The National Institute for Health Care Reform recently published a paper examining shared decision-making (SDM), the challenges to its widespread implementation, and policy options for increasing its use.
Health Care For All and the Consumer Health Quality Council are advocating for legislation to promote SDM in Massachusetts by establishing an advisory committee to work with DPH and by requiring insurance coverage of the use of shared decision-making tools. We think these concepts should be included in part of any payment reform legislation.
Shared decision-making is a process by which the medical provider and the patient and/or family member have a two-way exchange of information in order to allow for a more fully informed decision on medical treatment. The patient/family receives materials, possibly in a variety of media, to explain their options and the risks and benefits of each option. The provider gains a better understanding of the patient’s preferences and personal situation. And together they come to a treatment decision. Right here in Boston, the Foundation for Informed Medical Decision Making has been working to develop tools to better inform patients.
The article lists some of the challenges to wider adoption of SDM:
- A fee-for-service system that incentivizes the use of more intensive and expensive treatments and does not reward time taken to thoroughly discuss treatment options;
- Lack of training for doctors and other providers on how to conduct SDM;
- Concerns about liability if the chosen decision leads to an adverse outcome;
- The challenges of engaging patients in SDM especially in cases with low health literacy, multiple chronic conditions, and concerns about being denied care;
- Political hyperbole, such as that seen during debates on national health reform when the phrase “death panels” led to the elimination of Medicare coverage of discussions between providers and patients regarding end of life care.
With all of those challenges, the authors are optimistic that policy changes can advance the use of SDM. While SDM is mentioned in the national health reform law, the steps needed to promote its use have yet to receive funding.
Some of the policy options to advance SDM include:
- Paying providers for time spent with patients having these discussions about treatment options. This would need to be paired with measures of the quality of patient decisions to ensure it does not just become a “check the box” exercise.
- Also giving financial incentives to patients to use SDM tools, such as reduced or eliminated co-pays.
- Requiring Accountable Care Organizations (ACOs) to demonstrate SDM use and training of staff.
- Teaching SDM in medical schools and providing continuing medical education programs on SDM.
- Legislating the use of SDM in health care systems.
- Reducing concerns about liability by, as Washington State has done, giving a higher standard for informed consent when SDM is incorporated into the process.
- Requiring health plans to provide access to SDM tools for their members.
- Utilizing health information technology to advance the use of SDM tools by, for example, “prescribing” them via electronic health records, as is done as Massachusetts General Hospital.
An article in today’s New York Times about a gift given to the University of Chicago Medical Center to teach future doctors how to have effective and compassionate relationships with their patients is yet more evidence that all stakeholders in the health care system recognize the need to make it more patient and family-centered. Shared decision-making is an integral part of moving the system in that direction.