Transcript Shared Decision-Making - Consumer

Shared Decision-Making:
Using Patient-Centered Decision Aids to
Improve Outcomes and Reduce Overuse
Debra L. Ness
Co-Chair, Consumer-Purchaser Disclosure Project
President, National Partnership for Women & Families
Peter V. Lee
Co-Chair, Consumer-Purchaser Disclosure Project
Executive Director, National Health Policy
Pacific Business Group on Health
Invitational Working Session
July 1, 2009
Agenda
Welcome and Introductions
– Debra L. Ness, Disclosure Project and NPWF
Setting the Context for Shared Decision-Making
– Peter V. Lee, JD, Disclosure Project and PBGH
Overview of Shared Decision-Making Aids and Effect on Outcomes
– Lyn Paget, Foundation for Informed Medical Decision Making
– Catharine Clay, Ctr. For Shared Decision-Making, DartmouthHitchcock Medical Center
Public and Private Policy Options for Implementing SDM
– Eva DuGoff, Office of Senator Ron Wyden (D-OR)
– Elizabeth Barbeau, Health Dialog
Roundtable Discussion
– Peter Lee and Debra Ness
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Health Reform Elements
Major Policy Area
Critical Value Policies
Coverage expansion
and Financing
1. Align public and private policies
2. Connector or Exchange promoting value
Benefits
3. Assure core benefits promote affordable “right care”
System Reforms
4. Full measures and public reporting (including release
Medicare data)
5. Promote wellness and care coordination
6. Consumer and provider incentives for shared
decisions
7. Payment reform – Change payments AND the decision
process
Infrastructure
8. Patient-centered comparative effectiveness
9. HIT that promotes better care
10. Foster innovation
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Shared decision-making should encompass
four key elements in which a patient working
with their clinician:
• Understands the disease or condition (its risk and
seriousness);
• Understands the treatment/prevention options (including
the risks, benefits, alternatives, and uncertainties);
• Has weighed his or her values regarding the potential
benefits and harms associated with the treatment options;
and
• Has engaged in decision-making at a level at which he or
she desires and feels comfortable.
Adapted from Task Force on Community Preventive Services definition as described in
“How Might Clinicians Facilitate Patient Participation in Decision-making?,” Agency for
Healthcare Quality and Research,
http://www.ahrq.gov/clinic/3rduspstf/shared/sharedba2.htm#5
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Why Shared Decision-making (“SDM”)
is Core to Reforming Care Delivery
• SDM and use of Patient Decision Aids (“PtDAs”) are at the
heart of making care patient-centered. They recognize
that for preference-sensitive care, variation should be driven
by patient not provider preferences
• SDM has the potential of reducing unwarranted
variations in the use of preference-sensitive health care
options
• Numerous randomized trials indicate that Patient Decision
Aids (PtDAs) prevent overuse of options that informed
patients do not value
• Shared decision-making provides a patient-centered
foundation for the use of comparative effectiveness
research
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Challenges to Expanding Shared Decision-making
• History of “informed consent” being uninformed and
non-consensual (signing long legalese document prior
to procedure)
• Clinicians rarely trained or supported in engaging
patients/caregivers as partners
• Evidence gaps:
– Risks, benefits and alternative treatments
– What types of SDM or patient aids make the most difference
• No standard definitions of share decision-making
• Misaligned incentives – big money for DOING
procedures, no money for helping patients decide
what’s right for them
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Private Sector SDM Adoption: Wide Variation
in Employer Demand and Health Plan Support
• General Support: Responding to patients
and/or providers’ requests for information;
wide support for incorporating SDM features
as part of nurselines or general counseling
programs
• Specific Support: Growth in strategies to
facilitate SDM tools in clinical settings; using
data to identify patients who would benefit
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Purchasers Expectations of Health
Plans for SDM
“Purchasers expect plans to provide wellresearched and objective resources to support
members in making treatment decisions. Plans
are encouraged to incorporate benefit coverage
and Plan/network-specific cost information.
Purchasers also expect Plans to promote and
evaluate use of their treatment option support
services.”
eValue8 RFI Standard, 2009
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Examples of Health Plan Support of SDM
• Nurse call centers providing decision support for
preference-sensitive treatments in response to
questions/concerns of patients. But, many challenges,
including:
– Linking nurse services to how decisions are actually carried out at
point of service;
– Still very dependent on provider; providers need training in
“assess, advise, agree, assist, arrange” methodology.
• Targeted outreach (“push” strategies) to reach out to
individuals who may be considering preference sensitive
care:
– Data mining from claims to ID and reach out to individuals who
may be considering treatment options
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State Legislative Activity to Promote
Shared Decision-making
State
Major Provisions
Target Population
Bill Status
WA
Directs the Health Care Authority (HCA) to
establish SDM demonstration pilots at
group practice sites; Gives providers legal
protection by formally recognizing SDM
within informed consent context, and
defines what constitutes SDM.
Basic Health Plan
members
SB 5930 signed into
law, May 2, 2007
VT
SDM pilot programs to increase patient
awareness of treatment alternatives, with a
goal of reducing variation.
Public and
privately insured
S. 129 signed into
law, May 28, 2009
MN
Require providers to actively participate in
SDM process before referral is approved
or reimbursement is paid.
State employees
and Medicaid
enrollees
LD-1358 proposed
ME
Provide reimbursement to providers for
engaging in Shared Decision-Making.
MaineCare and
Private Health Plan
members
SF-696 proposed
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Federal Proposals to Expand SDM
Senate Bill 1133:
• Establish shared decision-making standards, requirements, and a pilot
program for the implementation of shared decision making under the
Medicare program.
• Financial assistance for the establishment and support of Shared
Decision-Making Resource Centers
• Bonus payments to eligible providers participating in the pilot program
who achieve high quality shared decision making
• Program would evolve to reducing payments for preference sensitive
care where patient did not previously receive SDM
Senate HELP Committee – Affordable Health Choice Act:
• Many elements parallel Senate Bill 1133 (Section 217)
• Expands measurement development of effective use of SDM, but:
– Does not make SDM covered benefit or establish a pilot program
– Does not expand to potential of non-payment where SDM does not occur
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Potential Roles for Consumer, Labor and
Employers in Expanding Shared Decision-making
• As Purchasers: hold plans accountable; develop benefit
design incentives;
• Negotiate with health plans to provide incentives to
employees/providers for using PtDAs
• Utilize Support Tools to educate employees
• Public advocacy for payment reform that pays for SDM
or pays less for preference sensitive care when SDM
not provided
• Support for development of standards or certification for
SDM and PtDAs
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About the Disclosure Project
The Consumer-Purchaser Disclosure Project is an initiative that is improving health
care quality and affordability by advancing public reporting of provider performance
information so it can be used for improvement, consumer choice, and as part of
payment reform. The Project is a collaboration of leading national and local
employer, consumer, and labor organizations whose shared vision is for Americans
to be able to select hospitals, physicians, and treatments based on nationally
standardized measures for clinical quality, consumer experience, equity, and
efficiency. The Project is funded by the Robert Wood Johnson Foundation along
with support from participating organizations.
Previous Discussion Forums are available at: http://healthcaredisclosure.org/activities/forums/
For More Information Contact:
Tanya Alteras, MPP
Associate Director
202-238-4820
[email protected]
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