“Top 5” Tops $5 Billion

Adoption of the Top 5 Lists in Primary Care generated by the National Physicians Alliance Good Stewardship Project would generate an annual savings of $6.76 billion according to an article published online in the Archives of Internal Medicine by Drs. Salomeh Keyhani, Minal S. Kale, Tara F. Bishop, and Alex D. Federman.
The research letter, published October 1 to coincide with the NPA’s annual meeting in Washington, D.C., used data from the 2009 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) to determine how often the recommendations included in the Top 5 lists were being followed in practice. The authors then estimated the cost savings that would have occurred if the recommendations had always been followed.
The Top 5 lists—generated for family practice, internal medicine, and pediatrics—reflect common clinical activities in primary care where the quality of care could be improved. The recommendations made by panels of NPA doctors are strongly supported by the scientific evidence and would lead to significant health benefits and reduce risks, harms, and costs.
The largest annual dollar savings ($5.8 billion) would be achieved by adherence to the recommendation to prescribe low-cost generic statins when initiating cholesterol-lowering treatment rather than high-cost, brand name drugs.
The total cost saving estimate of $6.76 billion is conservative, as the methodology used by the authors could not capture the cost savings for all items on the Top 5 lists in primary care. The items related to treatment of mild-to-moderate sinusitis; avoidance of early referral of serous otitis media to ENT; using corticosteroids to control asthma in children; not doing Pap smears on women who have had a hysterectomy for benign reasons; and DEXA scans on men less than 70 years old were not included in the cost saving figures. Thus, the total cost savings would be larger than the $7 billion estimate.
The authors note that except for the large savings that would accrue from using generic statins, the amount saved from the Top 5 lists in primary care represent only a small fraction of total health care costs.  The hope of the NPA Good Stewardship project and the American Board of Internal Medicine (ABIM) Foundation, which funded the project, is to have all specialties generate their own Top 5 lists. The widespread adoption of similar lists could go a long way towards changing the culture of medicine by encouraging physicians to make wise clinical decisions and be good stewards of finite clinical resources.
The NPA has received a second round of funding from the ABIM Foundation that will enable the Top 5 lists to be put into practice. Demonstration practices are being recruited to showcase implementation. Training videos are being produced to help physicians communicate with their patients about treatment plans consistent with the Top 5 list recommendations. A version of the videos is also being produced to be shown to patients in waiting rooms. These videos will be shared with other specialty societies embarking on their own efforts to generate Top 5 lists in their respective fields.