Shared decision-making as part of care management may lower costs

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Some past studies have not shown that care management lowers costs. But a study published in this week’s New England Journal of Medicine reports lower costs and fewer hospital admissions in people who received telephone-based care management that included the use of shared decision-making tools to help patients understand that they have options and to understand the tradeoffs involved in the different options.

There are many other compelling moral reasons to employ shared decision-making more commonly in health care. But money speaks, and this study may drive new attention to shared decision-making.

HealthDialog logo.jpg The NEJM paper was submitted by a team from Health Dialog Services in Boston, with Dr. David Wennberg as its lead author.

FIMDM logo.jpg (Disclosure: The Foundation for Informed Medical Decision Making, which supports my project, derives much of its funding from a partnership with Health Dialog. In collaboration with Health Dialog, the Foundation produces patient decision aids to support a shared decision making process. This partnership provides the Foundation with funding in the form of royalties used to fund research, support clinical demonstration sites, and advance the mission to amplify the patient’s voice in health care decisions.) David Wennberg is the son of Jack Wennberg, the Dartmouth medical school pioneer in small area variations research. Jack is also a co-founder of FIMDM, for whom I worked throughout the ’90s.

The total reduction in health care costs was 3.6% in the enhanced-support group – or about $8 less on average per person per month than in the usual-support group. The cost of the intervention was less than $2 per month.

The team defines the “enhanced support group” arm of the study as the group for whom a greater number of subjects were made eligible for health coaching through lower cutoff points for predicted future costs and through the expansion of the number of qualifying health conditions. Wennberg credits their “analytics” for helping to identify the correct population.

What seems noteworthy is that most of the lower costs were attributed to reduced inpatient and outpatient hospital spending. The hospital admission rate was 10% lower in the enhanced-support group. The team reports, “This reduction was almost entirely accounted for by a 13.3% population-based reduction in admissions for high-variation medical conditions and an 11.5% reduction in admissions for preference-sensitive conditions.”

One group of study subjects had chronic conditions such as heart failure, coronary artery disease, chronic obstructive pulmonary disease, diabetes and asthma. These people received behavior change and motivational counseling, as did people with high-risk conditions such as heart arrythmias, angina, obesity, tobacco use, depression or anxiety, hypertension with complications, back and neck pain, osteoarthritis, hyperlipidemia, abdominal pain – or people with multiple hospital or emergency room visits. Wennberg told me people in this category had “chaotic health care utilization patterns with lots of emergency room use.”

But the preference-sensitive category included people at risk for surgical intervention with conditions such as back surgery, knee or hip replacement or repair, heart bypass, prostate surgery for BPH, hysterectomy or myomectomy for benign uterine conditions. This was the group that received shared decision-making help.

DWennbergWeb.jpg In an interview, Wennberg called the results “a fairly large effect size, and not in any specific group but consistent across all groups.”

I asked him about the net $6 savings per month – $8 in cost reductions minus intervention costs of <$2/month. He said this was undoubtedly an underestimate of actual cost reductions, since there also would have been reduced out-of-pocket and copay costs for people in the enchanced-support group. Wennberg said the cost reduction in this study was far greater than that accepted as a goal in much of the Patient Protection Act & Affordable Care Act debate. And it is the potential for such work to have an impact on health policy discussions and on health care reform that makes it so intriguing. Many have looked for greater evidence of impact from shared decision-making. This study helps make the case. But the real money quote from Wennberg came at the end of our conversation when he said: “We see so many people who are simply battered by the health care system. They’re confused and unable to get even basic information on how to navigate their way through. This isn’t age-dependent; we see it in moms and dads worried about their kids on up through the Medicare population. It is sad to see how often people simply don’t know that they have options.” And that’s what shared decision-making gives them.

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Mike Pierce

September 22, 2010 at 9:51 pm

The results are very encouraging for wider adoption of SDM directly within corporations and organizations with high risk employee sub-populations. It would take years and countless consultations through a wellness or disease management program to demonstrate similar effects. Because outcomes are often improved or steady, this type of in-year ROI cannot be ignored and is compelling justification as a complementary benefit to traditional wellness programs. David’s final quote accurately personalizes the value proposition from an employee perspective, and when supported by the cost savings, identifies a powerful option for employers in reducing their spend while improving employee health. Businesses and their policy trade groups would be well served to embrace and advocate these programs.

Jeff Kreisberg

September 23, 2010 at 9:21 am

In order to be able to participate in your healthcare you must be informed which means that the provider must communicate and create meaning for the patient. To create the trust that is needed for effective patient-centered care providers need to be attuned to not only the emotions of their patients but also their own emotionality. The tools necessary to be an effective communicator and, hence, an excellent physician can be taught and measured. For shared decision making to succeed medical schools must include communication in their curricula. I can remember my classmates looking down on to their patients in the VA as alchies- cirrhotic livers and atrophied minds- not worthy of their respect. This attitude, which was taught by example, does not build trust that is needed for shared decision making to succeed.

PC Wizards

October 4, 2010 at 7:39 am

Let’s hope this encourages greater doctor-patient communication, but it shouldn’t merely be cost savings that provides incentive to doctors and the health care system as a whole to work with patients to allow them to make fully informed decision-making regarding their health care and treatment options.