Virginia L. Hood, MD, MPH, is a nephrologist at the University of Vermont Medical Center and a professor at the Larner College of Medicine at UVM.

Virginia L. Hood, MD, MPH, is a nephrologist at the University of Vermont Medical Center and a professor at the Larner College of Medicine at UVM.

This is the first in a series of blog posts by Virginia L. Hood, MD, MPH, about the Choosing Wisely program at the University of Vermont Medical Center and the Larner College of Medicine at UVM.

In the United States, health care costs are far greater than those in any other industrialized country but outcomes are worse. Currently at almost 18 percent of gross domestic product and 30 percent of government expenditures, US health care costs are increasing at an unsustainable rate and are encroaching on all other areas of spending both public and private.

The cost drivers include advances in technology where low value and high value are equally adopted; aging and chronic disease; high usage and prices of prescription drugs; lack of appropriate primary care services that provide prevention, early detection and coordinated care; medical malpractice; excessive administrative costs; abuse and fraud; and over use and misuse of diagnostic tests and ineffective treatments. These, as a group, account for up to 30 percent of the $2.7 trillion currently expended on health care in the US.

Good health care will always be expensive, and health care professionals want to provide the best care to all patients; however, we need better ways of delivering the quality care patients deserve at a cost society can afford. This is a multifaceted problem that society as a whole must address, but individual physicians, the medical profession, and patients do have considerable influence. All want the tests and the treatments ordered and delivered to be safe, effective and provide value – high quality with acceptable cost.

High value care is rational care, that which provides overall benefit. Some high value care may be costly and some low cost care may have no value. Pursuing high value, cost conscious care, does not necessitate rationing. Rationing means underuse of appropriate care. Rational care is providing care that is effective and safe.

To deliver rational care, we need more and better information about what is and is not effective; attitudinal change among physicians and patients about balancing harm and good; system change in health care delivery and payment to reward value not volume; educational efforts to educate and engage medical trainees; and resources to harness support from patients, the public, payers, policy makers and other health care professionals to disseminate the message. A key approach to changing the culture of excess is to consider harms, focus on care not cost and help people to recognize that “more” is not necessarily better.

Patients can be powerful allies. They don’t want harm, inconvenience or discomfort, lost time from work, co-pays or other expenses. They need reliable information to be effective partners in informed decision making and to help them take responsibility for factors they can control.

An initial effort to minimize harm and conserve resources is to reduce overuse and misuse of diagnostic tests. Current programs such as Choosing Wisely, a partnership of more than 80 medical societies and consumer groups in the US are providing information to physicians and patients about diagnostic tests of questionable value. Other countries are instituting similar initiatives.

Here at the University of Vermont Medical Center and in the Vermont, we are implementing programs to reduce overuse or misuse of diagnostic tests and procedures initially for selected groups of patients in hospitals. Eight such programs are underway, all initiated by physicians from the Department of Medicine and involving trainees. Preliminary results will be discussed in future blogs. In addition, through the Vermont Medical Society and hospitalist groups, programs will be carried out in hospitals throughout the state to reduce the number of blood tests in stable patients.

Change requires knowledge, capacity and courage. Physicians and patients need better information about what works and to build more effective partnerships among health care professionals, patients and the public to ensure changes in practice encourage rational care and conserve our limited health care resources for the benefit of all in need.

Virginia L. Hood, MD, MPH, is a nephrologist at the University of Vermont Medical Center and a professor at the Larner College of Medicine at UVM.

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