Shared Decision Making, Waste, & Progress

Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals & Managing Partner at Quo Magis Partners

The good news:  there continues to be progress in the arena of shared decision making (SDM), which I believe will be one of the most important tools to achieve optimal health care outcomes and medical economics. SDM represents a deeper dialogue involving clinicians, academics, health plans, patients and family members regarding how resources are best used and expectations of care are met.  If accomplished effectively, SDM will result in a more rational use of resources. More importantly, it will enable higher satisfaction on the part of all parties, but especially the patient.

The process of sharing the decision making has become its own medical expertise, representing a new field of greater study, complete with an evolving body of literature.  It is the place where science, technology, social, and economic factors converge; a place where the imbalance of power between who decides and who must live with the decision meet; a place where the one who pays the bills and the one who pays the consequences must deal with the nuances.  Does the decision at hand involve a clear path with easily understood risks and benefits or is it one that is fraught with vague and unknowable consequences, consuming both the patient’s limited financial resources and the system’s allocated spend, without meeting anyone’s expectations?   

As I have written before, perhaps the single greatest driver of health care cost is under the umbrella of “waste”.  Under this ignoble category, the labs have been ordered, prescriptions dispensed, and procedures done when the patient either did not want or comply with them, may not have understood the need or was disappointed in the results.  Perhaps the whole process yielded little benefit to them personally; and the use of the system’s resources may be categorized as “wasteful”.  Perhaps the physician who ordered these services did so because they were necessary; perhaps it was to cover the medical-legal checkbox.  Experts comment frequently on how the elimination of “fraud” will return billions of dollars back into the system.   But my take on it (without any statistics to back me up because I don’t believe there is an accurate way to measure either fraud or waste) is this: waste outweighs fraud by a factor of a hundred-fold. 

One article recently caught my eye which addresses the expansion of SDM as a method of better understanding decisions and consequences, each with different points.

The first article references the differences between the physician and the patient in terms of expectations of breast cancer treatment, citing the physician’s greater sense of “reality” as compared to the patient.  The study investigated “differences between patients and physicians with regard to the required efficacy of treatment and the factors influencing patients' and physicians' willingness to accept different therapeutic options.”  Clearly, the patient is not on the same “reality plane” as the clinician.  The study was published in Breast Cancer Res Treat. (2012 Aug 30), by FC Thiel et al, “Shared decision-making in breast cancer: discrepancy between the treatment efficacy required by patients and by physicians.”

What is most interesting to me is the last statement in the abstract which demonstrates what I believe:  that each patient has unique desires and expectations, even if they have the exact same disease state, with the same odds.  The uniqueness is where the opportunity for real SDM (or potential waste) comes into play.  This is fruit for new dialogue and new study, and I am anxious to participate in the discussion! 

(Available at the link below); “Approximately one-fifth of the patients were willing to accept treatment regimens even with marginal anticipated benefits, whereas one-third required unrealistic treatment benefits. Several influencing factors that were significantly associated with the quality rating of treatment regimens in the groups of breast cancer patients and physicians were also identified. In contrast to physicians, many breast cancer patients required treatment benefits beyond what was realistically possible, although a large group of patients were also satisfied with minimal benefits. Individual factors were also identified in both groups that significantly influence thresholds for accepting adjuvant treatment, independently of risk estimates and therapy guidelines.”

http://www.ncbi.nlm.nih.gov/pubmed/22933029

Terri is the founder of Cambria Health Advisory Professionals and a Managing Partner at Quo Magis Partners. Among her current clients: a large health sciences firm serving payers, pharmaceutical and device manufacturers and other stakeholders, a small special needs health plan as a 5 Star Consultant, and several other health related clients. The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Health Advisory Professional 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 IMS Health in late 2007.  She has both a BS and a PharmD in Pharmacy and an MBA.