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.
 

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.

Online Medical Consult Offered by HealthPartners

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

Minnesota companies have long been in the forefront of leading health care initiatives in technology, insurance, and consumerism. Certainly, HealthPartners is familiar to most of us in health care as one of those thought leading companies.

This week, they announced the launch of the “virtuwell” offering to consumers for 24-hours-a-day, 7-days-a-week on-line access to a medical professional (nurse practitioners) for the diagnosis and treatment of simple medical conditions for a small ($40) fee. Ostensibly, this treatment would be isolated to the treatment of conditions that are easily and safely confined to “evidence based” decision-trees and medical flow charts: such ailments as colds, cough and allergy, ear pain, yeast and urinary tract infection.

But the new online service does raise some interesting questions from several angles: legal/liability (who is responsible for quality issues that could arise) ; clinical best practices (you cannot really “see” or “touch” a patient or peek inside the ear or smell their breath or gain the context you can when you are in the same room); what is done for communication and follow up perspectives? There are additional questions that relate to privacy, quality of care without reliable access to a relevant patient history, and practical concerns relating to continuity of care if the patient does have a primary care practitioner or drug interactions if they are on other medications. Since most health practitioners (and particularly those that prescribe drugs) are licensed on a state-by-state basis, there are also interesting questions in terms of how the caregiver is licensed or managed in one state while rendering care to a person in another state. Will this care require payment outside of the established insurance process or will it be covered at all?

Regardless of the details or the answers to some of these compelling questions, this is certainly going to be a service of interest to many consumers. A key question that one must ask when you see a party blazing a new health care trail is this: Would I use that service for myself or a member of my family? The answer to that question (at least for me), is YES. I have personally already used one of the now famous in-the-retail-pharmacy nurse clinics. And as a pharmacist, I must admit, I was pleased with the care of the nurse practitioner treating my conjunctivitis.

Change is not always a great or even good thing. But this evolving way of relating to the needs of an individual patient may offer value in these cost and access-challenged times. At a minimum, it will be interesting to see what progresses from here.

Read the details at the following link: http://www.healthcareitnews.com/news/healthpartners-launches-247-online-clinic

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.

Giving People the Power to Make Choices is a Tricky Proposition

Terri Bernacchi, PharmD, MBA
Health Advisory Professionals
England’s infamous health care system is always undergoing flux and scrutiny as leaders try to find new and better ways to save money, provide care, and meet expectations for quality and outcomes. The concept of “shared decision making” and patient empowerment is proving to be difficult there, too, however, as evidenced by a recent article published in the British Medical Journal. The British government has publicized its plans to introduce wider choice and shared decision making within the NHS, but they are finding that it may be challenging to implement based on several factors, some of them unforeseen.

For example, evidence suggests that while patients like the idea of a choice of physician and being involved in personal health decision making, the clinicians are not necessarily warm to the idea. Changing these attitudes in the provider community requires changing entrenched styles and operating beliefs within the professional community itself.

Moreover, while the UK National Health System already provides patients with information on quality, safety and outcomes and promises to publish more detailed information in the future, the evidence suggests the patients are not using it! And it appears that physicians don’t really understand what the patients themselves want regarding information and decision making.

While there are decision aids for many diseases and conditions already in place, the NHS and its practitioners continue to struggle with how to embed these tools, and how to shift attitudes and skills so that shared decision making will be put into more routine practice.

How can this information from the NHS help those of us in the United States, where the idea that a patient would not have choices is a foreign, even hostile concept? 2010's health care reform has been unpopular with a large percentage of Americans. But the reality that every individual’s inevitable need for health care looms in front of all of us and the lessons learned by the NHS are helpful. In order to create a fully empowered (and accountable) patient in the US, we need to make sure that:  

• the patient understands the information that should be considered in making decisions and the consequences of each option
• the physician and other supporting clinicians are encouraged to work with the empowered patient which may mean reforming paternalistic patterns of communication and care
• the financial system that is the underpinning for the empowered patient must support the process of “Shared Decision Making”, without creating disincentives to the physician, the patient, or other stakeholders like family members.

Read more: http://www.4ni.co.uk/northern_ireland_news.asp?id=117833

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.

Getting to the Truth in Patient Medical & Pharmacy Encounters ---On Shared Decision Making

The survey explores the concept of Shared Decision Making----where the patient is enabled and empowered to participate as an equal in his or her own care. It’s a concept that is long overdue and maybe far off as it completely shifts the power dynamic and accountability back to the consumer / patient / person. The clinician is also empowered in that dynamic, as frank dialogue becomes the basis for communications. It's not about the money exchange in health care-----it's about the power for decision making and helping people have choices-----and this is something that may be as unique to us as our retinal patterns.

It is that shift that actually enables the free-market of health care for the person, the clinician, and the system because we cease paying for things that have low value or are not desired by the patient which might otherwise result in waste----redundant tests, unnecessary drugs or hospitalizations.

I am grateful for the opportunity to enlist a number of you in measuring your impressions in this survey with the hope that we can spark a national-----or international----dialogue on how to really improve care and take care of each other. Please copy and paste the following link into your browser page or double click on it to review the results. http://www.keepandshare.com/doc/view.php?id=963974&da=y