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Shared Decision-Making by Doctors, Patients Elusive Goal in Medicare, Panel Says

By John Reichard, CQ HealthBeat Editor

March 8, 2013 -- Medicare Payment Advisory Commission (MedPAC) members recently agreed that doctors should give patients a much better sense of their treatment options for certain serious medical conditions. But they were at a loss to recommend how to make that happen on a widespread basis.

"Sometimes MedPAC's role is to say, 'here's a problem and here's a fix,'" MedPAC Chairman Glenn Hackbarth observed after a 90-minute discussion of the issue by commissioners. "But sometimes our role is to say, 'here's a problem and it's just not a problem that's amenable to being fixed by Medicare payment policy in a targeted way.'"

Commissioners specifically wrestled with "shared decision-making," an approach designed to better incorporate patient preferences when it comes to treating such diseases as prostate and breast cancer and cardiovascular conditions where the medical evidence is unclear about which of several treatment options is best.

It perhaps was most famously and vividly demonstrated by Dartmouth researcher Jack Wennberg, who, a number of years ago, developed videos in which doctors with prostate cancer described the treatment options they had and explained why they picked the one they did. Different doctors picked different options based on individual preference. Patients, after watching the videos, then discussed with their own doctors about what they wanted to do.

Some preferred not to have surgery, which often leads to impotence. Others, aware that other medical conditions are likely to kill a prostate cancer patient long before his cancer does, preferred to put off an operation.

One trend that emerged was a preference for "watchful waiting" of prostate cancer symptoms and a delay in having surgery. Often, with respect to other procedures as well, shared decision-making leads to fewer surgeries with potential savings to the medical system.

MedPAC staffer Joan Sokolovsky briefed commissioners on the research literature examining the use of the technique, which involves "decisions aids" and gives patients information about the trade-offs of various treatments.

"Studies have consistently shown that decision aids, used with counseling, increase patients' knowledge, give them a more realistic perception of treatment outcomes, increase the proportion of patients who are active in decision-making, and improve agreements between patient values and the options that they choose," she said. "In general, the studies also show a reduction in more invasive treatment options without adverse effects on health outcomes."

Sokolovksy noted that in a study of shared decision-making involving about 9,000 osteoarthritis patients at Group Health Cooperative in Washington state, knee replacement surgery rates dropped 38 percent and the rate of hip replacement surgery fell 26 percent after use of shared decision-making began. Cost for these patients also fell, she said.

But Sokolovsky also noted that doctors lack financial incentives to follow the shared decision-making in a health system dominated by fee-for-service medicine. Choosing not to do surgery, for example, can mean a loss of revenue for a hospital or surgeon. If doctors are paid a salary that doesn't vary with the procedures they do or make more money if they deliver more efficient and higher quality care, they may be more apt to use shared decision-making. But right now that's not the norm in Medicare's traditional fee-for-service program.

Sokolovsky noted in her presentation to commissioners that in 2010 they suggested that the development of ACOs and medical homes could provide the incentive and the infrastructure to make shared decision-making more feasible. Those delivery models give doctors a financial incentive to deliver savings and higher quality care.

Since then, the use of shared saving is increasing, "but at a very slow pace," Sokolovsky said. One commissioner expressed doubt that ACOs would have enough of an impact, observing that while a hospital might have a better chance of getting a shared savings payment if surgery rates fell, its loss of revenues from not doing the procedure would be greater than the savings payment.

Another approach discussed would involve establishing a payment code within the fee-for-service billing system to pay for shared decision-making. But some commissioners doubted that adding such a code would produce the kind of patient education and shared deliberations that are needed to make the model work. Successful adoption of the process requires a basic change in the medical culture, one member of the panel said.

Hackbarth commented that to have such a regulatory approach "you really need precise definitions." Establishing a system would entail defining what constitutes shared decision-making for payment purposes, what procedures it could be used for, and what educational aids were appropriate.

If fee for service were no longer the dominant system, doctors might have more of a financial incentive to adopt the model, commissioners agreed. But one, Scott Armstrong, an executive with Group Health Cooperative, the health plan that has used the model successfully, noted that even when the payment incentives are supportive, there are issues such as proper tracking to know which patients should be offered which educational and decision-making tool.

Another theme of the discussion was alarm that such discussions do not occur as a routine part of the informed consent process in medicine. Hackbarth spoke for other commissioners when he said he considers use of the model an ethical imperative.

"As we've said over and over again, in a broad way, changing the Medicare payment incentives could make a huge difference. But targeted, specific solutions, you know, sometimes just are not within our reach. One of the things that Congress looks to us for is, as well as 'do this, do that,' is don't do something. It could well be that activities outside of Medicare" would be good things to test and develop. "But as far as Medicare is concerned it may be that what we can do is pretty limited."

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