How shared decision making empowers patients

“Shoulda, woulda, coulda.” That’s among the most disheartening thoughts you can have when it comes to the health of a loved one or your own health decisions.

Yet, that’s often the reaction from patients and their families upon learning about treatment options after the fact. Many say, ‘I wish I had known that treatment was available’ or ‘I delayed surgery because I was afraid. If I only knew how much better I could have felt, sooner.’ It can be incredibly disheartening, especially for the patient. I know this from personal experience.

A close family friend of mine suffered from hip pain and probably should have had hip surgery years ago. She started with over-the-counter pain relievers, but then eventually transitioned to prescription pain medication. At first physical therapy helped, but eventually she relied on a cane to walk and significantly cut back on what had been a very active lifestyle.

Stories like hers are why I’m an advocate for the broad use of shared decision-making (SDM) tools as a model for patient education and engagement in their care plans.

Shared decision-making is a process of open communication between patients and their clinicians, where physicians are encouraged to take time to understand patients related personal needs, concerns and circumstances that could affect choices of treatments, recovery and overall health. In this model, clinicians help inform patients about treatment options available to them and empower patients to play a role in healthcare decisions.

The value of shared decision-making is that “in collaboration” with their doctor, patients can make choices that are clinically and personally appropriate for them, which might also be the most cost-effective option. Interestingly, SDM also creates a greater sense of patient accountability. Not just for selecting the appropriate treatment, but by informing them of actions they can take to optimize their outcomes: should I have the minimally invasive approach instead of open surgery? What are the pain management options? How can I optimize a better outcome? What can I do to prepare? Lose weight? Exercise? Shower before surgery? (Yes, this really could make a difference.)

Some skeptics express concern that shared decision-making may result more often in patients self-diagnosing, postponing treatment or selecting less optimal care pathways. Instead, there is a huge opportunity for providers to enhance their relationship with patients by empowering them with information from trusted sources. SDM also allows physicians to feel confident in the care they prescribe.i

With the proliferation of high-deductible health plans and higher out-of-pocket costsii, some patients are embracing their role as smart consumers, seeking greater levels of care customization and seeking out information on the best and most affordable courses of treatment. Shared decision-making offers many of the tools and resources needed to support consumers along the way.

While there’s still a way to go with shared decision-making, the Centers for Medicare & Medicaid Services (CMS) recognizes it is a critical part of the process in improving quality of care and holding down costsiii. Currently, CMS provides health coverage for 100 million Americans and has two beneficiary engagement and incentive models: SDM and Direct Decision Support (DDS). CMS is planning to offer two SDM Models this year.

The first CMS model requires providers to integrate a structured four-step shared decision making process into the clinical practice of participating Accountable Care Organizations (ACOs); health systems that have voluntarily agreed to work together to provide high quality−key word here: coordinated−care to their Medicare patients. The four-step process includesiii: identifying eligible beneficiaries, distributing patient decision aids (PDA) to eligible beneficiaries, furnishing the shared decision-making service, and tracking and reporting the results. Episode of care areas include hip and knee osteoarthritis and stable ischemic heart disease. The SDM Model will pay participating ACOs $50iii for each SDM Service furnished by its SDM practitioner if all SDM activities are completed.ii

The second CMS Model−Direct Decision Support (DDS)−tests SDMiii outside the clinical delivery system by an organization that provides health management and decision support services. Throughout 2017, CMS plans to partner with up to seven Decision Support Organizations (DSOs) to provide direct decision support to 700,000 beneficiaries annually. Engaged beneficiaries will interact with decision support mechanisms such as web-based PDAs and tools, telephonic decision support and/or mobile e-health applications. The same disease states and similar incentives will be used.

In my work at Johnson & Johnson Medical Devices Companies, I am part of a team committed to empowering patients and expanding their access to treatment options. For example, our Health Partners app and Digital Care Navigation offeringIV, part of CareAdvantage, give patients valuable information to assist with their treatment decision which may include surgery. The Digital Care Navigation information provided to the patient has been vetted by their physician and the platform enables bi-directional communication as well.

If my family’s friend had understood all the choices, benefits and tradeoffs, she told me she would have opted for hip replacement surgery. By the way, she did finally have that surgery, and less than a year later, had her other hip replaced, too. She laments a little about the ‘shoulda, woulda, coulda’ of the years lost to chronic pain. But, she is literally stepping forward now with a bus trip to Washington, D.C., that includes walking the steps of the Lincoln Monument. And her cane? Now retired to the closet. No more “shoulda, woulda, coulda” for her.

i https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-12-08-2.html
ii https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/CMS-Quality-Strategy.html
iii https://innovation.cms.gov/initiatives/Beneficiary-Engagement-SDM/
ivCareSense, provided by MedTrak, Inc., a third-party vendor, is a cloud-based platform designed to help hospitals engage, educate, communicate, and guide patients through their episode of care.

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