Terri Bernacchi, PharmD, MBA
Health Advisory Professionals
Against the great backdrop of the 2010 US Congress’ vote on the health reform legislation (that a small majority of Congressional leaders voted for but many admitted they never read) is a key issue that often escapes those of us in and around health care. Who makes “the decision”?
Which decision is that? Any decision on health care---small or great----whether to start or continue a medication, join a health club, have a mammogram, vaccinate a child, eat a cheeseburger or to buy health coverage of a particular variety. All day-to-day health care decision-making for a specific individual can ultimately have a profound impact on personal, family, and social levels. As an example, the person who chooses to smoke, and becomes addicted to the tobacco, inflicts suffering and cost on her own life, but also effects those around her, the health plan that underwrites her and the society that could pick up the tab for her illnesses should she end up impoverished and in need of state-sponsored coverage. Yet tobacco use is a state-subsidized and legal activity. And the individual is exercising her own freedom in choosing to use it.
So, whose right or responsibility is the decision-making itself? Does it differ by today’s cost or risk impact of the decision (drinking a sugary soft drink versus choosing to have a full mastectomy rather than a lumpectomy)? Does it differ based upon which state one lives in or who pays for the health care coverage? Or, is it possible that the decision itself is ultimately the single right of the individual and is part of his inalienable right to life, liberty and the pursuit of happiness?
Is the responsibility of the decision “shared”, as is implied in an evolving domain of medical research known as “shared decision making”? This concept has been codified in the Patient Protection and Affordable Care Act (PPACA) as a new expectation in medical practice. The law incorporates measures to foster adoption of decision “aids” as well as to establish a series of standards for their quality and governmental support for the expansion of this concept.
Recently released results of the DECISIONS Study indicate that, “although patients perceive themselves to be informed participants in medical decisions, their recall of the important factual information deemed critical to decision making was found to be lacking. Furthermore, what patients described as ‘‘participating’’ often equated to assenting to the recommendations of their physician without much discussion in the way of options or weighing of risks and benefits.” 1
It is important to reflect on the fact that the financial yield of the physician or provider rests on the patient choosing to utilize the very services based on their recommendation (e.g., surgery, procedures, more visits)
Patients often sign “informed consent” documents without a real understanding of the implications of what will follow.
In the future, as a greater understanding of the options, costs and consequences is realized by patients through various means, the empowered patient make take on a more activist role in his or her own care, sometimes rejecting the recommendation of the clinician caring for him.
One aid that could help patients make more reasoned decisions---large or small---could be assistance from an experienced and empathetic health “guide” ---a clinical party with no financial stake in the patient’s care---one who sits on the same side of the table as the patient and the family, to review and compare options, weigh them, and understand them in the context of the medical, financial, spiritual, and social realities of the individual patient.
Such guidance may even save a few bucks, but the real payoff may be measured in the terms of an individual’s own humanity.
1[1] Braddock, Clarence H. The Emerging Importance and Relevance of Shared Decision Making to Clinical Practice. Medical Decision Making, Sep – Oct 2010. Pp. 5s-7s. Taken from the URL: http://mdm.sagepub.com/content/30/5_suppl/5S.full.pdf+html
Terri currently works for a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders in health care as a Senior Principal in Managed Markets. The thoughts put forth on these postings are not necessarily reflective of the views of her employer nor other Health Thought Leader colleagues. Terri has had a varied career in health related settings including: 9 years in a clinical hospital pharmacy setting, 3 years as a pharmaceutical sales rep serving government, wholesaler, managed markets and traditional physician sales, 3 years working for the executive team of an integrated health system working with physician practices, 4 years as the director of pharmacy for a large BCBS plan, 12 years experience as founder and primary servant of a health technology company which was sold to her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.
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