Tuesday, June 9, 2009

Medicare Reform Part 1 - Shared Decision Making

I've just gone through the myths of health care reform (so used to twitter I almost wrote #hcreform) and established that we need reform to increase choice, because right now we have socialized medicine.

There is a form of healthcare in this country that is single-payer, and it works (for the most part...). It is Medicare. And it is a behemoth; growing larger and more expensive by the day, yet unsustainable for physicians and hospitals to survive on the pittance of payments they receive relative to costs of treatment.

Clearly Medicare has problems and should not be the model of health care reform in this country. Certainly not in its current form. I have many suggestions on how to reform Medicare. Some are new ideas of my own. Some are ideas that are out there already.

First, I'd like to bring up a topic that is gaining a lot of traction, and something I only just learned about myself. It is called shared decision-making (SDM), and it is the new wave of health care cost reduction mechanisms that will soon impact how many physicians practice medicine. And it is not necessarily a bad thing.

First, I will go back one step:

Medicare, and by definition any Universal Health Care plan, suffers under the weight of cost pressures. We all know that Medicare is going to run out of money if something doesn't change. The same problems that plague Medicare will derail Universal Health Care. Unfortunately, the words "cost control" sound an awful like "rationing."

In my experience, controlling costs tends to mean restricting access to needed care, and cutting payments to providers of care (while increasing their paperwork, workload, and requirements). So I tend to be skeptical of a government push for cost controls.

However, there are some interesting patters that have been discovered that warrant discussion. Bear with me, I'll explain how the term "shared decision-making (SDM)" fits in shortly.

While Medicare has experience growth year after year above the national inflation rate, that is an average number, that according to the data compiled by the Dartmouth Atlas Project there is a wide variability of growth throughout the country, and in many cases neighboring cities and towns have dramatically different utilization rates (see map).

What the Dartmouth Atlas Project discovered (highlighted recently by testimony of Jonathan Skinner PhD to the Committee on Energy and Commerce, US House of Representatives, April 2, 2009), was that Medicare beneficiaries in higher spending regions are hospitalized more frequently for conditions that could be treated outside the hospital: i.e. for serious chronic illness, the frequency of physician visits is nearly twice as high in Miami as in San Francisco.

And yet, the Dartmouth brief, "Health Care Spending, Quality, and Outcomes: More isn't always better" demonstrates based on a number of studies over the past ten years, remarkably consistent results - higher spending does not lead to better quality of care, in fact, it is often worse.

There are certain conditions where the evidence is clear, and there is no dispute as to treatment, i.e. hip fractures in elderly patients need to be repaired. And Medicare spending on conditions like this are constant amongst all regions of the country.

There are also many conditions where the evidence is less clear, and there are many options as to how to treat, some more invasive, some more conservative. Individual doctor preference decides which option is pursued - hence the term given "Preference-Senstive Care." Examples of these types of conditions are chronic stable angina, hip osteoarthritis, claudication, carotid stenosis, herniated disc, and early stage prostate cancer. Thus, spending rates on these conditions varies tremendously.

The typical doctor-patient interaction is paternalistic, that is, the doctor makes the treatment decision and the patient usually goes along with that since "doctor knows best." But there is a growing movement to change this interaction to more of a collaboration where the doctor explains the diagnosis, the possible treatment choices, gives them materials that are from evidence based medicine (EBM) [note: we doctors love our acronyms...] to explain everything in terms they understand, and then ask the patient to make the treatment decision. The doctor can still give their opinion as to what they feel is the best course, but it is the patient who ultimately decides - i.e. medical management for herniated disc versus surgery.

Currently, if a surgeon wants to do a procedure on a patient, there is informed consent: The physician discusses the risks, alternatives and benefits of the procedure they feel you need. In other words, the treatment is already determined. In SDM (you knew I would finally get back to my topic, however circuitous the route), the physician gives out standardized materials that inform the patient on the current evidence of all treatments, then asks the patient their concerns and works with the patient to come to a treatment decision. The patient then signs a form accepting responsibility for any decision that was made, i.e. it is possible to have shorter survival from medical treatment for angina, and a patient picking that treatment choice would have to accept those risks.

As it turns out, when patients are given the decision-making ability, they typically choose the less invasive route. And this saves a lot of money to the health care system (Medicare in particular). Thus, there is a big push to roll out this new perspective on medicine, and Washington State is the first to enact this. While it would seem that only educated patients would benefit from SDM, a VA study showed that patients with less education were surprised to know that they had a choice in care. Patients are happy with this new model, which saves money, and protects the physician in the case of a bad outcome.

However, as someone who also writes on medical malpractice issues (www.epmonthly.com), I can immediately come up with a number of scenarios that could place a physician in legal jeopardy. I frequently encounter patients who are technically competent but experience poor judgment. If they are allowed to use their poor judgment to make a decision that leads to a bad outcome, could the physician be sued for "knowing" that a patient was making a bad choice? The law in Washington seems to be structured so that physicians are protected from bad patient choices. But a bill recently introduced by Congressman Earl Blumenaur (D-OR) H.R. 2580 "Empowering Medicare Patient Choices Act" does not seem to have any such legal protections. This bill establishes a pilot program that will take four years to fully assess whether this methodology would be a good choice for all of Medicare. Without significant medical malpractice reform, or protections from liability for patient decisions, I fear that physician acceptance will be low

But personally, I like a model that allows a team approach, educates patients better, and makes them feel empowered, and (if done as in Washington State) releases the liability for a decision from the physician and transfers it to the patient. Plus, it helps slow the growth of Medicare, and if applied to Universal Health Care Reform, could be an essential cost-control measure that is a win-win for everyone.

Next blog will talk about detailed Medicare Reform. See Part 2.

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