If shared decision-making is what some have termed the "sleeper provision" of the Affordable Care Act, it certainly is awake now. It's the newest movement in a quickly converging line-up of ideas streaming toward a value-based delivery system.
Shared decision-making is a quality measure for accountable care organizations in the Medicare Shared Savings program, and the National Committee for Quality Assurance deems it a criterion for patent-centered medical home recognition. And many think of it as a key cornerstone in patient engagement.
As in many cases in health care, shared decision-making isn't new. It's been lying in the weeds quietly growing, waiting for the right time to re-emerge. Its roots trace back to the 2001 report, "Crossing the Quality Chasm" by the Institute of Medicine, which emphasized shared decision-making in the 10 rules for redesigning health care processes. And those of us who are getting on up there, as they say — I mean in collective wisdom not age, of course — remember that it dates back to 1989 when John Wennberg, M.D., co-founded the Informed Medical Decisions Foundation at Dartmouth-Hitchcock Medical Center. (And if anyone knows how long it takes for new ideas to take hold in health care, it's Dr. Wennberg.)
Just to make sure we are talking about the same concept: Shared decision-making is a collaborative process in which patients and providers make health care decisions together, weighing the medical evidence of various options and considering the patient's values and preferences. Written materials, videos and other educational aids are used to help patients learn about and evaluate their treatment options. It is most germane when discussingin problems or conditions wherefor which there is no "gold standard" of treatment. Experts say that about one out of every three medical decisions has two or more clinically appropriate treatment options. Some examples include low back pain, early-stage breast cancer and prostate cancer, and hip and knee arthritis.
Shared decision-making weighs in on the value-based side because when patient preference is followed, many opt for less-intensive, less -costly treatments and report higher satisfaction levels with their care. Research numbers back this up. The New England Journal of Medicine reports that as many as 20 percent of patients who participate in shared decision-making choose less -invasive surgical options and more -conservative treatment.
Just as a reminder that no initiative applies just to us, Big Business is interested, too. The Robert Wood Johnson Foundation is actively educating employers about the concept, its benefits to their pocket book and their employees. The foundation is working with the National Business Coalition on Health, which represents about 7,000 employers and mucho dollars in health benefits. The trick for employers is to encourage participation in the process while staying far, far away from the employee's treatment decisions.
Certainly, complex obstacles abound, but some seem more simpler. Many physicians — even after training programs and retraining programs — thinkthey are practicing shared decision-making when they are not. And patients report that they feel informed even when they can't repeat the most basic information. Ah, human nature. It will be the undoing of us all.
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