The Cost of Assuming Doctors Know Best
The success of a hospital system in Washington state should be a strong signal that patient decision aids are powerful quality-improving, cost-cutting tools.
The success of a hospital system in Washington state is a strong signal that patient decision aids are powerful quality-improving, cost-cutting tools -- but change is stalled by bad financial incentives.
In most industries, quality-improving and cost-cutting innovations don't sit around for years while people keep muddling through with old technology. When an innovation is ready for widespread use, it disrupts the market, whether the market wants it or not. In the process, some entrepreneur usually makes a killing.
That process hasn't worked in healthcare, though -- and because of that, we have a whole set of rarely-used innovations that are ready for large-scale implementation, and that could start saving money today. Those technologies include simple things like broader use of generic drugs, which can reduce pharmaceutical costs significantly; and better hand washing, which reduces the transmission of disease within hospitals and doctor's offices. They also include more complicated interventions like Lean management, which has been implemented successfully at hospitals like Virginia Mason Medical Center in Seattle and Thedacare in Wisconsin, to make their care processes more efficient by cutting out useless steps.
Then there's shared decision making, which helps patients be better informed about their treatment choices and make better decisions -- and might be the most promising of the bunch in terms of improving care and reducing spending.
Shared decision making is a way of dealing with the tough questions posed by "preference-sensitive conditions" -- conditions where there are multiple treatment options, and none of those options is clearly better than the others. That includes conditions like arthritis in knees and hips, low back pain, stable angina (chest pain from heart disease), and early-stage prostate and breast cancer. (Obviously, it doesn't include emergency conditions like heart attacks and hip fractures, or conditions where there is clearly only one treatment.)
Deciding on a treatment for preference-sensitive conditions involves weighing a variety of risks and possible benefits, and different patients will end up making different "right" decisions because they have different values and preferences. The best example here is women with early-stage breast cancer. They can choose lumpectomy (surgery that preserves the breast) or mastectomy (which removes it entirely). The two options are equally good in terms of reducing the risk of dying of breast cancer, but they require different kinds of follow-up and different women prefer one over the other.
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Making such decisions means that patients must have the relevant information about all their treatment options, and doctors must understand their individual patients' preferences -- basically, what they want from treatment. But too often, patients only hear about one treatment option, the one the doctor usually uses -- and doctors routinely assume they know what their patients want without actually asking them. And in many cases, the doctor is wrong.
This habit of assuming the doctor knows best has created a system where huge numbers of patients aren't getting the treatment they would have chosen if they were fully informed. It also means that hundreds of thousands of patients are going through surgery that wasn't really worth it, and that they wouldn't have chosen had they understood their options.
Shared decision making is a process designed to ensure that patients are fully informed, and then use that information to get the treatment they want. A common though non-essential part of informing patients is a "patient decision aid." Decision aids can be videos, websites, or pamphlets, and they present the available medical evidence on all reasonable treatment options -- including the option to do nothing -- in a way that patients can understand. Decision aids also help patients understand what they value and how much risk they're willing to accept. Doctors can participate in the process, too, by clarifying things for the patient and helping make sure there's a good match between the treatment and what the patient wants.
There have been more than 80 randomized controlled trials on the effects of patient decision aids, and the results are pretty clear. According to the Cochrane Collaboration, which reviews groups of studies, using patient decision aids improves the match between patients' preferences, improves patients' knowledge of the possible results of treatment, and reduces the number of patients who still don't know what they want.
Here's the icing on the cake in terms of health care spending: Patients also tend to choose less invasive (and therefore less expensive) treatment options.
Even after those impressive results, shared decision making hasn't reached universal adoption. One reason may be that randomized control trials aren't always able to be generalized to medical practice as a whole. In theory, they're the scientific gold standard for measuring effectiveness, but the environment of the trial can sometimes skew the results (because patients or doctors in trials are different from their real-world counterparts, or because people behave differently when they're being watched).
But a new study from a hospital system in Washington state should be a strong signal to other hospital systems that implementation is possible, and shared decision making and patient decision aids are just as powerful as we expected them to be. Soon patients will understand their effects, and hospitals that don't use decision aids risk getting left behind.
The Washington legislature recognized back in 2007 that decision aids are a valuable tool for improving medical care by helping patients make better decisions. They passed a law providing greater legal protection to providers who use shared decision making, rather than standard informed consent, and that law required the state to study the effects of shared decision making. As part of that study, Group Health Cooperative (an integrated insurer and hospital system) gave all 660,000 of their patients access to decision aids when they were considering any of a dozen preference-sensitive treatments. They also made all of the doctors and staff watch the decision aids, and kept physicians informed of how many of their patients were choosing surgery.
The results were striking. The paper, published in the September edition of Health Affairs, covers two orthopedic procedures -- knee replacement and hip replacement for arthritis of those joints. During the year and a half immediately after they introduced the decision aids, rates of hip replacement fell over 25%; knee replacement went down 38%. Total spending went down 21% on patients with hip osteoarthritis and 12% for knee patients -- not just on those patients who skipped surgery, but for the whole study population. That amounts to well over $1000 a year in true medical savings -- money that can be spent on something else entirely, and isn't just shifted from one payer to another.
Allow us to reinforce something from that last paragraph: over a quarter of patients were choosing not to have surgery once they were better informed. Looking at that one way, it's great news: We can save a ton of money and make patients better off, just by doing a better job of targeting elective surgery. But it's also a vicious indictment of our current practices: every day we continue not using decision aids, our medical system knowingly puts patients at risk of a wrong-patient error.
If shared decision making is so wonderful, why aren't we already using it in every hospital and every doctor's office?
The answers are neither satisfying nor pleasant. The most important reason should be obvious: the way we finance healthcare is set up to reward doing more, rather than doing good. This is particularly the case when it comes to elective surgeries. Group Health was able to make money by using decision aids to improve care, because they're an integrated insurer and delivery system. When patients spend less on unwanted surgery, Group Health doesn't lose money. Similarly, all Group Health physicians are salaried, so their surgeons get paid the same amount whether their patients get lots of surgeries or not. Most healthcare organizations don't work that way, though--doctors and institutions get paid based on some form of fee-for-service, meaning they take in more money when they do more procedures.
Changing that payment system will be tough, but it needs to be done, because fee-for-service payment isn't just making us spend more money than we need to for good care -- it's actually making our medical system worse.
Shared decision making isn't the only technology being held up by bad financial incentives. Lean management, as we mentioned earlier, has been incredibly successful in reducing both process waste and overuse in a number of hospital systems across the country. But the payment system still forces systems that eliminate duplicative tests and unnecessary treatments to risk losing needed revenue. It's much easier to continue over-treating patients, and continue getting paid to do it. We need a system that rewards entrepreneurs for eliminating waste as well as it rewards them for giving us new options. We're not taking full advantage of the technology we have until we only use it where it works.