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Patients who indicated a strong preference for involved decisionmaking incurred healthcare costs that were 6% higher.

Shared decisionmaking may spur higher costs, longer hospital stays: researchers

By Maureen McKinney
Posted: May 27, 2013 - 3:00 pm ET

Engaging patients in their care is often touted as a surefire way to control costs and reduce utilization of services, but new research calls that assumption into question.

Armed with eight years of survey data from more than 20,000 patients, researchers from the University of Chicago argue that shared decisionmaking may actually result in increased inpatient spending and longer lengths of stay.

According to the study, published today by JAMA Internal Medicine, patients who indicated a strong preference for involved decisionmaking—based on their level of agreement with the statement, “I prefer to leave decisions about my care up to my doctor”—incurred healthcare costs that were 6% higher, or an average of $865 more per hospital stay. Their lengths of stay were also about 5% longer.

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“Lots of people, including me, believe that engaging patients will improve health outcomes and satisfaction,” Dr. David Meltzer, chief of hospital medicine and an associate professor of economics and public policy at the University of Chicago, and a co-author of the study, said in an interview. “People have extended that idea to mean that it also lowers costs, and that's not so clear.”

One reason why shared decisionmaking might not lower costsamong hospitalized patients is the prospective payment system, Meltzer said. Unlike fee-for-service environments, such as physician offices, hospitals have a payment structure in place that can incentivize more careful use of resources. Higher-level patient involvement, in that scenario, could lead to increased costs, he said.

And as the healthcare system moves toward a new system of capitation, spending will be controlled in other ways, Meltzer said, adding that shared decisionmaking shouldn't be thought of within a framework of cost control.

“This research will help us set expectations,” he said. “Empowering patients probably won't decrease costs, but it will do lots of other things that are very important.”

Meltzer's comments echoed the views of some patient- engagement experts who cautioned that shared decisionmaking should not be viewed as a financial strategy.

“If an organization engages in shared decisionmaking to look good, make more money, save money or improve outcomes, they may be disappointed,” Dr. Victor Montori, director of the Health Care Delivery Research Program in the Mayo Clinic Center for the Science of Health Care Delivery, Rochester, Minn., said in a January e-mail. “Shared decisionmaking is a manifestation of your commitment to the patient.”

But Dr. Mack Lipkin, professor of medicine at New York University and an attending physician at Bellevue Hospital, New York, found fault with the latest study's conclusion, arguing that patient preferences were subtle and nuanced, and not able to be captured accurately by a single survey question.

“Their methods leave me uncertain as to what is actually being measured,” said Lipkin, who wrote an accompanying commentary in the journal. “What people say on a questionnaire and what they prefer are not the same thing. When patients and doctors agree, there's more likely to be a coherent plan and adherence to treatment, and that is likely to reduce costs.”

Follow Maureen McKinney on Twitter: @MHMMcKinney

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