Making Health Reform Affordable & Patient-Centered
By Josh Seidman | Popularity: 20%What are the best strategies for ensuring that health care reform achieves our multiple goals of universal coverage, cost control, and improved quality? I certainly don’t have all the answers, but it’s worth starting with a few, and have all of you build on them.
To be more specific, my primary question here (I recognize there are other ways of framing the discussion for finding answers to the first question) is: What are practical reforms we could make to the delivery system that create better, more patient-centered care delivery at the same time as reducing (or slowing the rate of growth of) costs that free up money to cover un-/under-insured people?
To start with, we can gradually build an expectation of prescribed patient decision aids into the care delivery process. I described a practical model for implementing this model of shared decision making (SDM) here last week in describing new legislation introduced by Senator Ron Wyden (D-OR) and co-sponsored by Senator Judd Gregg (R-NH). The basic idea is to begin with pilots and the development of standards and measures that lay the groundwork for ubiquitous SDM embedded into future care delivery a few years down the road.
We can also take a different approach to how we deal with costly preventable hospital readmissions. The opportunity here is enormous, which is probably why legislators are seriously considering revamping Medicare payment policy in this area. An Agency for Healthcare Research and Quality (AHRQ) report estimated that hospitals spent almost $31 billion on over 4 million unnecessary readmissions in 2006. Almost 20% of Medicare beneficiaries are re-hospitalized within the first 30 days of hospital discharge. For heart failure, that figure rises to 27% and in half of those readmissions, there was no outpatient visit billed to Medicare in the month following discharge.
Thankfully, not only is the financial opportunity huge, but the solutions (comparatively speaking) do not require extraordinary measures. During a recent IxAction Alliance webinar, Mark Stewart from the American College of Cardiology (ACC) described the Hospital to Home (H2H) project ACC has developed in collaboration with Don Berwick’s Institute for Healthcare Improvement (IHI). This summer, 1,500 hospitals will engage in the H2H project (as CMS publicly releases hospital readmission rates for the first time) and implement solutions with information therapy (Ix) components such as:
- Pre-discharge education/assessment
- Medication reconciliation
- Follow-up within specific time frames
- Home health involving patient/family education
Success of H2H interventions will be judged primarily by how well patients and their families:
- Understand when & where to seek medical attention
- Can access and are familiar with their medications
- Can schedule and get to their follow-up appointments
ACC and IHI are just a couple of examples of leaders in this area. Content developers such as Krames, Healthwise and Emmi Solutions have created specific Ix interventions focused on reducing hospital readmissions as well.
Beyond patient decision aids/SDM and Ix to reduce hospital readmissions, what other strategies should be integrated into whatever comes out of Congress to reform the health care delivery system? Share your thoughts in the comments below.
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June 4th, 2009 at 11:50 am
I just read your article on SDM and have since done some research to understand just what is this? I am an MD and have not heard this term before. Given my blog on healthcare issues, I’d like to share this with my readers. But even after reading a number of articles and legislation, including the one by Charles in BMJ that is often quoted, I am having trouble differntiating between informed consent and SDM. In IC there is a flow of information about risks/alternatives/benefits. Patients can at that time share their concerns and request a different treatment. The MD will say that they don’t recommend that, but if the patient signs a form that documents that the patient is choosing a treatment plan not recommended by the doctor, they may do so.
In SDM, information on risks, benefits, alternatives is given - often in dynamic format i.e. DVDs, etc. And patients share their values and judgments and they both come to a decision. I can tell you, there is a very small percentage of patients that can sift through the medical literature and make an unbiased informed decision. In the end, the doctor makes the decision for the patient by offering their “medical opinion” and the few patients who refuse that course of treatment, assume full liability for anything that goes wrong.
The verbiage is different but the concept is the same. Please correct me and help me understand how this is a new a different concept.
thx
June 4th, 2009 at 1:29 pm
SDM is more about informed choice than informed consent. We know from research (such as by Dartmouth Atlas) that tremendous variation in procedure utilization exists unrelated to quality. Or, as Jack Wennberg said decades ago, “Geography is destiny.”
The goal of SDM is to bring the “informed” part upstream, so that the patient isn’t put in the place of just “refusing consent” but actually participates in an active, collaborative decision making process with clinicians. Equally importantly, it’s important that the patients not be responsible for “sifting through the medical literature” (it’s fine if they want to). Rather, the information to guide their decisions should be communicated in a way that meets their needs and provides them with both knowledge and respects their own values & preferences.
The best source on the planet for information on SDM & decision aids (including the Cochrane library summarizing all the peer-reviewed research on SDM) is through Ottawa Health Research Institute (available in English or French!): http://www.ohri.ca/DecisionAid/.
June 19th, 2009 at 4:49 pm
To add to Josh’s great explanation about the difference between SDM and Informed Consent, bringing the patient’s decision “upstream” is very important because, so often, one decision begets another. Since it is an ongoing process rather than an event, shared decision making can help both physician and patient understand the potential risks, benefits, and implications of the myriad decisions that go into the management of health and health care, both now and in the future. Because the pace of medical practice is so frenetic, informed consent is so often a one-shot event that does not offer the opportunity for physicians and patients to interact about the wide range of potential implications for the patient. Important to the success of these efforts, of course, is to provide an environment, through good policy, in which physicians can take the time to participate in this process.