Shared Decision Making is the Key to Fixing Broken Health Care System

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

Sometimes, it is just best to not “rephrase” or “critique” a perfectly honed message and to just let the message stand on its own merits.  I encourage you to read the linked article, slowly, and drink in the wisdom.  Note this is not about cost but about consequence and empowerment of the patient and family as equals in the health care process. 

• “One of the welcome shifts under way in medicine is the move towards “shared decision making,” where hubris and hierarchy give way to humility and equality. Part of a wider reshaping of the roles and responsibilities of patients and professionals, the shift is challenging the long held belief that doctors know best. Rather than experts who persuade, in the new model the professionals support people in making more informed decisions about their health. But what if we take this notion of a meeting of equals seriously? Could people help professionals to make more informed decisions?”

The author, Ray Moynihan, later in the piece cites the improvement that the patient gets from reassurances from a trusted doctor as he makes his decision.  One of the challenges in the current US healthcare system is the separation between the doctor and the patient in terms of who is going to decide what about the best course of action for any set of circumstances.  Clearly, the clinician is the expert but non-compliance with care is in the realm of 40 to 50%, so it is fair to say that person (often at his/her own hand) does not fully realize the benefits of the clinician’s expertise simply because they choose not to heed it. 

A frank and honest dialogue should begin with the very first meeting, where both the patient and the clinician set expectations and establish the rapport that becomes the basis for shared decision making.  One further complication to be discussed in future posts:  this takes TIME to do; under today’s health care reform environment, with pressures on reimbursements, it remains to be seen how this can occur unless the system will bear the cost burden associated with better dialogue.

Link:  http://www.bmj.com/content/346/bmj.f2789
 
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. 

 

 

Does Recent UK Physicians’ Strike Carry an Important Message for the US?

---Anna Shepherd, Health & Personal Finance Professional - Cambria Health Advisory Professionals

For this blog, I generally try to find news that raises prescient questions about healthcare and economics in our current climate. This article (link below) goes a little outside of that but I find it important nonetheless to keep in back of my mind as a guidepost of sorts. It details a recent strike effort by General Practitioner’s in England’s National Health Services (NHS) over a pension dispute with the government. The government has requested that the doctors contribute more to their pension plans as well as raise the retirement age in order to ease the burden on other health care workers such as nurses or porters (patient transporter). The story reports that this strike was small, affecting about 24% of practices, but was still effective due to the tumult the system saw from canceled surgeries, closed clinics and rescheduled appointments. What I find interesting about this article is the insight into NHS functions, and how we’ve experienced similar issues in the US, and what it meant to the patients. http://www.dailymail.co.uk/news/article-2162242/Doctors-strike-affects-10-patients.html

This illustrates a key inefficiency in the NHS: the doctors are not beholden to the consumers. The chairman of the doctor’s union even used the phrase ‘the fight is with the government’, implying that they are not trying to hurt their patients. But who gets hurt when their scheduled surgery, (an appointment that is often difficult to come by in the first place) has to be rescheduled? The power of the purse is in full display in this instance. In the US, we’ve created a society that engenders pride in the success of doctors. We want our doctors to be highly competent, well compensated, and esteemed for their efforts. Bumping them down a peg to the status of ‘cog in the machine’ will certainly not lead to better outcomes. 

We have had similar issues in the US with government employees. You may recall the air traffic controller strike of the 1980’s or rows in individual states over pay and pensions, such as the recent recall election of Scott Walker in Wisconsin. The very idea of public employee unions has been in dispute even going back to the FDR administration. In a letter to a Federal union he wrote,

• “All Government employees should realize that the process of collective bargaining, as usually understood, cannot be transplanted into the public service. It has its distinct and insurmountable limitations when applied to public personnel management. The very nature and purposes of Government make it impossible for administrative officials to represent fully or to bind the employer in mutual discussions with Government employee organizations.”

This seems pertinent still today, given that after the recent Supreme Court decision upholding the ACA, several commentators in the healthcare industry have been predicting the eventual unionization of doctors; if Britain serves as an example, it is not one we should be clamoring to follow. Here’s a link to a very good article on the effects doctors may see in the coming months: (http://news.heartland.org/newspaper-article/obamacare-expected-increase-loss-doctor-owned-practices)

Now to bring the focus back to the most important driver of healthcare: the patient. A problem lingers with the whole premise of having a doctor’s union. I can only ask the question---- because after much thought, I realized that my solutions got very murky, political, emotional, and ultimately led to naught (at least for the purposes of this blog):

What do you do when your doctor is in a union and you no longer trust him/her to put your best interests first? It seems far-fetched for the United States, given the culture I described above, but it’s all too real for thousands of patients in Britain right now.

Read more at the American Presidency Project: Franklin D. Roosevelt: Letter on the Resolution of Federation of Federal Employees Against Strikes in Federal Service   http://www.presidency.ucsb.edu/ws/index.php?pid=15445#ixzz1zbinKpWE

The Squeeze on State Budgets Means Health Care Reform (As Is) Is Infeasible

By Anna Shepherd, Health & Personal Finance Professional

The impetus for this post was the news of a small community in Washington losing state funding for health clinics due to budget problems. I think it typifies conditions throughout the country. States are already facing crippling budget crises that force them to seek federal monies to help pay for programs like Medicaid. When we consider the fact that health care spending is going to keep increasing (now at 17% of GDP—see WSJ article below) we can safely assume that states are not going to suddenly be able to pay more into Medicaid and related programs. So, the burden will fall to the Feds. However, at a time where we will inevitably (amidst much pandering to the contrary) have to raise the debt ceiling again, it only stands to reason that the money is simply not going to be there for a costly overhaul—on the state or Federal side.

Further recognition that the ACA legislation is not entirely feasible came today, as the Obama administration repealed an aspect of the bill due to start this year that includes end-of-life discussions in a regular physician appointment. When push came to shove, it wasn’t sensible and was repealed. Somehow, I think we’re going to be seeing a lot of that in the next few years. Unfortunately, it comes at a time when governmental action is a precious commodity. A gridlocked Congress already has too much on its plate just considering the budget; unraveling the labyrinth health care law seems like a Herculean effort. Nonetheless, I think we’re beginning to see a reality that was somehow not present last March.

So what’s the solution? Though it is my personal opinion that health care was passed without due diligence and if it had been proposed in segments over a longer term the sensible parts would have passed and the nonsense would have been left behind, we cannot turn back time. However, there are still actions to be taken. The first of them is a serious look at the Rivlin/Ryan proposal: people born after 1956 get a needs-based (adjusted for health risk and age as well) voucher to spend on private health insurance instead of Medicare eligibility (For more on this: http://www.ncpa.org/pub/ba736 ).

This is a start! Furthermore, as in the Forbes article linked below, companies need to take a long, hard, look at what their employees’ health means to the overall health of the company. Creating a scheme similar to 401k contributions, increasing participation in wellness-reward programs, allowing higher contributions to HSAs while funding high-deductible plans, personalized insurance products—all of these are feasible ways to make health care a more manageable part of corporate life. I firmly believe it will fall heavily on the private sector and the actions of individuals to make a difference in the state of health care in this country.

Source articles

• Washington community sees funding for health clinics cut due to budget crisis:    http://www.whidbeyexaminer.com/main.asp?SectionID=1&SubSectionID=1&ArticleID=5055
• Stimulus to states set to end with new Congress:  http://www.google.com/hostednews/ap/article/ALeqM5iSQbSnGouFW-eyk3ElbhWLELr-cA?docId=b9252430d82441d980d86e945f7af254
• Health spending at 17% of GDP http://online.wsj.com/article/SB10001424052748703675904576064173290792358.html
• Solutions for employers http://www.forbes.com/2010/11/29/health-care-reform-employee-retention-leadership-managing-costs.html?boxes=businesschannelsections