Benjamin Moulton, J.D., M.P.H., senior vice president for policy and advocacy at the Informed Medical Decisions Foundation, discusses at a recent event how shared decision-making has improved patient engagement and reduced costs.
The physician may know the science of a patient's health condition inside and out, but the physician can't make difficult treatment decisions alone. Patients need to understand the risks and potential alternatives to prescribed care or treatment so they can make informed contributions to decisions about their health.
A panel of health analysts recently discussed tools that can assist in this process during an event(www.youtube.com) hosted here by the Alliance for Health Reform.
Benjamin Moulton, J.D., M.P.H., senior vice president for policy and advocacy at the Informed Medical Decisions Foundation, said 25 percent to 30 percent of all medical care is "preference-sensitive," meaning that the patient has choices that carry the same rates of morbidity and mortality. Such cases call for shared decision-making between physicians and patients, he noted.
That shared decision-making, in turn, "is rooted upon mutual respect" and based on a foundation of "open and honest transparent communication," said Moulton. "It is not a ritualistic signature on a form, and the patient is entitled to accept or reject whatever is proposed before them." Many physicians define informed consent incorrectly in his classes on medical ethics to physicians, he added.
- Patients need to understand the risks and potential alternatives to prescribed care or treatment so they can make informed contributions to decisions about their health.
- A panel of health analysts discussed ways to help patients assist in informed shared decision-making at an event held by the Alliance for Health Care Reform.
- Certified decision aids can assist patients in considering their values and finances.
"Usually, a surgeon's hand goes up and (he or she) says, 'Oh, that's the form the hospital requires me to get from the patient,'" Moulton explained "And then usually a pediatrician or an internist raises their hand and says, 'No. It's not the form, it's the signature on the form.'"
Neither is correct.
"Informed consent is supposed to be this bidirectional communication between patient and provider whereby the physician tells the patient what the risks, benefits and alternatives are and the patient tells the provider what's acceptable to them -- in other words their preferences and values," he said.
Moulton cited a survey of breast cancer patients and physicians at Massachusetts General Hospital that revealed how these values can diverge. Ninety-six percent of physicians in the survey ranked extending life as long as possible via chemotherapy among their top three priorities, but only 33 percent of patients ranked it among the top three. Thirty-three percent of patients said reconstruction without prostheses was a priority, but zero percent of physicians agreed.
Certified decision aids that use evidence-based information are emerging to help patients weigh such difficult medical decisions.
A study published in Health Affairs in 2012(content.healthaffairs.org) linked the use of such decision aids to reduced election of expensive surgical procedures, increased patient participation in decision-making, reduced uncertainty about the appropriate course of action, and helping patients reach decisions that are more aligned with their stated values.
The state of Washington is considering payments to physicians who use such tools, and other states, including Massachusetts, Vermont and Minnesota, have passed similar legislation.(www.informedmedicaldecisions.org)
The tools also can help patients with the financial aspect of informed consent. One obstacle to patients making informed decisions is that many of them are reluctant to ask about costs and insurance coverage for procedures, and physicians often do not know the details of their patients' insurance plans.
A resource that can help with that situation is FAIR Health,(fairhealthconsumer.org) a nonprofit patient advocacy site that was established in a settlement after New York began investigating health insurance reimbursement practices. The site estimates both total and out-of-pocket costs for hundreds of medical and dental procedures by ZIP code.
Panelist Robin Gelburd, president of FAIR Health, said most adults still do not understand health insurance costs or networks or the vocabulary of medicine and insurance, so the site gives them tools they need to make informed decisions.
"In the past, employees were at the back of the chorus line because employers made decisions about health care," she said. "Consumers are now at center stage, but they don't have the script to navigate the insurance play."
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