Carrot or Stick? Should Patient Decision Aids Be Rewarded or Required?

Don kemper

  1. Should we incent or require providers to prescribe patient decision aids?
  2. 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 ( 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.

Don Kemper is the CEO of Healthwise. This blog piece is based on a white paper by the same title. Read the full paper here. Learn more about the new generation of decision aids at

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Categories: Physicians

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6 replies »

  1. Spike,
    In 1968 the SOAP note became the standard of documentation. In 1995 Documentation standarts expanded to a vast degree, further increased in 1997, just to get paid. Coders look for bullet points and basically score a chart for whether the documentation supports a certain “level”. All this programming for documentation essentially changed the practice of medicine, making it more cumbersome, less productive and more dangerous for the doc who might get audited and required to return losts of money retrospectively, without any regard to the quality of care actually delivered.
    The quality of the documentation does not really reflect the quality of care. It does reflect the government control over doctor behavior. There is a huge disconnect between care and documentation.
    I can remember what I did for you with far less documentation than is required for care.

  2. Wait, what? So this is me asking from pure ignorance, but how much of the documentation during a medical visit would actually happen without the threat of litigation or claim denial? Isn’t documentation good just so you’ll remember what you just did to me the next time you see me?

  3. Doctors and patients have disagreements all the time, no matter what the reason from the patient. When the rift places the doctor at perceived liability risk, the patient gets to sign out AMA (against medical advice).
    Accountability costs me 25% of gross income. By the time each chart is dictated, coded, filed, refiled, paid and posted, the overhead per record is significant. Factor in my time wasted dictating just to get paid and just to provide fodder for the attorneys and you have cost me the opportunity to see 2-3 more patients per hour. So don’t try to claim that accountability will save money. Once all the costs are compiled over the proper denominator, accountability costs, not pays.

  4. Interesting that we are still referring to our health care system as “fee-for-service”. I thought that health care costs were being “managed” by MCO’s that 25 years ago became the gatekeepers of health care services with promises of slowing/reversing the rising costs of health care. That experiment has been a dismal failure and yet those companies still exist and still siphon off huge amounts of health care dollars to support their for-profit nature – with no results and no benefits to consumers.

  5. The idea is preposterous, adding another layer of officious intermeddling with medical care.
    If Congress, Medicare, and other insurers halted the freeze on fees and compensated doctors to provide cost effective and accountable care, many layers of interference would disappear and what will evolve to be unneeded hospital beds will close.
    Pity the poor hospital administrators and lower level intermeddlers when they are on the unemployment line.

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