Q&A: 'We have to involve patients in decisionmaking'

The Lown Institute is named after 95-year-old Dr. Bernard Lown, who helped develop the first widely used cardiac defibrillator in the 1950s and founded International Physicians for the Prevention of Nuclear War, which won the Nobel Peace Prize in 1986. The institute in Brookline, Mass., champions his idea that doing as much as possible for the patient can also mean doing as little as possible to the patient. Dr. Vikas Saini, president of the Lown Institute, spoke with Sabriya Rice, who recently left Modern Healthcare to join the Dallas Morning News, about the group's work. The following is an edited transcript.

Modern Healthcare: Do you think most clinicians see overuse as a medical error?

Dr. Vikas Saini: The challenge is in labeling something as unequivocally being overuse. Once you do that, almost all clinicians would say, if they agreed, “Oh, this wasn't necessary.” But the question is harder because labeling something as overuse takes a lot more examination. So much of what we do in healthcare has a very modest, if any, basis in hard scientific evidence. Much of it is opinion. There's nothing wrong with expert opinion. But we shouldn't pretend that it is science the way 2+2=4 is a truth. The majority of care is in a gray zone and that is why it's not straightforward. So getting agreement that something is overuse is the challenge. We need a lot more research; we need a lot more understanding of how these decisions are made; we need a much clearer and better understanding of what the incentive structures are, what the evidence is, and how those can interact. Because so much care is not based on hard science, we have to include and involve patients in the decisionmaking. You can't have right care for the vast majority of what we do unless the patient really understands and not just consents, but understands why and how to move forward with a particular test or procedure.

MH: Can you explain what the term “right care” means?

Saini: Overuse and underuse are often happening in the same city, often in the same hospital, and, amazingly, often in the same patient. You can have an overuse of unnecessary blood tests, technology, X-rays, even unnecessary procedures. And in the same person we can have under use of listening to what their real concern was, why they really came, and addressing that. The term “right care” (means) we have to strive for something that is efficient, affordable, not wasteful, faithful to the patient's own goals and wishes for life and health, and in all of that be aware that our decisionmaking matters, both to the individual patient, and more broadly, to all of us in society.

MH: How do you get that information into the patient's hands, into the practitioner's hands, so that everyone's on the same page when that patient comes in for care?

Saini: It's very difficult to get all those pieces of information into the patient's hands. That's asking a lot of patients. It's why we went to medical school. It's why we went to nursing school. We're supposed to have a lot of that information. The real strength of the “Choosing Wisely” initiative has been clearly establishing the principle that there's a lot we do for which there's no evidence and there's no benefit, and so if you do it, you're only asking for harms. You're only asking for either complications or side effects, or waste of money. The broad question is how do we deliver the right care? We came up with close to two dozen or more drivers (of inappropriate care). And these drivers act in complicated ways.

MH: How?

Saini: Some of it has to do with habits. Some of it has to do with local culture. Some of it has to do with poorly understood science or, actually, biased science. There's a certain amount of fudging or slanting of interpretations in the data because a lot of money is involved. So, in many ways, with all of that going on with all of these drivers, our own view is that to get to the place where you make the right decisions is as much a matter of reimagining and rejuvenating the relationship between clinician and patient. (It means) really establishing an attitude or a style of care as much as a series of things you should check off. You need both. But our view is you definitely need that point of view and that style.

MH: Do you think the Affordable Care Act has done enough in this area? There's been a push for more comparative effectiveness research, value-based payments and incentivizing the right care. What else is needed?

Saini: I don't think it's done enough. It's had a few modest initiatives and they certainly are beginning to move many healthcare institutions in the right direction. But a big part of what's happening with the ACA is that the affordability of insurance on the exchanges depends on a mechanism of high copays and deductibles, which means that patients are being put in the position of having to figure out whether the extra cost to them for any given visit or test or procedure is worth it. I don't think our patients and communities really have enough knowledge and understanding to make that decision. I think it's unfair to do it that way. There is a theory that if people have skin in the game, they will make better choices. In healthcare that may be true, but it's true at the margin if you have the leisure of thinking about it. “I'm not feeling that bad, and they said I need an MRI and maybe I do and maybe I don't. But let me shop around and find the right place.” First of all, you can't get the prices, so the ability to shop around is limited. Second, even if you could, the number of cases in healthcare that operate in a way where “skin in the game” would make a difference is really, really small. Too much of what we do and the kind of interactions we have and the kind of decisions patients have to make, they're not equipped to do. So what we're really doing is shifting the cost. Certainly aligning payment incentives is a help. But we can't succumb to magical thinking that by aligning payment structures things will get better.

MH: Besides financial incentives, what else could have that impact?

Saini: Part of the problem is that you can have too much care and you can create financial disincentives for that. You can have too little care and you can create financial incentives to improve that. But reconciling those two is not obvious. While it's true that financial incentives will change behavior, finding the sweet spot, the exact balance, or figuring out what's the right financial incentive structure for “the right care,” is not at all obvious. I have seen many settings where the incentives to avoid unnecessary care led to not giving appropriate care. So, it has to be done carefully; it has to involve patients and communities; it has to involve the clinical community. I'm not saying it's not possible, I'm saying that it is a huge challenge and I think the small efforts we've made really need to be amplified a hundredfold.