Health Care Reform’s Clarion Call to Physicians: What’s Your “Top 5 List”?

Guest Commentary

A curious thing happened along what has been a muddy and meandering road to health care reform. 

Dr Howard Brody observed that insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals have gone on record saying that they would limit future profits to support health care reform.¹ Okay, let’s give them the benefit of the doubt. Something is still missing.

In a similar vein, Dr Brody viewed physician responses as either tepid or nonexistent. One response offered support but contingent on promises that physician income would not suffer. Others ascribed soaring costs solely to malpractice litigation. Dr Brody observed, “Unfortunately, the myth that physicians are innocent bystanders merely watching health care costs zoom out of control cannot be sustained.”¹ He then proposed that each specialty produce a “top 5 list.” That list would consist of 5 tests or treatments commonly performed by a particular specialty that are expensive but do not provide significant benefit.

TOP 5 FOR ONCOLOGY
There have been constructive responses. Oncology suggested 5 changes in oncologic behavior and 5 changes to oncologists’ “attitudes and practices.”² Selected portions can illuminate their thinking. For instance, “Limit chemotherapy to patients with good performance status;” “Replace the routine use of white cell–stimulating factors;” and “Better integrate palliative care” are reasonable and understandable to all physicians. Not long thereafter, primary care—inclusive of internal medicine (IM), family medicine (FM), and pediatrics—did its part as well.³

TOP 5 FOR PRIMARY CARE
IM and FM had some suggestions in common:
•Use imaging for low back pain only if “red flags,” such as neurological defects, are present or if cancer or osteomyelitis is suspected; imaging without red flags before 6 weeks of symptom duration increases costs but does not improve outcomes.
•Avoid so-called routine laboratory studies (screen only for lipid abnormalities and diabetes).
•Do not order annual ECGs (little evidence of benefit) or dual-emission x-ray absorptiometry scans for young patients (not cost-effective).

Others on the primary care list were unique to one or the other adult primary care specialty (i.e., IM or FM): do not routinely prescribe antibiotics for sinusitis (FM, most sinusitis is viral; 16 million office visits for this complaint with $5.8 billion annual costs); do not offer Pap tests for patients younger than 21 years (FM, spontaneous regression of dysplasia occurs typically); and use generic rather than brand-name statins (IM).

In the primary care of children, pediatrics made the following suggestions:
•Limit antibiotics for pharyngitis (unless there is a positive culture for Streptococcus).
•Decrease use of head imaging after head trauma without loss of consciousness (few positives are discovered that require intervention).
•Use inhaled corticosteroids for asthma.
•Do not refer otitis media with effusion “early” because most cases resolve within 3 months without adverse consequences.
•Advise parents not to give children cough or cold medicines (little evidence of benefit).

Since the construction of these lists used evidence-based medicine, the guidelines represent more than intuition. It is obvious, however, that they will require patient buy in. It is not fair to place the blame for the poor stewardship of resources to date solely at the feet of physicians. That said, physicians have a critical role in health care reform and a “top five list” is a great place to begin. This is the first “salvo”; there will be much more to follow. ■