Getting from choosing wisely to spending wisely.

It is intuitively true that the most just ways of reducing health care costs are to reduce unnecessary tests and interventions and improve the efficiency of care. Neither of these imperils outcomes (and may improve many) nor involves restricting care (and developing efficient care may require expansion of overall care). The first activity comes under the aegis of reducing waste, and the second, under improving processes. The two are not necessarily mutually exclusive. In 2010, Howard Brody proposed that specialty societies commit to the development of a top-five list. This would identify five diagnostic tests or treatments that were commonly used but had no evidence of meaningful benefit.1 Simultaneously, the National Physicians Alliance, supported by a grant from the American Board of Internal Medicine Foundation, was charged with developing and deploying “activity lists of evidence-based, quality-improving, resource-sparing activities that could be incorporated into the practices of primary care providers in family medicine, internal medicine and pediatrics.”2 The process for selection of these activities was proposed and tested and the initial report published in 2011.2 From this initial work, the Choosing Wisely campaign emerged. Nine specialty societies were recruited to begin the initiative, including the American Society of Clinical Oncology (ASCO).3 Since then, more than 35 specialty societies have developed more than 200 recommendations.4,5 ASCO has now released its second set of five Choosing Wisely recommendations,6 and the American Society for Radiation Oncology (ASTRO) has issued its first set of five.7 This represents great progress, but the intent of the program purportedly remains modest. These “recommendations should not be used to establish coverage decisions or exclusions. Rather, they are meant to spur conversations about what is appropriate and necessary treatment”.8 The mandate is to reinforce the discussions physicians have with patients and educate patients as to what is best for them based on the best science. But it is fair to ask if something more profound is occurring. One can take what can be called a strict constructionist view of evidence and value. This can be addressed symbolically with the value equation: