Hospital Studies Blows Apparent Hole in Concept of Shared Decision Making Reducing Costs

---Terri Bernacchi, PharmD, MBA,  Cambria Health Advisory Professionals, Senior Partner at Valiant Health, Managing Partner at Quo Magis Partners

Answering an important question, “Does “SDM” (shared decision making) reduce cost?” was the focus of a study published by JAMA (see link below) that utilized a survey given to ~20,000 inpatients over 8 years at a single institution.  They concluded that while the classic SDM concept that engaging patients in their care can help control costs and reduce utilization, SDM can actually increase lengths of stay and inpatient spending.  Patients were asked to rank a preference for the statement, “I prefer to leave decisions about my care up to my doctor”.  Investigators drew inferences from this as to their interest in SDM and specifically reviewed an inpatient setting.  The survey data were linked with administrative data to find conclusive results.

They found that Length of Stay was longer (by 5%) and incurred cost was higher (by 6% or about $865) for people that were more inclined to want to be involved in their decision making process. One of the primary co-authors, Dr. David Melzer has been quoted by Modern Healthcare as attributing some of the lack of cost reduction to the fact that prospective payments in hospital environments already incentivize more careful resource use, and that SDM could actually increase costs. 

But not so fast here.  I think there may be a larger concern: conclusions about attitudes toward SDM using a generic question at the exact time a person is in an inpatient hospital setting is the exact wrong time to evaluate SDM.  The principles of SDM involve the patient as an equal in the process----much has been written in the literature about the power dynamic / power imbalance between doctor and patient.  This is the wrong time and the wrong way to measure its effectiveness. 

In the Modern Healthcare article (requires a subscription) Melzer goes on to muse that SDM should not be thought of within a framework of cost-control, which I agree with.  If the principles of SDM get misrepresented as one more way to ration resources or cut costs at the patient’s own expense, there will be no basis for trust (an essential ingredient in real SDM).  SDM will fail.  

(Link takes you to an abstract and not the full article:  http://archinte.jamanetwork.com/article.aspx?articleid=1691765 )

I wonder what a patient would think about whether or not their doctor would see any survey response that indicates they prefer NOT to leave decisions about their care to the Doctor.  In the inpatient setting, someone is making almost all decisions for you---from how much you can eat or drink to what tests are going to be done and when you can go home. 

The problem lies not with posing the question but with the way in which it was measured and the environment in which it was measured.  Better yet to have asked more nuanced questions BEFORE hospitalization ever occurs and gauge the avoidance of hospitalization and other procedures (and the associated cost savings) rather than the methodology of asking a patient at his /her most vulnerable time in the hospital. 

 Terri is a Senior Partner at Valiant Health, LLC, and founder of Cambria Health Advisory Professionals and a  Managing Partner at Quo Magis partners.  The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Valiant Health 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 of 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.Managing Partner at Quo Magis partners.  The thoughts put forth on these postings are not necessarily reflective of the views of her employers or clients nor other Valiant Health 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 of 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.