ABIM Foundation’s Daniel Wolfson Analyzes Impact of Choosing Wisely Campaign at 5 Years

Daniel Wolfson – ABIM Foundation

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Mark Masselli: This is Conversations on Healthcare , I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret , the opioid crisis continues to confound us as a nation ,
first there is the human toll some 60,000 Americans died from overdoses in 2016 alone
and now the Council of economic advisers say that in 2015 the crisis cost the US
economy more than $500 billion in medical costs , lost wages and cost in treatments as
well .

Margaret Flinter: And tha t of course is to say nothing of the toll that has taken on
families and really on entire communities .

Mark Masselli: And we ’ re starting to see an interesting trend emerging in the medical
community far fewer opioids are being prescribed , it's creating a due issue for a large
swath of patients who suffer from chronic pain ; m any of these patients who are relying
or even depended on opioids for true pain management will be looking for alternatives .

Margaret Flinter: But we’re through our o wn experience here in our organization that it
takes an integrated approach to pain in terms of medication but also mindfulness
meditation , chiropractor and physical therapy interventions , other therapies are helpful
and effective in working with patients who have chronic pain . But that also takes a real
commitment on the part of the provider and the whole practice I would say , that ’s
something many practices just don’t have.

Mark Masselli: And there does seem to be momentum growing across the healthcare
landscape to scale back significantly on opioids , m eanwhile our guest today is a big
proponent of scaling back .

Margaret Flinter: Daniel Wolfson is the Chief Operating Officer of the ABI M Foundation
he will be talking about the Choosing Wisely c ampaign launched five years ago to
reduce the amount of waste in American health care and we look forward to hearing
from him.

Mark Masselli: And also Lori Robertson is the Managing Editor of FactCheck.org , but
no matter what the topic, you can hear all of our shows by going to chcradio.com.

Daniel Wolfson – ABIM Foundation

Margaret Flinter: And as always if you have comments, please email us at
[email protected] or find us on Facebook or Twitter; because we love hearing from
you. We will get to our interview with Dr. Daniel Wolfson in just a moment.

Mark Masselli: But first here ’s our producer Marianne O'Hare with this week's headline
news.

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Marianne O'Hare: I am Marianne O'Hare with these healthcare headlines. President
Trump’s pick for HHS secretary was on the hill answering questions on a number of
topics though it wasn’t the official hearing for the former insurance industry executive
Alex Azar. Whil e Azar spent a decade as a top executive at Eli Lilly it was a period of
unprecedented growth in drug prices under his tutelage skyrocketing drug prices have
proven of late to be fair game from both sides of the aisle . Speaking of drugs the opioid
crisis will be a leading item on the HHS secretary's agenda if he's approved, Azar , if
approv ed will have to initiate policies to address the crisis which led to over 60,000
deaths i n 2016 alone .

There are just a couple of weeks left for open enrollment under the Affordable Care Act
and efforts are a mping up in certain parts of the country , California is actually
outspending the federal government in messaging to the masses in that s tate . Trump
Administration slashing the marketing budget by 90% this year while the federal
government has slashed the marketing budget to $10 million nationally for 39 states .
California is spending in excess of $111 million investing in online advertis ing , radio and
TV campaigns to get the message out .

Some slightly promising news on the advent of World AIDS Day December 0 1, 2017
according to a report by the Centers for Disease Control and Prevention the time
between HIV infection and diagnosis and tre atment has been shortened by seven
months which is in turn having an impact on overall infection rates . Just less than
40,000 new cases diagnosed in 2015 , the cases were diagnosed on average seven
months closer to the ir actual date of infection . CDC Dire ctor Dr. Brenda Fitzgerald
noted a slight improvement in the infection rates can be attributed to quicker diagnosis
but there are still pockets where co - infection is higher among young men of color in this
country , IV drug users , a group that has grown ste adily in recent years with the opioid
epidemic . I am Marianne O'Hare with these healthcare headlines.

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Daniel Wolfson – ABIM Foundation

Mark Masselli: We are speaking today with Daniel Wolfson, Chief Operating Officer of
the ABI M Foundation , a nonprofit supporting organization of the American Board of
Internal Medicine which certifies physicians who practice internal medicine . Previously
Mr. W olfson served for nearly two decades as the Founding President and CEO of the
Alliance of Community He alth Plans . Mr. W olfson received his Masters degree in
Health Service Administration from the University of Michigan School of Public health .
Daniel, welcome back to Conversations on Healthcare .

Daniel Wolfson: Great to be back, Mark.

Mark Masselli: Yeah, five years when the ABI M Foundation launched, very ambitious
the Choosing Wisely campaign and it really was shaped by this just ever growing
medical cost $3.5 trillion of expenditures and Choosing Wisely enlisted the support of
many m edical societies to commit to reducing the overprescribing of antibiotics and
other drugs take our listeners back to the start of the campaign and what your specific
goals were .

Daniel Wolfson: So when we last talked Mark , there was nine specialty societ ies
developing 45 recommendations regarding what tests and procedures had risk that
outweighed the benefits . And we would tried to start a conversation between patients
and physicians about the notion of unnecessary tests and procedures particularly based
on the evidence that was being produced by the specialty societies . And we went from
nine specialty societies to today having 80 specialty societies and over 500
recommendations .

Mark Masselli: Wow, that’s impressive.

Daniel Wolfson: So we wanted to start a conversation about the issues so patients and
physicians could choose the best option for them knowing what the evidence was and
the recommendations of specialty societies . So not only are we spread throughout
United States but it's in 20 countries internationally with the same kind of principles of
physician led , consumer participation , evidence - based and multi - professional , we also
have nonphysician clinician organizations like n urses , OT , POINT, chiropractors and
optometrists . So we' ve really expanded the team.

Margaret Flinter: Well Daniel , the foundation has just issued a five - year report on the
Choosing Wisely campaign and in your report you note that there has been some
impressive results from certain sectors and you've got some real pockets of
improvement . And I think our listeners would love to hear about some of the successes .

Daniel Wolfson – ABIM Foundation

Daniel Wolfson: You know I think patients are beginning to talk about more is not
always better , and I think there are questions that patients are no w giving to their
physicians about are there other options , what are the cost of this procedure then we
are seeing a shift in physicians as well as the specialty societies have given them a
strong message that , no there is unnecessary care and we need to g et rid of it and it
potentially put s people at harm . But then what you have to see is some kind of
reminder to the physician and maybe the patient as well that there is this eviden ce that
when they’re ordering a test, think twice . One is that you have been given data by your
hospital or your group or your clinical practice that show your use of these
recommendations compared to your peers . And that creates a kind of peer pressure
you might get a reminder in your medical record that says , antibiotics ar e not really
useful for sinusitis , there is t his chance to have this conversation between patients and
physicians and you know the patient gets consumer friendly materials about the
recommendations as well . So both are equipped with the evidence to make i nformed
decisions about what tests and procedures are really needed .

We've seen incredible reductions for instance in antibiotics more than 20% out of 14
grantee s that we work with . We ’ve seen an amazing reduction of lab work , you know
sometimes in hospi tals they'll order labs for everyday , needed or not you'll get the same
lab test, if it's unnecessary why put the patient at uneasiness . Not only is it important to
decrease some of the se lab test s or drug s but you know it's the kind of the downstream
e ff ect of some of these tests and procedures when you give somebody a sedative
they’re more likely to fall . Sometimes it's a cascade effect that increasingly puts the
patient at harm .

Mark Masselli: You know Daniel I want to pick up on a couple of things that you said
the , patient s saying that more is not better or patients clearly are important and when
you think about the changes in healthcare or having voice of the patient around the
table is so important , so what is the role that patients are playing h ere , how are you
actively engaging and educating them ?

Daniel Wolfson: So the first thing we do is give them the recommendations and things
that you and I can understand . In some practices we provide posters that ask s you
know these five questions ; are there other options ; is this necessary ; what are the costs ;
what would happen if I did nothing , so equipping them with that information really puts
the patient and physician on the same page . It took us 30 years or 40 years to get here
and overuse that to tals $210 billion a year , it's going to take some time for this sea
change to occur . But we are headed in the right direction , a nd really I think what we
need to do is to gauge clinical practices and health systems and hospitals and really
focusing on thi s and doing the kind of quality management .

Daniel Wolfson – ABIM Foundation

Our goal is to get reduction , not to a 100% because some of these things are
sometimes needed you know the lower back pain you shouldn't do a CT scan unless
there is some red flag , then you should do a CT scan but beyond that we hope that the
reduction is dramatic you know financial harm is increasingly talked about and I think
you'll see that is a major issue in the coming years . I got to do a shout out to people in
Connecticut , t here is a Connecticut Choosing Wisely collaborative , they’re actually one
of four statewide programs and we ’ re seeing statewide efforts. They're saying , no this is
a real safety issue and we should be working together to get this problem solved .

Margaret Flinter: Absolutely . And I wonder if we also still have the issue even when
care is necessary of just the price of care and of course we marked to the passing of
our good friend and renowned health economist Dr. Uwe Reinhardt and I am reminded
on his pap er , “ It's the price stupid ” in which he posits that Americans don't use
healthcare services more than other industrialized nations but everything here cost s so
much more and the prices are often secretive and lack transparency . And as we see
people increa singly having high deductible health plans they are getting kind of a front -
line sticker shock certainly when they pick up pharmaceuticals but also in their practices
as they pay for diagnostic testing and they are like , are you doing any work looking at
the problem of price transparency for consumers ?

Daniel Wolfson: I also want to recognize the passing of Uwe, he was a great man , but I
do think it's both the utilization and price , when you don't use anything the price is zero
and our utilization is 25% about what it should be . The campaign is really focused on
use , and it's not focused on drug price transparency , but do I think that that is important ,
absolutely . But I really like to frame it as financial harm , we ha ve physical harm and we
have financial harm whether you know the cost need to be lowered or there needs to be
more transparency , absolutely . I think we will get better at the price transparency
become more acceptable because it's bankrupting patients .

We need two things in price transparency ; one , we need the prices and particularly the
pharmaceutical prices , and I don’t think we ’ re that far away from that, and two, we need
physicians to know how to talk about it . And that's where I see our role is havin g
physicians be comfortable to talk about the cost like here’s some options , this costs this,
this costs this , they are equally as effective , what do you want to choose ? And to know
when patients are in fact if you will price sensitive but physicians don' t have the skills to
talk about it and to help their patients navigate the price cost landscape .

Mark Masselli: We are speaking today with Daniel W o l f son , Chief Operating Officer of
the A BIM Foundation , a nonprofit supporting organization of the American Board of

Daniel Wolfson – ABIM Foundation

Internal Medicine which certifies physicians who practice internal medicine . The
foundation just released a five - year report on the results of Choosing Wisely campaign ,
a coordinated effort across multiple medical disciplines to reduce wasteful spending .
Boy Daniel, I have been thinking with the Choosing Wisely program right alongside of
the expansion to access to health coverage under the Affordable Care Act we've been
talking a lot about the Aff ordable Care Act from this volume to value , maybe talk a little
bit about what you see some of the benefits that the ACA has set in motion and how
does that sync up with the goals of Choosing Wisely .

Daniel Wolfson: So I often say that we had the right e nvironment for Choosing Wisely ,
the ACA set out Accountable Care Organizations and different alternative payment
systems , s o okay I'm a physician and I'm now under some risk s, where should I start ?
And Choosing Wisely is , wel l here are some recommendation s from your specialty
society about how you can lower unnecessary care , improve quality , and oh by the way
it's going to be more affordable . So this movement from volume to value I think is just
paramount to our success in the Choosing Wisely campaign and the sustainability of the
healthcare system ultimately empowering physicians and clinicians to have their own
rains [PH] that they control the expense and revenue side of healthcare . And in a Fee -
for - service system all I really care about is producing more unit s, the mindset changes
when you're talking about health and healthcare this health system $3 trillion we have
enough money in the system we need to use it better .

Margaret Flinter: Well Da niel , we often look beyond the clinical excellence and we
strive for , we look at two other thin gs to advance the patient centered approach to
improving care , o ne of them is research and that ensures that we can keep improving
on best practices and second i s training the next generation of healthcare providers .
And you and your campaign have generate d a lot of new research on identifying some
of the se drivers of overuse and you've also partnered with organization of young
physicians who launched Costs of Ca re . So talk wish us a little bit about this growing
body of research that you ’ r e assembling and disseminating and how you see this
emerging generation of new clinicians tackling this challenge , where do they go from
here ?

Daniel Wolfson: You know Choosi ng Wisely is all about partnerships and we've
developed a partnership with Academy Health , a not - for - profit organization that tries to
stimulate research , health services research , evaluating essentially what works in the
reduction of overuse , s o that's be en a great partnership , a nd trying to generate the
notion that this is a scholarly and important area to address and it's been very
interesting . Univers ity of Michigan is looking at how you think about the implementation
like let's take a visit for diabet es and what things would you want to reduce in a diabetic

Daniel Wolfson – ABIM Foundation

visit ? So very I think important to think about different ways of the implementation that
usually is that how you do something more ?

On the training side I think this is a real success story prima rily because of our
partnership , but Cost s of Care some young physicians who have taken this on and
we've done challenges or competitions try ing to highlight best practices , webinars and
there's been a book produced by this cadre of people about value - based care a nd they
have again spawned off young faculty just doing some marvelous work . Johns Hopkins
now has a high value healthcare alliance where they are bringing in academic
institutions to talk about real value and high value , American College of Physicians has
developed several curriculum . There has been a sea change and I think we have a
cohort now of five years medical students graduating , residents graduating and I think
they think and act differently . It's go ing from , why didn't you do that task to why did you
do that task? And that’s slight cultural difference is makes all the difference in the world
about you know training and thinking about what is really needed ? Those changes are
occurring and I find it very rewarding to see these changes occur .

Mark Masselli: We ’ve been speaking today with Daniel W olfson, Chief Operating
Officer of the ABIM Foundation about their just released five - year report on Choosing
Wisely campaign . You can learn more about thei r work and access the Choosing
Wisely report by going to a bim foundation .org or you can follow them on Twitter
@ ABI MF oundation . Daniel , thank you so much for your work and for joining us on
Conversations o n Healthcare today .

Daniel Wolfson: Great to be back.

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Mark Masselli: At Conversations on Healthcare, we want our audience to be truly in the
know when it comes to the facts about healthcare reform and policy. Lori Robertson is
an award - winning journalist and managing editor of FactChec k.org, a nonpartisan,
nonprofit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori what have you got for us this week?

Lori Robertson: The Senate Republican tax bill includes a provision that eliminate s the
Affor dable Care Act penalties for most individual s who do not purchase health
insurance that would have an impact on the number of people who have insurance . But
some Democrats have wrongly claimed that 13 million people would have their health
insurance taken away from them . Democratic Minority Leader Chuck Schumer for
instance said that , repealing the mandate would “boot”, according to CBO , 13 million

Daniel Wolfson – ABIM Foundation

people from the health insurance rolls , t hat distort s with the Congressional Budget
Office and Joint Committee on Taxation have said .

The nonpartisan c ongressional analysts estimated that 13 million fewer Americans
would have health insurance by 2025 without the mandate with similar results if just the
penalty itself were eliminated . But that doesn't m ean that all 13 million would be kicked
off their insurance plans , many of them would voluntarily give up their health coverage .
In 2025 if the mandate were rescinded the analyst said , an estimated 5 million fewer
people would be enrolled in Medicaid , 5 m illion fewer people would get insurance
through the non - group or individual market , 3 million fewer people would get insurance
through their employer and as many as 500,000 fewer would no longer have some
other form of health insurance . CBO and J CT say , t his would happen mainly because
healthy people would be less likely to get insurance particularly in the individual market
or those without employer or government insurance by their plan . With fewer healthy
people in the market premium s would increase cau sing more people to drop coverage ,
the report doesn't say how many would willingly give up insurance and how many would
be priced out of the market . And that’s my fact check for this week, I am Lori Robertson
Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact, that you would like checked, email u s at
www.chcradio.com . We will have FactCheck.org's Lori Robertson check it out for you
here on Conversations on Heal thcare.

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Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Fitness trackers have become
all the rage but another trend has emerged in the age of wearable devices , after a few
months about a third of user simply stop using them leaving a lot of costly devices
sitting on the shelf and not in use . The reality capture d the i magination of Tufts
University School of Medicine Professor Dr. Lisa Gualtieri .

Dr. Lisa Gualtieri : I had read about the abandonment rates and I thought , what if you
could take all of this abandoned trackers and give them to the people who could benefit
most from them?

Mark Masselli: She thought , what if we could get disinterested owners to donate their
use d fitness trackers to be a repurposed to underserved populations ?

Daniel Wolfson – ABIM Foundation

Dr. Lisa Gualtieri : A lot of the work that we have been doing has been with older adults,
racial and ethnic minorities and for a lot of people the cost is prohibited so I think that
that’s a barrier.

Mark Masselli: So in 2015 she launched her nonprofit enterprise RecycleHealth an
online social media campaign to raise a wareness for her program which seeks donated
wearable devices to provide these expensive devices for free to those in need . She
partner ed with organizations working with low income adults , seniors in fall prevention
programs and veterans as well . Her goa l is to start collecting vital data o n the
deployment of these devices and the impact they may be having on behavior change .

Dr. Lisa Gualtieri : What we do is talk to people about how active how sedentary they
are and coming up with a reasonabl e and achi evable goal where they might start off
with 2000 steps of their goal but they know now have to make that higher when they are
ready to.

Mark Masselli: So far the numbers of donated devices have numbered in the low
thousands , she is hoping to scale that n umber up significantly in the future and to
expand their data collection on health outcomes for vulnerable populations .
RecycleHealth , a simple repurpos ing of personalize d wearables , providing these tools
for free to vulnerable populations , empowering the m to engage in activities that can
improve their own health , provide useful data on using this devices to improve
population health , now that's a bright idea .

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Margaret Flinter: This is Conversations on Healthcare, I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Healthcare, broadcast from the campus of WESU at Wesleyan
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