Although this March marked the fifth anniversary of passage of the Affordable Care Act many of its promises to place patients at the center of care remain elusive. No where is this more evident than in the law’s provision to improve shared decision making.
Oftentimes there is more than one reasonable medical treatment to choose from. Shared decision making helps patients partner with health care providers to make more informed decisions about treatments based on patients’ personal beliefs and values and their informed understanding of their medical choices. Frequently, patients are simply told what course of treatment they are to undergo without considering alternatives.
A well-accepted path towards aligning patients’ preferences with medical care is to use decision aids. These tools include written educational materials, informed face-to face encounters, or videos with instructional images that explore different options for care by providing the risks and benefits of interventions and their alternatives, exploring individual values and preferences, and offering testimonials from other patients who have experienced the various choices.
It is an astounding fact that after five years the Centers for Medicare and Medicaid Services (CMS) has certified only a single decision aid. Even in a city infamous for bureaucracy, this is inefficient at best – especially given that the overwhelming number of studies demonstrate that decision aids align medical care with what patients want, while also saving the health care system billions of dollars.
There are nearly 100 randomized controlled trials that suggest when patients use decision aids as compared to usual care, they are more likely to get medical treatments aligned with their values. Consider a study published just last month that explored decisions about aggressive life-prolonging interventions like CPR and breathing machines in elderly hospitalized patients with an advanced illness. Half of patients received usual care when making a decision, while the other half used a video tool explaining the risks and benefits of these interventions. When the researchers followed patients in the usual care arm for one year, 22% of patients who did not want these aggressive procedures received them nonetheless. What about the patients who used the video support tool? Only 4% received such interventions. The study authors suggest that patients using the video tool were more likely to feel empowered with knowledge and to have conversations with their doctors about their wishes.
Decision aids place patients at the center of their care. They also save the health care system billions of dollars.
In one representative study published in 2012 by Group Health Cooperative in Washington State, the use of video decision aids for knee and hip surgeries resulted in a 38% and 26% reduction in these surgeries respectively, saving the health care system millions of dollars in unnecessary costs. The usefulness and cost-savings of decision support tools have been a well-accepted and foregone conclusion by most of the medical establishment due to the robust evidence of the research; unfortunately, it has fallen on deaf ears at CMS.
To remedy this state of affairs, CMS should immediately certify and reimburse providers for the documented and appropriate use of decision aids in some of the leading interventions where multiple medical options exist. As in the Group Health Study, starting with knee and hip surgeries would be a welcome beginning, quickly followed by back surgeries, interventions at the end of life, and other questionable yet very expensive interventions.
For decision aids to stick and be self-sustaining in the practice of medicine, the largest payor of health care services in the land – CMS – must take a leadership role. Instead it has remained silent on the issue of shared decision making. Given the lucrative nature of many of these medical interventions, lobbyists will vehemently oppose the use of decision aids. These interests will create specious arguments about the rigorous science behind the evidence or the impracticality of implementing these tools.
Unfortunately, the only ones who pay for this sclerotic behavior by CMS and who undergo millions of wasteful and unnecessary procedures in our health care system are our parents and grandparents, and someday, ourselves.
Dr. Angelo Volandes is a physician and researcher at Harvard Medical School and Massachusetts General Hospital and is president of ACP Decisions, a non-profit foundation that produces video support tools. His recent book is The Conversation: A Revolutionary Plan for End-of-Life Care.