Abstract

Keywords: Shared decision making, health policy, patient-centered care, evidence-based medicine, decision aids, health care reform.
Citation: Osborne-Stafsnes JM. Shared decision making: using federal health policy as a lever to support implementation. J Participat Med. 2013 May 10; 5:e19.
Published: May 10, 2013.
Competing Interests: The author is employed by the California Center for Rural Policy.

 
On February 23, 2013 in Humboldt County, California, a group of primary care providers, medical specialists, and local patients met to discuss variance of preference-sensitive treatments in rural northern California. The meeting was the result of a year-long project coordinated by the California Center for Rural Policy and the Humboldt-Del Norte Independent Practice Association. Throughout the project year, the three stakeholder groups met with a series of medical experts to better understand why Humboldt County had higher rates of elective care for preference-sensitive conditions than the rest of the state. The meeting on the 23rd was the first communal convening of all three stakeholder groups and acted as a forum to discuss possible drivers and interventions. During the course of the meeting a nearly unanimous perspective emerged: formal shared decision making (SDM), through the use of evidence-based decision aid tools, should be implemented in the local medical community. Yet implementation will not be without challenges, the most significant being a lack of federal policy that exists to help actualize SDM efforts.

According to Coulter, SDM is a “process in which clinicians and patients work together to select tests, treatments, management, or support packages based on clinical evidence and the patient’s informed preferences.[1]” Shared decision making ensures the non-biased delivery of evidence-based information and places patient preferences in the center of the decision making process.[1] This deference to patient preference is important, as research from the Dartmouth institute indicates that “the treatment a patient receives depends more on the physician’s recommendations than the patient’s preferences.[2]”

In addition to advancing patient-centered care efforts, health policy researchers believe that SDM may combat overuse and reduce cost.[3] While the field of evidence on SDM and health care spending is still emerging, several studies build a case regarding the relationship of decision aids and reduced cost. Veroff and colleagues point to evidence that demonstrates that patients who are informed about their treatment options more frequently choose lower intensity and more cost-effective treatment options.[4] Group Health also demonstrated cost-savings during a 12-month study from 2006 to 2007. Using shared decision making as part of an enhanced health coaching model, they showed a reduction of $23.27 per member per month, as compared to standard health coaching (with no shared decision making program).[4]

Despite the many incentives and having overcome the hurdle of stakeholder support, Humboldt County, like many other communities across the United States, still faces an uphill struggle in the implementation of SDM. Shafir and Rosenthal point to “process ambiguities, certification issues with decision aids, and provider reimbursement and engagement” as barriers to implementation.[3] Mirroring this, Lin and colleagues discuss physician involvement and support as challenges during SDM implementation at five primary care practices in Northern California.[5] Specifically articulated physician concerns included lack of time to use the decision aid with the patient, lack of reimbursement for SDM, and fear of liability.[5] Legare and Witteman identified similar barriers in their review of 38 SDM implementation studies.[6]

Many of these barriers could be mitigated by a nationally comprehensive approach to SDM implementation. However, federal policy supporting SDM is limited and has been stunted by lack of funding. Section 3506 of the ACA calls for pilot projects to develop and update patient decision aids, yet financial provisions to support this effort have not been identified, making the feasibility of the provision unlikely.[7] More promising is SDM integration into the Center for Medicaid and Medicare Services (CMS) Cost Savings Plan, in conjunction with Affordable Care Organizations (ACOs) and the creation of the Center for Medicare and Medicaid Innovations, which identifies SDM as a key focus area in funding pilot projects.[8] While these efforts are a step in the right direction, they position SDM to be integrated into specific projects, rather than robust implementation into everyday care practices.

Despite the lack of federal progress, state policy has incentivized the uptake of SDM in Washington, Oregon, Minnesota, Maine, and Vermont, providing essential lessons learned and building the case for enhanced federal policy to support implementation. King and Moutlon call out Washington State’s incentive-based approach which offers “enhanced legal protection for physicians who follow certain shared decision-making procedures.[9]” Building upon 2009 state legislation, Vermont has planned for a SDM demonstration project to be integrated in state-wide health reform strategy.[3] Similarly, Oregon has undergone efforts to incorporate SDM into medical home standards and implement SDM in the state’s newly developed Coordinated Care Organizations.[3] These state policy initiatives can serve as the foundations on which to guide the development of a comprehensive, federal approach to SDM implementation.

Shared decision making may deliver on many promises, if a clear and coordinated national strategy can support its implementation. Humboldt County serves as just one example of many medical communities across the United States that have stimulated ground-level buy-in and enthusiasm, but may fumble with next steps given the lack of federal policy to provide a framework or financial incentive for their efforts. It is crucial that federal policy and financial incentive be established to incentivize widespread adoption.

References

1. Coulter, A. Patient engagement — what works? J Ambul Care Manage. 2012 Apr-Jun;35(2):80-9. doi: 10.1097/JAC.0b013e318249e0fd. ↩
2. The Dartmouth Institute. Improving Patient Decision-Making in Health Care: A 2012 Dartmouth Atlas Report Highlighting the Pacific States. 2012. Available at: http://www.dartmouthatlas.org/publications. Accessed May 6, 2013. ↩
3. Shafir, A, Rosenthal J. Shared Decision-Making: Advancing Patient Centered Care through State and Federal Implementation. 2012. Available at: http://www.nashp.org/sites/default/files/shared.decision.making.report.pdf. Accessed May 6, 2013. ↩
4. Veroff D, Marr A, Wennberg D. Enhanced support for shared decision making reduced costs of care for patients with preference-sensitive conditions. Health Aff (Millwood). 2013 Feb;32(2):285-93. doi: 10.1377/hlthaff.2011.0941. ↩
5. Lin G, Halley M, Rendle K, Tietbohl S, May S, Trujillo L, Frosch L. An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles. Health Aff (Millwood). 2013 Feb;32(2):311-20. doi: 10.1377/hlthaff.2012.1070. ↩
6. Legare, F. & Witteman, H. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood). 2013 Feb;32(2):276-84. doi: 10.1377/hlthaff.2012.1078. ↩
7. Informed Medical Decisions Foundation. Affordable Care Act. 2011. Available at: http://informedmedicaldecisions.org/shared-decision-making-policy/federal-legislation/affordable-care-act/. Accessed March 30, 2013. ↩
8. Friedberg M, Van Busum K, Wexler R, Bowen M, Schneider M. A demonstration of shared decision making in primary care highlights barriers to adoption and potential remedies. Health Aff (Millwood). 2013 Feb;32(2):268-75. doi: 10.1377/hlthaff.2012.1084. ↩
9. King J, Moulton B. Group Health’s participation in a shared decision-making demonstration yielded lessons, such as role of culture change. Health Aff (Millwood). 2013 Feb;32(2):294-302. doi: 10.1377/hlthaff.2012.1067. ↩

Copyright: © 2013 Jessica M. Osborne-Stafsnes. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.