The Patient Protection and Affordable Care Act is frequently criticized as not having enough features to significantly reduce the cost of the American healthcare system (bending the cost curve). However, a careful reader of the law will find many sections that could have an immense impact on the costs of care in the U.S. if effectively implemented. One of these is section 3506, “Program to Facilitate Shared Decision Making.” Shared decision making is a concept that has been advanced by Jack Wennberg at Dartmouth for many years as a way to empower patients and reduce unnecessary costs in the system.
The focus of shared decision making is surgery where there is no single right or wrong treatment option, but where the key issue is whether one option or another is right for the patient. For example, among women with early-stage breast cancer, both mastectomy and lumpectomy followed by radiation yield similar mortality benefit. Many women have strong preferences for one or the other, so quality of care extends beyond the surgeon’s technical skills to the decision-making process.
Traditionally, patients have delegated treatment decisions to their physicians: The physician determines medical necessity and diagnoses the patient’s preference, and then the patient gives informed consent. Policymakers, in turn, have assumed that physicians’ decisions reflect both medical need and patient demand. However, the remarkable degree of variation in the utilization rates of discretionary surgery raises questions about these assumptions.
For example, Wennberg found that among the 306 U.S. Hospital Referral Regions (HRRs) in 2002-03, the incidence of joint replacement for chronic arthritis of the hip and knee and of surgery for low-back pain varied 5.6-, 4.8-, and 5.9-fold, respectively, from the lowest to the highest region. The pattern of variation is remarkably stable over time, such that for most common procedures, variation among regions today is highly correlated with the pattern a decade ago.
Shared decision making is a tool that can be used to address this problem. It includes highly sophisticated and evidence-based patient decision aids which inform the patients of both the benefits and risks of a procedure. It also includes trained health professionals who can counsel patients on this use of the decision tools and support the patient’s decision. Finally, performance monitoring is also essential as part of a shared decision making program.
Section 3506 provides funding to develop standards for patient decision aids, certify providers of these aids, and to develop a program for updating this information. In addition, HHS will also fund a shared decision making center to develop and disseminate best practices in the use of patient decision support aids.
The cost curve can be bent dramatically through the use of shared decision making.
A Cochrane review identified trials of seven conditions commonly treated surgically among the Medicare population: arthritis of the hip and knee; low-back pain from a herniated disc; chest pain (stable angina); enlarged prostate (benign prostatic hypertrophy, or BPH); and early-stage prostate and breast cancer. The review documented that although the uptake of surgery following shared decision making (compared to control groups) varied from study to study, a 21-44 percent decline was typical. Patients in shared decision-making arms of the trials were better informed about treatment options and made choices more consistent with their values.
Although the potential for savings are great, the challenge will be implementation as the reduction in surgery will be resisted by both surgeons and hospitals. Can primary care providers resist the pressure from these major forces and effectively implement shared decision making, or will it fade away as another failed “good idea”?
1. Wennberg, J. E., A. M. O’Connor, E. D. Collins, and J. N. Weinstein. 2007. “Extending the P4P Agenda, Part 1: How Medicare can Improve Patient Decision Making and Reduce Unnecessary Care.” Health Affairs 26(6): 1564.
2. J.N. Weinstein et al., “Surgical versus Non-operative Treatment for Lumbar Disc Herniation: The Spine Patient Outcomes Research Trial (SPORT) Observational Cohort,” Journal of the American Medical Association 296, no. 20 (2006): 2451-2459.