The Crisis of Unnecessary Medical Care

Over $265 billion is spent annually in the United States on unnecessary care. A significant portion of that care is provided by well-intentioned clinicians delivering treatment, tests, and services they deem appropriate based on their clinical judgment. But much of this care falls into the category of “potentially harmful, little chance of helping.”

-->

Identifying potentially unnecessary and harmful care

Most clinical decisions are made in the gray areas of medical guidelines, where physicians must rely on personal experience, patient circumstances, and sometimes imperfect information, to make case-by-case decisions. When we add up all those cases, we find tremendous variation, even when controlling for known exceptions, between physicians’ practice patterns, even within the same organizations and clinics.

Practicing Wisely develops measures in the highest-use, highest-cost specialties (like cardiology, orthopedics, and gastroenterology) to create visibility for physicians into their own practice patterns compared to guidelines and peers, to improve care delivery and avoid potentially harmful care.

ImageExample Appropriate Use Measure:
MRI for Uncomplicated Back Pain

Our Physician Advisory Council includes leading academic and community physicians from across the US, who lead the ideation, development, review, and approval of our Appropriate Use Measures. Measures are not only grounded in guidelines and peer-reviewed evidence, but also account for nuances in real-world clinical scenarios – giving physicians the most accurate assessment of their personal practice.

There is widespread consensus that low back pain can be adequately managed without imaging, formalized in guidelines from the American Academy of Orthopedic Surgeons (AAOS), the American Association of Neurological Surgeons (AANS), the North American Spine Society (NASS), the American College of Physicians, the American Academy of Family Physicians… to name a few. Imaging does not alter clinical management, and leads to equal or worse outcomes compared to conservative approaches like physical exercise and over-the-counter pain relievers. However, imaging modalities such as MRI continue to be overused, leading to substantial costs for the population.

Every physician has a unique patient mix. Where other companies adjust for mix using unintuitive risk scores that are often irrelevant to the specific treatment decision, Practicing Wisely risk-adjusts by excluding cases with complicating factors, leaving the cases where medical society guidelines and clinical recommendations are often most applicable, and where physicians value apples-to-apples peer comparison.

Variation in how frequently US orthopedic surgeons and neurosurgeons perform MRI for uncomplicated back pain

12,627 orthopedic surgeons and neurosurgeons seeing 845,827 cases of uncomplicated back pain (Original Medicare claims, 7/1/2015 to 12/31/2017)

"The Practicing Wisely measures allow the physician to objectively see where they stand relative to their peers. Once you have the information, it allows you to improve yourself. The concept of value-based care is vital to the health of our profession.”

Dr. Caroline Chebli, Chair, Orthopedic Surgery Advisory Council