It's a fact: "consumerism" has arrived in healthcare. That means providers are redoubling efforts to deliver patient-centered care and actively engage patients in their healthcare decisions.
In some cases, this emphasis on shared decision-making is fueled by high-deductible health plans that hold patients responsible for higher care costs. In other cases, better diagnostic tools and wellness incentives are propelling patients toward more collaborative and proactive health choices.
While shared decision-making is not a new concept in healthcare, a recent Journal of the American Medical Association commentary (Chhabra, et al. JAMA. 2017;317(4):357-358.) sheds new light on its increasing importance. The article reopens the conversation about the value of incorporating patient preferences into the discussion of surgical treatment plans.
In brief, the JAMA commentary reviews three large randomized studies that compared an accepted surgical treatment to non-operative alternatives for three common conditions. The authors conclude that often there is no single "best" treatment plan for a particular diagnosis. Instead, studies seem to suggest that "best practice" really depends on the outcome valued most highly by the individual patient. The commentary argues that in many cases several treatment options may offer equally desirable outcomes; therefore, general best practices should become more patient-specific.
For example, many potential appendectomy patients can be treated with either surgery or with antibiotics. While both are solid clinical practices, the decision ultimately should revolve around each patient's preferences. A patient worried about surgical complications might prefer the antibiotic approach, even if it results in recurrent appendicitis. Yet the patient who doesn't want the potential disruption of repeated illnesses may prefer definitive surgery.
Consider the newly diagnosed patient who comes in for a consultation. Patient "A" has stacks of information about his or her condition and the type of treatment he or she wants. Patient "B" simply says, "If you were me, what would you do?" The provider potentially has different values and preferences than either patient. However, providers who explore and try to understand their patients' values are beginning the shared decision-making dialogue.
Tools to facilitate the conversation
The informed consent discussion offers an ideal opportunity to strengthen shared decision-making. To encourage it, however, the typical consent conversation must addresses the variables in treatment options. Providers who question patients' thoughts about the importance of factors such as staying active versus a lengthy recovery, for instance, can help identify patient values and apply them to the care decision.
This approach recognizes two experts at the table: the physician and the patient. The physician holds the clinical knowledge and knows the range of treatment options while the patient is an expert on his or her values and preferences.
Expanding the conventional informed consent process to consider patient values may be easier with certain tools that put information and detailed assessments of different treatment options in the hands of the provider and patient. For example, the Department of Veteran Affairs uses an automated informed consent tool as part of its Electronic Support for Patient Decisions initiative to facilitate in-depth conversations for about 3,500 different treatments and procedures. That electronic tool puts educational materials and the risks, benefits and alternatives of various treatments at the provider's fingertips to support the evaluation of treatment options with patients.
Patients may also benefit from the ACS NSQIP Surgical Risk Calculator from the American College of Surgeons (riskcalculator.facs.org). This precise and personalized tool empowers patients with a quantitative analysis of treatment risks and complications. The calculator helps patients evaluate their level of risk based on factors such as age, sex, BMI and medical history. It combines a patient's input with an optional provider adjustment to help patients assess and estimate their personal risk profile for various treatment options.
Incentives for patient-centered care
The Centers for Medicare & Medicaid Services (CMS) is about to test two patient engagement models that will evaluate different approaches to the shared decision-making process. The Shared Decision Making Model will reimburse participating Accountable Care Organizations (ACOs) $50 for each Medicare beneficiary who is enrolled in a four-step shared decision-making process.
The Direct Decision Support Model with evaluate the impact of Decision Support Organizations (DSOs) on patient engagement, utilization patterns and cost of care. Significantly, DSOs are outside of the clinical delivery system. DSOs will be reimbursed on a per-patient, per-month basis subject to a holdback performance incentive.
The two CMS models that are about to be tested will add much to our understanding of best practices that help to place patients at the center of care decisions. That said, those initiatives are constrained to Medicare beneficiaries – patients who present with medical conditions, and also with values and preferences, that may differ from those of other patient populations.
Patient engagement, satisfaction with outcomes likely to improve
While providers have practiced shared decision-making for years, the latest developments in trends, tools and technologies may warrant revisiting the concept to fully incorporate it into clinical practice.
The first step is to formalize the shared decision-making discussion with patients, ensuring their values and preferences are consistently captured. Next, providers must take the time to understand and apply patient values to care decisions as they present treatment alternatives and collaboratively create a plan of care.
Taking these steps may help boost patient compliance — and even outcomes — since patients are likely to feel more ownership of their care plans. Patients who feel they've helped devise their treatment plans also tend to report greater satisfaction with their providers.
Consumers are increasingly well-informed, demanding and expecting of a personalized experience. Healthcare has arguably been late to adapt to a consumerism landscape that has long existed for other industries. By embracing a consistent shared decision-making process, providers and healthcare organizations will be able to better partner with their patients to reach the "optimal" treatment plan for each one.
Timothy Kelly, MS, MBA, is a Director at Taylor Healthcare
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