Shared Decision Making

A recent Journal of the American Medical Association commentary highlights use of shared decision-making between patients and physicians for certain illnesses or conditions which have multiple acceptable treatment modalities.  (JAMA, vol. 301, p. 2539, 6/24/2009)  The long-standing research suggesting significant variation in treatment and spending patterns in different geographic areas has spawned a variety of explanations, one of which is that where there are choices in treatment, known as preference-sensitive conditions, some physicians will tend to select higher cost, more intensive care delivery.  One potential solution is to ensure that the patient is more informed about the alternatives and require the physician to consult extensively with the patient in selecting a treatment.  When this happens, patients appear to select the more conservative, less costly option more frequently than the physician alone, and are more satisfied with their care.  Outcomes are the same.

While such consultation appears very desirable on its face, it rarely happens.  Studies show that less than 10% of the time patients are involved in consultations that meet the criteria for shared decision-making.   Believing that it has the potential for significant cost savings and better patient satisfaction, Washington state passed a law in 2007 mandating a demonstration project to assess shared decision-making for certain illnesses.  Other states are considering  legislation to require  use of shared decision-making, in some cases specifically for government employee plans and Medicaid.  Senator Ron Wyden has proposed similar legislation at the federal level.

This appears to be one of those areas which all parties could agree on as both a quality improvement and a cost saving method.  Some physicians have expressed fears over loss of control and others believe the extra time shared decision-making takes will cost them revenue.  The latter objection can be fixed with reimbursement changes and the former is inconsistent with fundamental principles of informed consent and delivery of care that accords with a patient’s values.  Shared decision-making is consistent with the objective of having consumers more engaged in, even in charge of, their health care and we should hope that any federal reform includes its mandated use.