Newsroom
Leading Researchers Identify Methods for Medicare to Improve Patient Care and Reduce Costs Using Shared Decision Making
Better Informed Patients Opt for Less Surgery When Choosing Treatment Options
When Medicare patients face treatment choices about discretionary surgery, the patients should get unbiased, complete information that allows them to make an informed choice about which treatment option they prefer, according to a November/December 2007 Health Affairs article.
John E. Wennberg and co-authors Annette O’Connor, E. Dale Collins and James Weinstein, all of the Dartmouth Institute for Health Policy and Clinical Practice, urge the Centers for Medicare and Medicaid Services (CMS) to lead in establishing informed patient choice as the standard for determining medical necessity for discretionary surgery. The authors cite the example of early stage breast cancer, for which mastectomy or lumpectomy followed by radiation yield similar mortality outcomes. “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.”
In these discretionary cases, the patient should engage in a process known as shared decision making, augmented by patient decision aids, to work with their physician to achieve informed patient choice. Shared decision making helps patients become fully informed about their illness, understand the likely outcomes of various options, think about what is personally important about the risks and benefits of each option and participate in decisions about medical care. The decision aids are tools – in formats such as DVDs and pamphlets – that explain fairly and clearly the pros and cons of each option.
“Failing to make sure that patients fully understand their options when making medical decisions is both unethical and a recipe for bad decision making,” said Floyd J. Fowler, president of the Foundation for Informed Medical Decision Making, which works to advance patient choice. “In this country, health insurance pays for procedures but does not routinely pay for providing high quality information and counseling needed to make sure patients receive the care that is best for them. CMS should take a leadership role in providing support for providers who take the steps needed to ensure that patients are informed and have the chance to participate fully in decisions that will have a major effect on their lives.”
Pointing to research that shows that informed patients are less likely to opt for surgery despite what might be a doctor’s initial recommendation, the authors state, “There is growing evidence that the amount of surgery that can be justified on the basis of traditional practice guidelines actually exceeds the amount of surgery that patients want when fully informed.”
For that reason, the authors urge Medicare to launch a pilot program to determine the best way to implement shared decision making nationally, followed by a pay-for-performance program that rewards hospitals and surgery centers that make informed patient choice the standard for medical necessity, and that eventually cuts off those who do not.
According to the authors, “CMS should take steps to ensure that Medicare beneficiaries facing discretionary surgery have access to high-quality shared decision making. The goal should be to establish the informed patient as the arbiter of medical necessity for clinically appropriate medical options and ensure that the rates for discretionary surgery reflect demand based on patient preferences.”
The authors note that there are potential economic benefits to Medicare. “Although the argument for informed patient choice is based on ethical principles of patient autonomy, the clinical trial data suggest that implementing high-quality shared decision making could also result in Medicare savings via a drop in utilization. The impact on the overall use and cost of medical care, however, needs to be measured over the longer term, with careful monitoring of outcomes.”
The article, entitled, “Extending the P4P Agenda, Part 1: How Medicare Can Improve Patient Decision Making and Reduce Unnecessary Care,” is in the current November-December 2007 issue of Health Affairs. http://content.healthaffairs.org/cgi/content/abstract/26/6/1564
About the Authors
Wennberg is the Peggy Y. Thomson Chair in the Evaluative Clinical Sciences at the Dartmouth Institute for Health Policy and Clinical Practice and is a professor of medicine and of community and family medicine at Dartmouth Medical School. He is a co-founder of and consultant to the Foundation for Informed Medical Decision Making. O’Connor is a professor in the School of Nursing and Department of Epidemiology and Community Medicine at the University of Ottawa. Collins is director of the Comprehensive Breast Program, Norris Cotton Cancer Center, at Dartmouth-Hitchcock Medical Center, and an associate professor of surgery at Dartmouth Medical School. Weinstein is professor and chair of orthopaedics, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, and the director of the Dartmouth Institute for Health Policy and Clinical Practice. For more information, visit tdi.dartmouth.edu (http://www.dartmouth.edu/~cecs/)
About the Foundation for Informed Medical Decision Making
The Foundation for Informed Medical Decision Making’s mission is to assure that people understand their choices and have the information they need to make sound decisions affecting their health and well being. The Foundation organizes and frames medical evidence in an unbiased manner to help people evaluate their options, particularly in instances where differences in individual preferences and perspectives are likely to affect personal choice. For more information, visit www.fimdm.org.
|
