- Should we incent or require providers to prescribe patient decision aids?
- Should we incent or require consumers to use patient decision aids?
Over-treatment is the most celebrated cause of runaway health care costs, but we shouldn’t blame the doctors. The fee-for-service system sets them up for over-treatment. First, they have been taught that offering all possible cures to every patient is good medicine. Second, malpractice law pushes them toward offering more testing and services, not less. And third, they generally get paid more when they do more. It’s hard to buck a triple-threat system like that without a little help from the patient. Fortunately, it’s not that hard for patients to provide that difference.
Patient decision aids are tools that help people participate with their doctors in key medical decisions. These aids are useful when there is more than one medically reasonable option to diagnose or treat a health problem—particularly when the options have different costs, risks, or benefits that some people might value differently than others.
To be “official,” a patient decision aid should meet all or most of the extensive criteria laid out in the International Patient Decision Aids Standards (IPDAS). The IPDAS standards (http://ipdas.ohri.ca/) include both content and process requirements that together assure that the decision aids are balanced and easy to use, include people’s preferences, and help in making decisions. NCQA and other organizations are considering developing an independent certification process for decision aids based on IPDAS standards—perhaps as early as 2010.
Yes, requiring (or at least incenting) physicians to provide decision aids to patients is a very good idea. Doctors, with very few exceptions, are trying to do the right thing. They don’t intentionally try to over-treat because of the financial rewards. But over time, the steady influence of a fee-for-service economic bias leads to standards of practice that make it just too easy to go with the medical flow. Incenting doctors to provide decision aids to patients is enough to tip the scale in the other direction so that the economic bias is neutralized.
Yes, we should require (or incent) consumers to use patient decision aids. Cost control in health care can never be restored without the help of the patient. But most consumers have been in the passive patient mode for so long that they need a little help re-engaging in the shared decision-making process. Some combination of carrots and sticks for the patient will speed the adoption and increase the value of patient decision aids.