.
Don’t perform stress cardiac imaging or coronary angiography in patients without cardiac symptoms unless high-risk markers are present.
Don’t perform cardiac imaging for patients who are at low risk.
Don’t perform radionuclide imaging as part of routine follow-up in asymptomatic patients.
Don’t perform cardiac imaging as a pre-operative assessment in patients scheduled to undergo low- or intermediate-risk non-cardiac surgery.
- Use methods to reduce radiation exposure in cardiac imaging, whenever possible, including not performing such tests when limited benefits are likely.