Shared Decision-making’s Place in Health Care Reform

Peter V. LeeExecutive Director National Health Care Policy, PBGH

Co-Chair, Consumer-Purchaser Disclosure Project

Foundation for Informed Medical Decision MakingResearch and Policy Forum

January 28, 2010

Health Care Reform Isn’t Dead

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Health Care Reform

Reforming Health Care Delivery Core “Reform” Elements

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Major Policy Area Disclosure’s Critical Value Policies

Coverage Expansion and Financing

1. Align public and private policies2. Connector or Exchange promoting value

Benefits 3. Assure core benefits promote affordable “right care”

System Reforms 4. Full measures and public reporting (including release Medicare data)

5. Promote wellness 6. Consumer and provider incentives for shared decisions7. Payment reform – Change payments AND the decision

process 

Infrastructure 8. Patient-centered comparative effectiveness 9. HIT that promotes better care10. Foster innovation

Patient & Payer Consensus on Key Delivery Reform Elements

Groups representing consumers, patients and purchasers developed recommendations that identify the best provisions of the House and Senate health reform provisions to improve quality and slow cost growth in health care: Payment reform Comparative Effectiveness Research Performance Measurement Public Reporting

For complete report, recommendations and broad list of endorsers go to: http://www.pbgh.org/news/pubs/commentary.asp

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Why Shared Decision-making is Core to Reforming Care Delivery• Shared decision-making and use of patient decision aids are at

the heart of making care patient-centered. They recognize that for preference-sensitive care, variation should be driven by patient not provider preferences.

• Shared decision-making has the potential of reducing unwarranted variations in the use of preference-sensitive health care options.

• Numerous randomized trials indicate patient decision aids prevent overuse of options that informed patients do not value.

• Shared decision-making provides a patient-centered foundation for the use of comparative effectiveness research.

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Shared Decision-making in Federal Reform 2010

• House of Representatives (HR 3962):Shared decision-making demonstration

program.• Senate (HR 3590):

Support and technical assistance for shared decision-making.

Shared decision-making as a CMS Innovation Center activity.

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House: Shared Decision-making Demonstration Program (HR 3962)• Purpose: To improve Medicare beneficiaries’ understanding of their medical

options.• Program:

Providers to schedule “follow-up consulting visit” for Medicare beneficiaries after they view a patient decision aid. Providers to be reimbursed for visits through creation of new payment code.

Includes collection of outcomes and quality data. No more than 30 providers (groups). Must have experience implementing, and have

invested in infrastructure to implement shared decision-making. • Structure: Operated through CMS Innovation Center.• Evaluation & Expansion:

Within 12 months Secretary to submit report to Congress with recommendations for legislation and administrative action.

Report includes evaluation of impact on health quality, utilization of health care services, and improving quality of life.

No explicit expansion path.

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Senate: Support and TA for Shared Decision-making (HR 3590)• Purpose: Help clinicians engage patients and caregivers through information

about trade-offs among treatment options, and incorporating patient preferences and values into the medical plan.

• Program: Secretary of HHS to contract with an entity to: (1) establish measures; (2) endorse

measures; and (3) certify patient decision aids. Secretary to award grants:

• To develop, update, and produce patient decision aids for preference sensitive use; test materials; educate providers on use.

• Fund Shared Decision-making Resource Centers to supply TA to providers.• Support health care providers for development and implementation of shared

decision-making techniques.• Structure: Funding to begin in FY 2010. No $ specified.• Evaluation & Expansion: Not addressed.

© Consumer-Purchaser Disclosure Project, 2010 8

Senate: Shared Decision-making as CMS Innovation Center Activity (HR 3590)

• Purpose: Assisting eligible individuals make informed health care choices. Innovation Center serves Medicare and Medicaid beneficiaries.

• Program: Pay providers of services and suppliers for using patient decision-support tools. Budget neutral.

• Structure: Shared decision-making is one of the broad roster of potential programs identified for the Innovation Center, BUT the Center is not required to test shared decision-making (or any of roster of programs).

• Evaluation and Expansion: Secretary has authority to expand duration and scope of model that improves care

and/or lowers costs and terminate or modify models that do not. Secretary to submit to Congress report in 2012 and annually thereafter. Report

has recommendations on payment models.

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Quick Comparison of House & Senate

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Topic House Demo Pilot Senate TA and Support

Senate Innovation Center

Population Medicare Medicare Medicare (and

Medicaid?)

Program elements defined in detail

Yes Yes No

Provider financial incentives

Yes No Yes

Consumer financial incentives

No No No

Set standards for patient decision aids

No Yes No

Funding for development of patient decision aids

No Yes No

Evaluation Yes No Yes

Provides for potential expansion Unclear N/A Yes

Shared Decision-making Advocates: Recommendations to Improve Provisions• Clarify focus of shared decision-making on “preference

sensitive care”.• Ensure robust conflict of interest provisions (patient decision

aids used are developed in a way to be balanced, evidence based, and free of bias and conflict of interest).

• Ensure shared decision-making is extended into other payment pilots.

• Ensure (for Senate support and TA function) clarification of distinct roles relative to: Development of measures for patient decision aids Endorsement of measures Certification of patient decision aids

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Is Changing Medicare Enough?

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Changing Medicare: Necessary but NOT Sufficient

The full story:• Medicare represents only 19% of total

health spending.• Medicare IS the largest single payer.• Medicare CAN have an important

sentinel effect.• Many efforts need to promote

consistency across payers.

To Learn More and Additional Resources

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www.healthcaredisclosure.org — Consumer Purchaser Disclosure Project, good source for background and resources on the value agenda

www.pbgh.org — an overview of PBGH programs and initiatives, commentaries and policy positions

www.centerforpaymentreform.org — Center for Payment Reform, multi-stakeholder collaborative working to reform public and private payment to promote quality and cost containment

© Consumer-Purchaser Disclosure Project, 2010

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