Is Shared-Decision-Making Compatible with Current US Medical Delivery Models?

By---Terri Bernacchi, PharmD, MBA, Health Advisory Professionals

Based on the title of this log entry, you already understand the premise of this debate. The current US Medical Delivery Model is probably not ideally tuned into the concept of Medical Shared-Decision-Making. At its root, this philosophy involves a patient who is actively, rather than passively, involved in driving his own treatment. It implies that the patient (and family members theoretically most affected by his health) has enough information about the options available and the consequences of his own behavior on successful outcomes.

Surprisingly, perhaps, the discussion of these concepts in the literature is just beginning to mushroom, but the patient and his or her active compliance has always been the 800 lb gorilla in the room. Ask any cardiologist what the most important variable in a patient’s outcomes, and he is likely to tell you that it is the patient himself. How much salt; how much exercise; how compliant is he with necessary medications and diet?

While it’s amazing to me that this has taken so long to be center-stage in health care, our financial realities may the primary driver for why it will finally happen. Shared decision making is now a topic of global concern as individual governments face bankruptcy and austerity world-wide. To be sure, in those countries where the government funds all or most of the health care cost, the common sense reality that is sinking in is for reformation starting with how the patient himself figures into the system.

For example, the recent debate over this concept in the United Kingdom within the NHS has centered on reluctance on the part of clinicians to offer a choice (see October 22 blog). The British government is undertaking reforms as part of wide-ranging changes due to be implemented in early 2011, with a renewed emphasis on joint decision-making by patients and healthcare professionals. (See the recent article in the Irish Times by a medical doctor, Muiris Houston, discussing the debate: http://www.irishtimes.com/newspaper/health/2010/1026/1224282000782.html )

One downside is the time it consumes. After all, it takes precious time from the doctor-patient interaction to discuss the alternatives---and it is hard to think about how to squeeze more time out of a day, without adding a lot more cost. And even with that, there are some patients that want the doctor to make all the decisions about what is best for them.

The same is true in the US, where the business model of the medical practitioner centers on how to treat an acute disease, provide preventive services such as vaccinations and monitor vital signs, adjusting medication, diet, and exercise programs to delay chronic disease. The patient (or more commonly, the health plan) pays for the service and the doctor moves through the day like a conveyor belt, seeing patients, making decisions, and filling out paperwork.

The article in the British Medical Journal suggests that least three factors are critical to boost shared decision-making to its place as centerpiece of clinical practice:  

1. ready access to evidence-based information regarding;
2. clinical guidance on how to rank the options;
3. a supportive clinical culture that facilitates patient engagement.

My position on this is simple: The first three things are possible now more than they ever have. The #3 factor is coming, albeit slowly, but is being forced by the economic tsunami we are facing with our aging populace.

I would add a fourth factor: someone besides the primary clinician (who stands to gain financially each time a visit is made, a test ordered, or a surgery performed) needs to be available to talk frankly to the patient about his circumstances----helping to objectify the decision and weight the factors that are within the control of the patient. This advisor MUST NOT be involved in the recommendations nor the path chosen (and therefore cannot be paid by the insurance company to contain costs or the doctor’s office, to promote procedures). The patient can see his advisor on his own terms, referred by friends, the health plan or the doctor. But it is the patient’s own decision that is the critical path.

This is the basis for the evolving business model promoted by Health Advisory Professionals, LLC -----seeking a future state where the empowered patient understands the options and consequences and makes rational decisions based on what is right for him or her, as only he or she can know. 

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.