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.
 

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. 

 

 

Shared Decision Making, Screening Mammograms and Quality Care

----Terri Bernacchi, PharmD, MBA, Cambria Health Advisory Professionals & Managing Partner at Quo Magis Partners
  Issues in medicine typically evade grouping into “necessary” versus “unnecessary” or “good” or “bad” categories. Such is the case with the topic of screening mammography, perhaps, when viewed from the perspective of a patient or family member trying to make the most of a shrinking dollar while maximizing their health as they get older. For example, few would have argued that early diagnosis and treatment improves outcomes in most cancers.

The federal government, in fact, has endorsed screening mammograms in its 5 Star program, by paying Medicare Advantage plans explicitly for maximizing the percentage of female members between 40 and 69 who receive them every 2 years. Recently, a study in Lancet was published that concluded that for every life saved by mammography screening, 3 women will be “over-diagnosed” and ultimately treated for a cancer that may never have caused the trouble for a given person. The article suggests that screening “reduces breast cancer mortality but that some overdiagnosis occurs.”

In his book, “Overdiagnosed: Making People Sick in the Pursuit of Health”, Dr. H. Gilbert Welch, refers to some cancers as “incidentalomas” which are discovered as part of the screening we can now do enabled with-ever-more-sensitive technologies.

While I am not going to take a position on this topic, the point that I want to make is that it is confusing, at best, to the average patient. Certainly, what we “know” as indisputable fact today will be contradicted or clarified at some point in the future.

The best thing that can be done, then, for the average patient is to provide supportive guidance that stops short of being dogmatic about the use of such tests. While the quality indicators that are now driving Medicare Advantage Star ratings don’t take such nuances into account and carry real financial consequences for the plans if the member does NOT have the mammogram, the clinical and personal realities for a patient are shaded with elements that are not population-based, but very individualized. The things that motivate or demotivate a patient to receive that mammogram: fear of pain of the test or results that come from it, personal time and money, perceptions about the benefit versus the risk, and a variety of other factors. These are the real reasons a person will decide to have or not have a mammogram. And the quality question---may remain open for debate.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61216-1/fulltext

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.

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.

As Rx Coupon Debate Goes On, Massachusetts Reverses Stance

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

I have written a number of times on the potential benefit that drug coupon programs can afford all parties in the health care exchange, but also recognize that this is a very controversial subject. Specifically, coupons programs can benefit the manufacturer who seeks to penetrate a market, a patient who is looking for a financial benefit for a drug that the physician believes is necessary, and, if done in collaboration, can help a payer manage high-cost drugs.

Recently, Massachusetts announced that it is officially lifting its long-standing (since 1988) ban on prescription drug coupon programs. Massachusetts was the last state in the country with such a ban. Certainly, the controversial methods which make these programs very attractive to the consumer continue to stir heated debate in PBM, plan, pharmaceutical manufacturer, and regulatory circles. And those parties who hope to eliminate them have to jump a significant public relations hurdle.

You can tell from the tone of the attached article that the lifting of this ban is popular with consumers. (See link: http://www.wcvb.com/health/Massachusetts-lifts-long-standing-ban-on-prescription-drug-coupons/-/9848730/15929808/-/a3k66g/-/index.html  ) But coupons are an important and beneficial tool as health care reform gets underway and costs are shifted to the consumer, who will continue to act in his /her own perceived self-interest.

Case in point: The application of coupons in health care is not only about drug manufacturer but is also applied to provider services. In an article by Judy Wang Mayer, “Health Care Providers’ Use Of Groupon Stirs Up Controversy” on August 10, 2012, the author warns health care providers (dentists, physicians, surgeons) to be careful with social coupon websites. She says that although no providers have yet been disciplined by state licensing boards, it is “only a matter of time before most state boards of licensure and national professional associations take a position on the legality of these types of promotions. Until then, health care providers should be cautious and consult an attorney before signing up with a daily deal website like Groupon or Living Social.” (See link: http://www.mondaq.com/unitedstates/x/191090/Healthcare/Health+Care+Providers+Use+Of+Groupon+Stirs+Up+Controversy)  

A few links that are a little older that describe some of the controversy are included for the reader.

1. A number of employers/unions (County and Municipal Employees District Council 37, American Federation of State, the Sergeants Benevolent Association, the Plumbers and Pipefitters Local 572, and the New England Carpenters) have sued pharmaceutical manufacturers in federal court over the presumed legality of these programs (March, 2012, see link: http://www.insurelane.com/insurance/blog/health/2012/03/08/Drug-Companies-Sued-By-Insurance-Plans-Over-Coupons.html)   
2. Adam Fein, PhD, of Pembroke Consulting has written considerably on this topic and is a good source of the overall topic, including this Drug Channels article from November of 2011: http://www.drugchannels.net/2011/11/pbms-launch-new-attack-on-copay-cards.html   
3. In the article, “Co-pay coupons: Good deal for consumers, headache for health insurance companies” by Mary Kay Jay, the author makes the case for the fact that the consumer wins while the insurance company is left to pay for a product that is many times more expensive than the generic drug they'd prefer to see be used.  http://www.netquote.com/health-insurance/news/co-pay-coupons.aspx#ixzz23SMuKDYC  

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 her current employer three years ago. 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

Feds Grant Millions to the “Shared Decisions” Endeavor

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

The proud announcement about more federal funds ($36.1 million in funding, part of a $1 billion “Innovation Grant”) being “won” by a handful of large, integrated health systems exudes optimism as it explains the use of these funds is “primarily to hire and train an estimated 48 patient and family activators over three years to help with shared decision-making (SDM) related to hip, knee or spine surgery, and for patients with diabetes or congestive heart failure.” (By my math, that is $750,000 per “activator” or $250,000 per activator per year, to help what can only amount to a handful of patients.)

While I could comment on the wisdom of bleeding these funds on a speculative project at a time when we are in pretty dire economic circumstances, I won’t indulge that instinct. And those who read my blogs or know me personally know that I am passionately enthused with the concept of “shared decision making” in health care. SDM can be the primary means to improve patient satisfaction and optimize results ----which reaps (only as a by-product) REAL cost-savings based on a reduction in resource waste due to non-compliance or over utilization. http://www.ama-assn.org/amednews/2012/07/02/bisd0703.htm  

My larger concerns in this article and with this approach is described at the end of the article: that a physician can prescribe a “video” for the patient to watch which will result in a “shared decision” for the patient to have (or not have, gasp!) a surgery. SDM is more than “tools”----it is a process that requires time and deliberation. The article quotes Dr. Goldbach, the Chief Medical Officer of HealthDialog as saying, “It can be a matter of a physician “prescribing” a video for a patient deciding whether or not to get knee surgery.”

HealthDialog is a “private, wholly owned subsidiary of Bupa, a global health and care company of more than $12 billion in revenues headquartered in London, England. Health Dialog provides population analytics, interactive decision aids, and healthcare decision programs to over 17 million people around the world. Health Dialog provides population analytics, interactive decision aids, and healthcare decision programs to over 17 million people around the world.” Clearly, this private company is heavily linked to our health care reform initiatives in its relationships with CMS.  http://www.healthdialog.com/Utility/Company

 Shared decision making involves give and take between the clinician and the patient (and sometimes the family). It is as intimate as a confessional and is not something that can be slap-dashed together as part of a “program”.  It occurs in local surroundings and not in corporate offices, conducted by call-center personnel.  Shared decision making happens ONE patient, ONE situation at a time.

Terri is the founder of Cambria Health Advisory Professionals. 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 her current employer three years ago. She has both a BS and a PharmD in Pharmacy and an MBA.