The Side Effects of a Better-Informed Patient

While shared decision-making for elective procedures could negatively affect volumes, leaders need to consider that, like value-based reimbursement, it's coming. So is it better to get ahead?

This article first appeared in the January/February 2016 issue of HealthLeaders magazine.

Healthcare leaders routinely mention the importance of patient engagement and experience. And a solid majority (85%) considers the patient-as-consumer trend to be an opportunity, according to the 2016 HealthLeaders Media Industry Survey. But it's pretty clear that provider organizations don't always share with these consumers all the information they need to make an informed decision. Why not?

Well, it's complicated. The industry has only recently begun to retreat from the paternalistic model that put the physician clearly, and solely, in charge. Another reason is a problem endemic to healthcare under fee-for-service: Screwy financial incentives mean healthcare providers are paid for intervention, not nonintervention. Yet to some, serving the patient's best interests means educating him or her about all the possible repercussions, from a decision to pursue, for example, elective surgery, even if that means the patient ultimately decides to pass on the procedure, leaving the provider with little reimbursement, if any.

As the payment system slowly changes, so does institutional interest in shared decision-making, a concept by which care teams help patients understand the potential impacts they may face from an elective surgery, essentially helping them decide?based on their own goals, the rehab time and effort, and the likely outcome of the procedure?whether they ultimately will decide to go through with it. Under a capitated system, the incentives to engage patients align nicely. Under fee-for-service, which is still the majority payment system for most providers despite a recent push toward value-based purchasing, not so much.

Weighing considerations
For the provider, whether it's a hospital, a surgeon, or a health system, there are many concerns with implementing a shared decision-making program, not the least of which is the potential financial impact. If implementing such a protocol for patients considering elective surgery cuts volumes significantly, all but the most integrated health systems would suffer financially. It's also a cost to staff such a program, even if it consists of just a few people. But if shared decision-making is in the patient's best interest, all other concerns should be secondary, right?

So says Group Health Cooperative, a Seattle-based member-governed, nonprofit healthcare system that coordinates care and coverage; nearly two-thirds of its 600,000 health plan members receive care at Group Health Medical Centers in Washington and north Idaho. Group Health has incorporated shared decision-making in elective procedures since the mid-2000s, says David Arterburn, MD, a senior investigator and consultative internal medicine physician with Group Health Research Institute, the nonproprietary, public interest research center within Group Health Cooperative.

"Group Health was in a good position to make use of this in part because its model of reimbursement is not tied to volume of procedures or diagnostic tests," he says. "In a fee-for-service setting where a provider's salary is based on throughput or volume, it can seem threatening because a fair bit of the evidence suggests well-informed patients are less likely to choose invasive treatments."

Group Health started its shared decision-making program with bariatric surgery and has moved on to incorporate the process in a variety of possible procedures, such as joint replacement. Arterburn is charged with making sure all the medical information presented to patients as part of the process is fair and balanced in terms of the appraisal of risks and benefits of such procedures.

"We work heavily with leadership at physician practices and hospitals to identify clinical champions and leaders to help us work with their colleagues around engagement," says Arterburn. "This is about patient knowledge, satisfaction, and clinical quality because there's strong evidence from 115 randomized trials that show these aids improve the quality of patients' decisions."

Getting the evidence
For some highly integrated provider organizations like Group Health, shared decision-making has been a critical piece of their patient education programs for elective surgeries for years. Mayo Clinic, for example, has taken the process so far that it offers a Shared Decision Making National Resource Center to help other organizations incorporate the concepts.

"There's been a renaissance in terms of provider interest in shared decision-making," says Peter Goldbach, MD, chief medical officer at Health Dialog, a Rite-Aid company that offers care management and analytical services to health plans, providers, and employers. "What I would call early adopters on the provider side?typically these entities were interested because they thought it fit their mission, and it was something they thought they should do in terms of increasing patient quality as well as unwanted variation in utilization."

Now with value-based reimbursement, we are experiencing a renewal in shared decision-making, he says.

Goldbach says patients are often asked to make healthcare decisions in the face of what he calls avoidable ignorance. Medical experts have found that patients often have had only a fraction of the evidence they need to make an informed decision about something as invasive as major elective surgery.

"The Dartmouth Atlas shows the likelihood of patients to receive healthcare services, and that leads one to believe that the patient's ZIP code is more important than their medical condition in whether they receive more healthcare services," he says.

Goldbach says providers can take on this task without much investment, but they have to want to do it at the top leadership level.

"The management team has to be on board and accept responsibility for owning the process," he says. "You can't just list it on your website. It has to become part of normal patient education."

Goldbach says he has empathy for leaders who, for the most part, are still judged on the bottom line, and who still have significant, if not the large majority, of operations under fee-for-service reimbursement.

"But we are meeting leaders who nonetheless are convinced this fee-for-value thing is here to stay and you need to get out in front of it, actively making investments now," says Goldbach.

He says the federal government has provided significant leadership on the subject. Announcements from Medicare about rapid movement toward value-based reimbursement protocols should provide advance warning that much of healthcare providers' reimbursement will shift to value and, further, that they should branch out from having only the bottom line as a gauge of success.

Capitation is an important tool, but it's not the only tool. Section 3506 of the Patient Protection and Affordable Care Act supports shared decision-making through funding an independent entity that would develop and certify standards and patient decision aids. In addition, the U.S. Secretary of Health and Human Services can fund, through grants or contracts, development and evaluation of such tools. Hospitals, according to the law, are eligible for grants to implement these tools. The Centers for Medicare & Medicaid Services is also empowered to test such shared decision-making models.

Still, the hard work is up to providers.

"It's no easy task to bring any kind of cultural change," says Goldbach. "But one thing about the medical community is they respond to incentives, and to education."

Workflow integration
Weaving shared decision-making into the workflow is one of the big challenges to successfully changing the culture, says Arterburn. Consider: Every time a patient is referred for elective surgery, a decision aid, and possibly counseling, gets ordered. For example, no patient recommended for knee replacement undergoes surgery without receiving a decision aid.

"Delivering evidence-based information is one hand of the shared decision-making process," Arterburn says. "The second part is having well-trained providers who understand how to incorporate these decision aids, and in how to have a shared decision-making conversation."

One step often not emphasized is assisting patients in evaluating options based on their own goals and concerns as they relate to the risks and benefits of different treatment options. Two patients may have the same acuity level of osteoarthritis, with very similar severity and mobility issues, but those two patients may have different assessments of risks and benefits. One may be very risk averse. Another may have a different lifestyle or needs and may feel a greater urgency for the procedure.

"One major barrier we face is payment reform that values communication and high-quality decision-making on a level that would make it even more attractive to fee-for-service–setting providers, or at least most providers, to engage in this regardless of what the patient chooses," Arterburn says. "Some providers will tell you they're doing this, but once you train them, you realize they're not actually doing shared decision-making as it's intended to be performed. We're fighting an uphill battle currently. We're seeing slow dissemination of shared decision-making outside organized care systems where finance and care delivery are integrated."

Resistance from patients and physicians
It comes down to being able to count on clinical champions.

Amy Fox, RD, CDE, a registered dietician and program director at Sutter Weight Management Institute in Sacramento, California, credits clinicians with buying in to Sutter's shared decision-making program and making it a success. SWMI is part of Sutter Health, a network of doctors, hospitals, and other healthcare service providers that reported 2014 operating revenues of $10.9 billion.

Despite the program, bariatric surgery volumes at Sutter are on the rise, but Fox stresses that the institute's goal has nothing to do with volumes.

"That might be an outcome, but my goal is not more surgery; my goal is founded in the fact that better-informed patients make better decisions and are better partners in their own healthcare," she says.

Part of the program involves requiring prospective patients to participate in a group class, led by a clinician, on possible outcomes from a decision to have the surgery. Unsurprisingly, she says, at first her difficulties were with the surgeons.

"The surgeons still have some reservations about it. They feel like it is a barrier to surgery; they feel they already told the patients everything they needed to know," Fox says. "But this is not meant to be education in the sense of clinical terms. This is about how the surgery will affect their life going forward. It's not my decision, and I'm not sure I can share it with you. It's also not all informed consent; it's informed decision-making."

She says another barrier is the patients themselves. Often what's difficult about teaching the class, she says, is that patients always want to ask the instructor's opinion.

"As an instructor, you have to have it firmly implanted in your head that this decision is not about me, I help [the patient] explore," she says.

Fox says the program is working well thanks to the executive leader buy-in she had.

"My main executive sponsor did a lot of research on it when I was trying to convince him that it would work. He was very supportive of the concept with the physicians."

That said, evaluating the success of such a program is difficult.

"When I say it's working really well, that's from a purely clinician point of view. We are continually collaborating with the surgeons to improve and refine the process," she says, noting that more than 30% of patients who complete the program go on to choose surgery.

There's no real objective metric to determine success of the program, yet anecdotally, patients appreciate it, she says, adding that the technique would be useful for "anything elective." Sutter is considering expanding it from bariatric surgery to other procedures.

"My definition is purely patient feedback. This feels more coordinated, like there's a process that educates the patient," Fox says. "In elective medical procedures, I just see it as huge, because the patient knows what's going to happen. It lays out the whole journey and lets them choose what path they want to take. Now that he or she has a clinician telling them what to expect, that puts it on their level, and makes it more real."

Reprint HLR0216-6