Background

In the USA, healthcare costs are far greater than those in any other industrialised country.1 Currently, they comprise almost 18% of the gross domestic product and 30% of government expenditures.2 US healthcare costs encroach on all other areas of spending public and private. Cost drivers are multifactorial but up to 30% of Medicare spending is potentially avoidable without worsening health outcomes3 ,4 with overuse and misuse of tests and treatments accounting for approximately 10%. Physicians have a responsibility to ensure that the diagnostic tests and treatments they order are safe, effective and provide value.5 ,6 Hence, they can lead the effort to preserve scarce resources while promoting quality, reducing harm and controlling cost.7

Initial calls for action from the medical profession came following an Institute of Medicine report describing the need to reduce costs and improve outcomes.3 ,6 Initiatives were launched in the form of the National Physicians Alliance ‘Top 5’ in primary care8 and by the American College of Physicians High-value Cost Conscious Care Initiative.9 ,10 National attention was focused on this issue in April 2012, when the American Board of Internal Medicine Foundation convened a group of nine national medical specialist organisations and Consumer Reports to mobilise the effort to reduce overuse or misuse of tests and procedures that provide little benefit or can cause harm.10 This ‘Choosing Wisely’ campaign has now been embraced by more than 70 specialty societies and 18 consumer-oriented organisations.10 However, processes to implement and sustain programmes in local, state and national settings are rarely described.11 We report here on our initial 2 years’ experience, which took a grass-roots approach to developing a high value care (HVC) programme. The goals of this project were to improve the care and experience …