Obamacare’s “shared decision-making” rules take money from docs without helping patients

2:38 pm by | 2 Comments

This week's New England Journal of Medicine contains a perspective piece by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. entitled "Shared Decision Making to Improve Care and Reduce Costs." The original paragraph of the piece sets the tone:
"A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there's not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients' preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option's outcomes, including benefits and possible side effects; the health care team's skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.
However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs."
What a nice, lovely, fuzzy bunny. Who couldn't want such "shared" decisions in complex medical care? Especially nice simple teaching aids for Medicare's top 20 procedures printed at the "8th grade level" that are "brief?"

Doctors, don't you know that this will become simply another box to check on your EMR for Medicare reimbursement?
And yet the benefits of cost savings that these "shared" decision making tools' will have on health care are assumed, especially when deployed nationwide, despite what the authors claim. Note that the 2011 Cochrane Collaborative review of the 86 studies they reference said nothing about cost savings.

Doctors know this and so do the authors.

Why else would the authors require a cudgel to impose their "shared" decision making benefit if other real life clinical doctors fail to follow along?
"Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."
Ms. Lee and Dr. Emanuel, in their zeal to impose their Progressive mindset upon America's physicians have forgotten several important tenets of health care delivery:
  • First, decisions made in medicine are each unique to a patient's constellation of medical problems, socioeconomic and cultural background, age, gender, religious beliefs, etc. In other words: decisions are made in concert with an individual's situation, and not based on the government's desire (necessarily) for cost savings (even if it is couched in euphemisms such as "shared decision making").

  • Second, actual cost information (both out-of-pocket and real health care system costs) for patients and doctors will remain shrouded in secrecy since payers rely on obfuscation of actual cost information to extract their portion of fees before patients receive any value for their dollar. Also, other similar pay-for-performance measures have already uniformly flopped at demonstrating cost savings. Then imagine for a moment if the cudgel for shared decision making is imposed. The potential for a 10-20% Medicare physician fee cut on top of a 30% Sustainable Growth Rate cut that is likely to reappear in 2014 will be untenable for US physicians.

  • Third and very importantly, the ACA legislation has created a whole new "institute" of salaried individuals within government called the Patient-Centered Outcomes Research Institute (PCORI) to develop the authors' soon-to-be-mandated decision aid materials while another branch of government already exists to produce such education aids called the Agency for Healthcare Research and Quality (AHRQ). Wouldn't our health care system benefit far greater from cost savings by not duplicating services already performed by another government agency? How much, exactly, will the PCORI cost us?

  • Fourth, the push to re-invigorate the mass-production of physicians via three-year medical school curricula while simultaneously failing to increase residency slots assures poorer trained, inexperienced doctor-patient discussions about complicated medical issues, not better ones. Shared does not mean better.

  • Finally, liability risks remain for doctors caught in these unenviable mandates that fail to recognize the individual complexities of an individual patient's care. Until doctors sense a modicum of effort for liability reform, they will continue to offer care that exposes both themselves and their patient's to the path of lowest legal risk, irrespective of what teaching aids they give to patients.

Doctors and the AMA should demand transparency in the cost of creating and funding the PCORI and its shared decision making materials, yet another layer in the runaway middleman health care behemoth emerging as the front lines of health care delivery are systematically decimated.
If that doesn't matter to all of us, then share away.

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Westby G. Fisher, MD

By Westby G. Fisher, MD

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005. He writes regularly at Dr. Wes. DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.
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When is the last time a patient without serious mental illness demanded to be kept awake during surgery, watch the surgery via live via video camera and came to a shared decision with the surgeon about the specifics of every instrumentation maneuver the surgeon was to perform prior to performing it?  Is Medicare planning on docking surgeons' fees if they don't?  Why are cognitive services and not procedural services fair game for this type of interference?  It takes just as much training and experience to provide either type.

Rational Patient
Rational Patient

Dr. Fisher - You make some excellent points. SDM is an academician's approach to solving healthcare, especially when it relies solely on the use of decision aids (as it is defined by the ACA, Dartmouth Institute, Foundation for Informed Medical Decisions, and PCORI). And yet it fails to jump the chasm to mainstream clinical practice because it can't without active buy-in from both physicians and patients. Informed, engaged patients can help optimize both care decisions and outcome improvements, but the current approaches to SDM you refer to are wholly inadequate for helping physicians and patients get there. In addition to what you outline, SDM does nothing to integrate with the underlying behavioral and financial incentives, yet makes big assumptions on its cost savings potential. PCORI can beat its drum all day but it won't get anyone to adopt SDM until it aligns with those. Great piece.