Physicians and other health care providers are just beginning to talk with patients about health care costs and quality. On the leading edge of this trend are oncologists, some of whom are developing tools to stimulate these conversations with cancer patients.
In 2013, Nick Mulcahy reported for Medscape that oncologists at the Duke Cancer Center used the term “financial toxicity” to describe the high cost of cancer care and its effect on patients.
“Out-of-pocket expenses related to treatment are akin to physical toxicity, in that costs can diminish quality of life and impede delivery of the highest quality care,” Mulcahy wrote, citing a pair of articles in Oncology by S. Yousuf Zafar, M.D., a medical oncologist at the Duke Cancer Center, and Amy P. Abernethy, M.D., a medical oncologist at the Duke University School of Medicine. Continue reading
Here’s a recent story that touches on a whole lot of themes in health reform – without getting bogged down in a lot of jargon. Value-based purchasing. Evidence-based medicine. Shared decision-making.
Jackie Crosby of the Minneapolis Star-Tribune writes about how a Minnesota insurer, HealthPartners, has introduced a new approach for patients with low back pain. Before they get surgery, they have to get a consult on nonsurgical alternatives.
If they still opt for surgery, they can have it. But the thinking is (based on what other health systems have learned) that many will opt for physical therapy and rehabilitation once they learn more about the pros and cons, risks and benefits, of all their options.
“Patients can still see a surgeon if they wish. But after this visit, they’ll be better informed about all of their options, and can make decisions more aligned with their own values,” the story quoted Dr. Thomas Marr, HealthPartners’ medical director of clinical relations as saying.
“In general, it’s a bad thing when the doctor and patient can’t determine the treatment without interference from the insurance company or the government,” spine surgeon Jeffrey Dick was quoted as saying. But this is an exception, he said. Surgery is appropriate for only about one out of eight low back pain patients he sees. Getting them into appropriate care from the start can save money – not to mention years of lingering back pain.
“These aren’t HealthPartners criteria,” he added. “These are treatment algorithms for low-back pain that we all should be following – but maybe haven’t been by all practitioners.”
The story also noted how HealthPartners is working with stakeholders and monitoring patient reaction and satisfaction to minimize criticism and misunderstandings.
So what are those health reform themes?
Value-based purchasing – loosely translated – is paying for what works.
Evidence-based medicine is what it sounds like – and the evidence is that a lot of back surgery is unnecessary. Sounds simple but it’s not always practiced – even in those cases where the evidence is strong. Sometimes it’s even derided as “cookbook medicine.” Financial incentives are certainly one big impediment: surgeons, hospitals, etc., make money from procedures that may not always be the best choice for the patient. Practice patterns – how physicians are taught and what’s done in the medical culture of a given hospital or community – play a role. And patients often want treatments they don’t need because they don’t understand that it’s not necessary, or they think surgery is a reliable quick fix.
Some researchers exploring medical decision-making have found that physicians are a lot more likely to talk about why to have a certain procedure, including back surgery, than why not. Clinicians and researchers are beginning to develop models for “shared decision-making” and there’s even a bit of language in the health reform law to promote it.
So are there programs like this rolling out in your local hospitals or health plans? We’d like to hear more. It will be interesting, too, to watch how people react to the HealthPartners and similar ventures. Will patient/beneficiary attitudes begin to change? Will they come to understand that more isn’t always better? Will they be glad to find out they really don’t need surgery? Or will there be a backlash about choice and control. The answer may depend on whether patients feel the decision is shared, or imposed.
Shared decision making is of public interest – at least to anyone who thinks they might one day go to the doctor.
“This must be gratifying to Jack Wennberg,” panel moderator Gary Schwitzer, publisher of HealthNewsReview.org, mused at the end of the question and answer session following the panelists’ presentations.
“He couldn’t get his work published for 30 years. He was laughed at, considered a pariah. Finally, he had to publish in Science, which is not exactly a standard journal for variations in health care.” Using Medicare data, his Dartmouth Atlas of Health Care demonstrated striking variations in the kind of care patients receive – and the resulting costs – depending simply on where they live.
As it has been applied, Wennberg’s pioneering research revealed a large number of medical procedures where there is no clinical consensus as to the course of treatment. In response, there is movement to educate – and mandate – physicians to include their patients in the decision-making process.
AHCJ member Chris King, of the St. Louis American, writes about the shared decision-making panel.
Do doctors really want their patients involved in decision making? And even if many do, what are the barriers that prevent such involvement from taking place? Well, a new survey sheds some light on the issue and finds that many doctors would welcome more interaction with their patients when it comes time to make decisions, according to the Foundation for Informed Medical Decision Making.
The survey of 402 primary care physicians found that 93 percent say that the concept of shared decision making sounds like a positive process, and 52 percent described it as a “very” positive process, particularly for tackling lifestyle problems and chronic conditions. In fact, about 80 percent say patients would be “much” more likely to improve in these areas with the technique. But there was slightly less confidence about using the method for reviewing surgery, cancer screening and taking new medications.
There are some important barriers, though, to implementing shared decision making. Time was cited as the largest challenge, followed by the perception that patients do not understand all they need to know and preferring patients rely on physician advice for medical decisions. For example, 82 percent say it is “very” important for patients to be informed about taking new prescription medications, but only 16 percent say most of their patients are well informed in this area.
And 78 percent say recent changes in reimbursement rates have, not surprisingly, decreased the time they can spend with each patient. And 51 percent say they are very concerned, in general, about not having enough time to spend with patients.
Just the same, the foundation believes that, by using shared decision making, physicians and their patients can “determine which choice matches what is most important to patients – delivering high quality care that is both evidence-based and patient-centered.” Here is the white paper with still more interesting insights.