Ob­sta­cles ahead

Shared de­ci­sion­mak­ing faces road­blocks, de­spite push, in­cen­tives

Modern Healthcare - - THE WEEK IN HEALTHCARE - Mau­reen Mckinney

Driven by fed­eral in­cen­tive pro­grams and a grow­ing body of re­search, providers are ramp­ing up at­tempts to en­gage pa­tients and pro­mote shared de­ci­sion­mak­ing. But those ef­forts could face sig­nif­i­cant ob­sta­cles, hin­der­ing one of the cen­tral tenets of the health­care re­form law.

The over­ar­ch­ing goal of such pro­grams, said Dr. Nan Cochran, a pri­mary-care physi­cian and as­so­ciate pro­fes­sor of medicine at Dart­mouth Univer­sity, Hanover, N.H., is to pro­vide pa­tients with the best tools and in­for­ma­tion so they can make de­ci­sions that align with their own pref­er­ences and pri­or­i­ties. Many ex­perts also be­lieve that shared de­ci­sion­mak­ing can lead to lower uti­liza­tion of ser­vices and a pos­si­ble an­ti­dote to bal­loon­ing health­care costs.

Cochran cited a wide range of de­ci­sion aids that physi­cians can pro­vide to pa­tients, in­clud­ing ex­plana­tory DVDs, pa­per-based health in­for­ma­tion and on­line risk cal­cu­la­tors.

For in­stance, when treat­ing women with the bone disease os­teo­poro­sis, Cochran uses a cal­cu­la­tor to ex­plain each pa­tient’s in­di­vid­u­al­ized risk of frac­ture based on fam­ily his­tory, age, al­co­hol use and other vari­ables, and then to show how much that risk will be re­duced by med­i­ca­tion.

“We want to make sure they’re mak­ing an in­formed de­ci­sion,” she said.

De­spite the ever-in­creas­ing fo­cus on in­clud­ing pa­tients in care—2013 has been re­ferred to by many as the “year of pa­tient en­gage­ment ”—ex­pense, physi­cian ac­cep­tance, train­ing and work­flow still present thorny chal­lenges, Cochran said.

“The data has shown us that physi­cians do a no­to­ri­ously bad job of pre­dict­ing pa­tients’ pref­er­ences on their own,” she said. “Un­for­tu­nately, though, doc­tors have not been trained to re­spect pa­tients’ au­ton­omy as much as they should. That re­quires real cul­ture change.”

Pa­tient en­gage­ment is a cor­ner­stone of the fed­eral government’s Medi­care and Med­i­caid elec­tronic health-record in­cen­tive pro­gram. The pro­gram’s Stage 2 mean­ing­ful-use re­quire­ments, set to go into ef­fect in Oc­to­ber for hos­pi­tals and in Jan­uary 2014 for physi­cians, re­quire providers to com­mu­ni­cate with pa­tients us­ing elec­tronic mes­sag­ing and pro­vide them with timely ac­cess to health in­for­ma­tion. Pa­tient en­gage­ment and shared de­ci­sion­mak­ing are also em­pha­sized in other fed­eral pro­grams, in­clud­ing the Medi­care Shared Sav­ings Pro­gram.

Those pro­grams will pro­vide a much needed nudge, Cochran pre­dicted, as will a Septem­ber 2012 study from Seat­tle-based Group Health Co­op­er­a­tive, which showed that de­ci­sion aids could re­duce elec­tive surgery rates and hold down costs.

Dr. Richard Wexler, chief med­i­cal of­fi­cer of the In­formed Med­i­cal De­ci­sions Foun­da­tion, Bos­ton, con­tends that fi­nan­cial in­cen­tives will prob­a­bly need to be much more ex­plic­itly tied to shared de­ci­sion­mak­ing, how­ever, in or­der to ef­fect real change.

“It’s very hard to get shelf space for this be­cause physi­cians have so many com­pet­ing op­por­tu­ni­ties to do good things re­lated to im­prove­ment,” Wexler said. “Un­less we re­align in­cen­tives to high­light shared de­ci­sion­mak­ing and at­tach some real fi­nan­cial im­por­tance to it, I think we’ll have trou­ble com­pet­ing with the other things that are re­warded in our sys­tem.”

Wexler is tak­ing a wait-and-see ap­proach to the EHR in­cen­tive pro­gram, par­tic­u­larly un­til the Stage 3 cri­te­ria are un­veiled. “If mean­ing­ful use gets us there, that will be a very sig­nif­i­cant step,” he said.

Of­fice vis­its may be short, but physi­cians can be suc­cess­ful if they are equipped with the right de­ci­sion aids and train­ing, said Dr. Vic­tor Mon­tori, di­rec­tor of the Health Care De­liv­ery Re­search Pro­gram in the Mayo Clinic Cen­ter for the Sci­ence of Health Care De­liv­ery, Rochester, Minn. A leader in the field of pa­tient en­gage­ment, Mon­tori has devel­oped and eval­u­ated such aids for nearly a decade, mak­ing them avail­able free of charge through the Mayo Clinic Shared De­ci­sion Mak­ing Na­tional Re­source Cen­ter.

“When prop­erly sup­ported by point-of-care tools, we find clin­i­cians are able to do this fairly pain­lessly,” Mon­tori said in an email. “We have done suc­cess­ful work now in the emer­gency de­part­ment, so the is­sue of time can clearly be over­come.”

Physi­cians who em­brace shared de­ci­sion­mak­ing need to do so be­cause they be­lieve in pa­tient em­pow­er­ment and not be­cause they ex­pect a fi­nan­cial car­rot, he added.

“If an or­ga­ni­za­tion en­gages in shared de­ci­sion­mak­ing to look good, make more money, save money or im­prove out­comes, they may be dis­ap­pointed,” he said in the e-mail. “Shared de­ci­sion­mak­ing is a man­i­fes­ta­tion of your com­mit­ment to the pa­tient.”

Even if the “it’s the right thing to do” ar­gu­ment res­onates with physi­cians, in­te­grat­ing a new tool or process into their work­flow can present a sig­nif­i­cant hur­dle, said Dr. Glyn El­wyn, a vis­it­ing pro­fes­sor and se­nior sci­en­tist at the Dart­mouth Cen­ter for Health Care De­liv­ery Sci­ence. El­wyn and his col­leagues have been work­ing on one-page aids called op­tion grids, which briefly re­view com­mon ques­tions and com­pare treat­ments.

The op­tion grids, also avail­able free of charge, cover dis­eases and con­di­tions such as breast can­cer, Crohn’s disease and sci­at­ica, with more tools coming soon for angina, carpal tun­nel syn­drome and oth­ers, he said.

Like Wexler, of the In­formed Med­i­cal De­ci­sions Foun­da­tion, El­wyn says the cur­rent fi­nan­cial in­cen­tive frame­work is not well aligned with shared de­ci­sion­mak­ing. Even so, he said, clin­i­cians’ in­ter­est is boom­ing.

“I’ve never seen de­mand like this, and that tells me some­thing.”


Aids such as tablets, DVDs and on­line risk cal­cu­la­tors can help doc­tors bet­ter pre­pare pa­tients to make in­formed de­ci­sions.

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