Bringing the Public to the Table

Integrated Healthcare Association (IHA), a multistakeholder collaboration in California, received a Choosing Wisely® grant from the ABIM Foundation (through support from the Robert Wood Johnson Foundation) and is working with several partners, including Center for Healthcare Decisions (CHCD), to promote appropriate care. IHA is also providing technical assistance to the Statewide Workgroup on Reducing Overuse, established by the three largest purchasers in California.

To inform both of these efforts, CHCD developed the Doing What Works (DWW) project to gather public perspectives on health care waste. Unlike most patient engagement efforts to understand the needs and perspectives of individual patients, DWW asked health plan members to respond as if they were “policymakers” whose role is to improve medical care for everyone, not just themselves.

Using a half-day deliberative process, DWW hosted 10 groups of health plan members across California (including two conducted in Spanish) to get input about fair and reasonable ways to reduce unnecessary tests and treatments.

Nearly 120 people participated, discussing case scenarios related to overused interventions targeted by the work group and IHA’s Choosing Wisely project, including antibiotics for adult bronchitis and MRIs for acute low back pain.

After learning more about overuse, participants were asked individually to vote for possible approaches to reduce overuse and then collectively debated the pros and cons of these approaches. CHCD recently released a report that outlines key themes and findings from the sessions.

To frame the purpose of their discussion, participants were asked: “While improving the health of Californians, what strategies are most acceptable for reducing the use of medical care that is harmful and/or wasteful?” Results showed:

• 57 percent favored approaches to change physicians’ behavior through external approval or internal monitoring.
• 21 percent believed that the most productive approach was to have patients financially responsible if they insisted on an ineffective medical intervention.
• 13 percent proposed financial disincentives through penalties or non-payment to physicians who prescribe unneeded care.
• 9 percent supported the option to take no additional action, leaving care decisions entirely up to individual doctors and patients.

Additionally, the report highlighted five principles that rose from the discussions. These principles can potentially inform strategies to reduce overuse moving forward:

• Physicians should lead efforts to provide high-quality care and correct the problem of overuse.
• Actions to reduce overuse should be effective, efficient and credible.
• Not wasting resources is a valid reason for reducing unnecessary care.
• Respect for patient choice must be balanced by ethical practices.
• Patients have a responsibility to be better informed about overuse.

The report acknowledges that projects like DWW are not common practice as they require an investment of time and resources, yet bringing the public to the table adds credibility to values-based decisions for responsible health care changes.

“It’s a wake-up call to policy leaders that the public cares and wants to be involved in these discussions,” Marjorie Ginsburg of CHCD said about the report. “Participants were thankful that somebody was asking their opinion on issues that affect them as citizens and as patients.”