News Release

Adding Patients to the Decision Equation

WASHINGTON, D.C. –– While evidence suggests that patients’ medical decisions in the United States, even momentous ones, are seldom well informed, greater use of shared decision making between clinicians and patients might help bridge the gap between the care patients want and the care they actually receive, according to a new Policy Analysis from the nonprofit, nonpartisan National Institute for Health Care Reform (NIHCR).

Written by researchers at the Center for Studying Health System Change (HSC) and Mathematica Policy Research, the policy analysis describes shared decision making (SDM), explores SDM’s potential role in improving the quality of care; reviews challenges to more widespread use of shared decision making; and identifies a range of public and private policy options that could foster shared decision making.

“Shared decision making involves patients and clinicians…making health care decisions in the context of current evidence and a patient’s needs, preferences and values. SDM typically is used for preference–sensitive conditions, or common health problems for which scientific evidence demonstrates more than one medically acceptable treatment option. Some examples of preference–sensitive conditions include low–back pain, early stage breast cancer, benign prostatic hyperplasia, and hip or knee osteoarthritis,” according to the analysis.

“However, barriers exist to wider use of shared decision making, including lack of reimbursement for physicians to adopt SDM under the existing fee–for–service payment system that rewards higher service volume; insufficient information on how best to train clinicians to weigh evidence and discuss treatment options for preference–sensitive conditions with patients; and clinician concerns about malpractice liability. Moreover, challenges to engaging some patients in shared decision making range from low health literacy to fears they will be denied needed care. Adding to these challenges is a climate of political hyperbole that stifles discussion about shared decision making, particularly when applied to difficult end–of–life care decisions,” the analysis states.

The Policy Analysis—Policy Options to Encourage Patient–Physician Shared Decision Making—is available here
and was written by Ann S. O’Malley, M.D., M.P.H.; Emily Carrier M.D., M.S.C.I., an HSC senior researcher; Elizabeth Docteur, M.S., formerly of HSC and now an independent consultant; Alison C. Shmerling, a former HSC research assistant; and Eugene C. Rich, M.D., senior fellow and director of the Center on Health Care Effectiveness at Mathematica Policy Research.

“The 2010 health reform law established a process to encourage shared decision making, including setting standards for patient–decision aids and certification of these tools by an independent entity. However, Congress has not appropriated funding for these tasks. Along with ensuring the scientific rigor and quality of patient–decision aids, liability protections and additional payments for clinicians are other policy options that may foster shared decision making. In the longer term, including SDM as an important feature of delivery system and payment reforms, such as patient–centered medical homes, accountable care organizations and meaningful use of health information technology, also could help advance health system changes to improve care and contain costs,” according to the analysis.

Potential policy options to encourage shared decision making fall into three main areas:

  • Reducing Barriers to Clinician Participation. Lack of reimbursement, lack of training and information on best practices, and fears of malpractice liability all present obstacles to clinician adoption of shared decision making.
  • Engaging Patients. Providing access to patient–decision aids, using patient financial incentives and defusing political sensitivities are all possible avenues to engage and encourage patients to be more involved in treatment decisions.
  • Building Shared Decision Making into Systems of Care. Reforming provider payment to move away from fee for service, identifying effective ways to engage providers and patients, and using health information technology are all possible ways to foster shared decision making.

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The National Institute for Health Care Reform (NIHCR)is a nonpartisan, nonprofit 501 (c)(3)organization created by the International Union, UAW; Chrysler Group LLC; Ford Motor Company; and General Motors. Between 2009 and 2013, NIHCR contracted with the Center for Studying Health System Change (HSC) to conduct high-quality, objective research and policy analyses of the organization, financing and delivery of health care in the United States. HSC ceased operations on Dec. 31, 2013, after merging with Mathematica Policy Research, which assumed the HSC contract to complete NIHCR projects.