Providers have concerns over how they would get paid and budget their time under an emerging model of care that lets patients take a more active role in deciding their treatment. The concept, known as shared decisionmaking, is supposed to offer patients the chance of becoming more informed consumers and active participants in their care, with the goal of improving quality.
Sharing in caring
MedPAC examines dual-decisionmaking concept where patients take active role
The Medicare Payment Advisory Commission took a look at the concept last week as a possible avenue to explore for Medicare, though some commission members questioned whether it will work without added reimbursement for physicians. And, it would eat up a precious commodity that primary-care doctors always fall short of: time.
The issue was addressed because of the need to narrow the gaps in the provider-patient relationship, Joan Sokolovsky, a principal policy analyst with MedPAC, told commissioners. Patients goals in making treatment decisions are not always what the provider assumes, she said. Both parties often identify very different goals in choosing a treatment option, with the patient focusing more on benefits and harm and the provider tending to focus more on the pros of a treatment decision.
The shared decisionmaking model aims to improve decision quality and reduce unwarranted variation in care, Sokolovsky said. The concept has been used at 361-bed Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and 907-bed Massachusetts General Hospital, Boston, and is being pilot-tested in Washington state at multispecialty group practices.
Some commissioners were buoyed by the idea of patients taking on a more self-sufficient role in their care. I think its a good thing to have more informed patients who will be able to engage with physicians on treatment options, said MedPAC Chairman Glenn Hackbarth.
Others were concerned about the extra time it would require of primary-care physicians. I dont know how this would fit into fee-for-service. Theres no compensation for this, said MedPAC Commissioner Ron Castellanos during the meeting. Kate Clay, director of the Center for Shared Decision Making at Dartmouth-Hitchcock Medical Center, which has been in operation for 10 years, claims the program has been successful in diffusing patient anxiety and creating more informed patients by showing instructional videos to the patients prior to meeting with the physician to discuss treatment. Videos for patients with breast cancer, for example, talk about the disease and all of the treatment options, featuring patients who have made different types of decisions on their treatment, Clay said. While doctors dont want to be replaced by a video, this initial tool sets the stage for a much richer conversation between the patient and doctor, she said.
Concerns exist, however, that the additional time that shared decisionmaking would require may disrupt the flow of an office practice. Sokolovsky acknowledged that its not necessarily appropriate for all types of patients and circumstances. As an example, shared decisionmaking would not be useful in an emergency situation, where the patient may not be coherent.
Richard Roberts, professor of family medicine at the University of Wisconsins School of Medicine and Public Health in Madison, said that shared decisionmaking tends to work best with larger, more momentous decisions, such as whether to have back surgerya case in which there would be enough data on the various treatment options available. For the smaller, more ongoing or recurring issues that patients deal with every day, its not going to be as useful a tool.
To reduce office disruption and save time, Roberts said that patients could take materials home with them, such as interactive video disks, to help them make informed decisions about their care.
Castellanos suggested that the practice be tested within the context of the medical home, where elementary patient care could be delegated to nurse practitioners, freeing up more time for the physician to engage in a shared decisionmaking relationship with the patient. Shared decisionmaking should also be supplemented with other patient-centered tools, such as an advance directive, Castellanos said. A health surrogate to the patienta friend or relative to speak on behalf of the patientwould also be beneficial in the event the patient ends up in the hospital and is incapacitated, he said.
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