Choosing Wisely: It’s About Communication, Not Coverage

It’s been one year since the American Chiropractic Association released its Choosing Wisely list, which features recommendations designed to help patients start conversations with their chiropractors about appropriate care. In an era of evidence-based care and shared decision making, patients need this type of information to have meaningful discussions with their doctors that lead to better care and, ultimately, better outcomes.

Research tells us that it is poor communication, not physician competency, that is the source of most complaints against doctors. Effective communication, on the other hand, can have far-reaching benefits such as “higher-quality outcomes and better satisfaction, lower costs of care, greater patient understanding of health issues, and better adherence to the treatment process,” according to one published review on the subject.

ACA’s Choosing Wisely list identifies five targeted, evidence-based recommendations that can support communication between chiropractors and their patients. They should be viewed as opportunities to educate patients about health care procedures that are common, but whose usefulness in some cases is not supported by evidence. ACA’s recommendations touch on five areas:

  • X-rays for initial onset of low back pain
  • X-rays for monitoring patient progress
  • palliative physical therapy modalities
  • psychosocial assessment for people with long term chronic pain, and
  • back supports.

While the recommendations are a starting point for talks between patients and their doctors, it’s important to understand that they are not intended to be prescriptive. They simply aim to make an important though sometimes sensitive subject – appropriate care – easier to broach for patients and providers.

ACA and the Choosing Wisely campaign believe that decisions about care should be made based on the best available evidence, the clinical judgment of the doctor, and the preferences and goals of the patient. Our recommendations state what the best evidence says, but it is then up to the doctor and patient to discuss and together come to an agreement on a plan of care.

For this reason, as well, use of recommendations should not expand beyond conversations in the clinic. The Choosing Wisely website states explicitly that its recommendations “should not be used to establish coverage decisions or exclusions.” Just this week, we learned that a health plan had included ACA’s recommendations in a list of references that are part of its chiropractic services policy. In response, both ACA and the ABIM foundation, which runs the Choosing Wisely program, sent letters to the health plan requesting the removal of the reference.

Should a chiropractic service be denied based specifically on the recommendations, ACA urges doctors to contact us immediately at [email protected] with this information. We will vigorously challenge any attempt to undermine the original intention of our Choosing Wisely recommendations.

Dr. Tuck is president of the American Chiropractic Association.