Law, Shared Decision Making & Health Disparities

Transcription

1 Law, Shared Decision Making & Health Disparities Ben Moulton, J.D., MPH Senior Legal ladvisor, FIMDM Lecturer in Health Law, Harvard School of Public Health

2 Practice Variation: Evidence for Poor Decisions 8,500 Medicare Sp pending AS SR Adjusted 7,500 6,500 5,500 4,500 3,500 2,500 Red Dots Indicate HRRs Served by U.S. News 50 Best Hospitals for Geriatric Care

3 DECISIONS Survey Conducted by University of Michigan Nationwide random-digit dial telephone survey Probability sample of 2575 English speaking Americans age 40 + Reported a discussion of 1 of 9 medical decisions with a health care provider within the past 2 years Response rate 51%

4 Decisions Survey: Decisions Addressed Surgery Back surgery, knee/hip replacement cataract extraction Cancer screening Prostate, Colorectal Breast Medications Hypertension, Hyperlipidemia, Depression

5 Epidemiology of Medical Decisions in US In the past 2 years: 56% discussed starting or stopping meds for hypertension, hyperlipidemia or depression 72% discussed a screening test for cancer 16% discussed one of the 4 operations

6 What did Clinicians Recommend? Surgery: about 65% of recommendations: do it Screening: about 95% of recommendations: do it Medications: over 90% of recommendations: do it

7 Were Patients Asked for their Opinions? For surgery: About 1/2 the time for the orthopedic surgeries; 1/3 of the time for cataracts For screening: Less than 1/5 of the time for decisions about cancer screening For medications: About 1/3 of the time

8 How Much did Patients Know? Clinical experts identified 4-5 facts a person should know, for example, common side effects of medications or surgery Respondents were asked the knowledge questions related to their decision For 8 out of the 10 decisions, fewer than half of respondents could get more than one of the knowledge questions right.

9 By RICHARD J. ABLIN Published: March 9, 2010 The Great Prostate Mistake EACH year some 30 million American men undergo testing for prostate-specific antigen, an enzyme made by the prostate. Approved by the Food and Drug Administration in 1994, the P.S.A. test is the most commonly used tool for detecting prostate cancer I never dreamed d that tmy discovery four decades ago would lead to such a profit- driven public health disaster.

10 23 Patient vs. 25 Physician States 2Hybrids Patient Standard Physician Standard Hybrid (NM & MN) 10

11 Physician Based Standard Defined Physician Based Standard requires physician to inform patient of risks, benefits and alternatives to treatment in the same manner that a reasonably prudent practitioner in the field would -Tashman V Gibbs (VA 2002)

12 Physician Based Standard:Why it fails Assumes that physicians provide universal standard of acceptable treatment. Divides patients & physicians Preserves paternalism Hinders improvements in treatment and communication

13 Patient Based Standard Defined Patient based standard requires physician to provide patients with all the Information on risks, benefits and alternatives to treatment that a reasonable patient would attach significance to in making a treatment decision -Canterbury vs Spence (D.C. 1972) 13

14 Patient Based Standard:Why it fails Based on belief that all reasonable people value the same health outcomes and lifestyle choices in the same manner Physician continues to control dissemination of information

15 Shared Decision-Making: i a Definition i i Integrative process between patient and clinician that: Engages the patient in decision-making (Charles C, Soc Sci Med 1997; 44:681) Provides patient with information about alternative treatments Facilitates the incorporation of patient preferences and values into the medical plan

16 Summary of WA State Legislation: The Washington State legislation is significant in several respects: 1) Shared decision making and the benefit of using decision i aids are formally acknowledged dfor the first time by a state legislature; 2) Washington will undertake a demonstration project to evaluate the implications of incorporating SDM and the use of decision aids into everyday practice; and 3) the bill provides legal protection to physicians who choose to engage in Shared Decision Making with their patients. 16

17 Maine & Vermont Salient Features VT contemplates a plan and report by 2010 for a shared decision-making project that is to be integrated with the state s Blueprint for Health initiative. The purpose of the shared decision-making project is to improve communication between patients and health care professionals about equally or more effective treatment options The Maine Quality Forum Advisory Council is charged with implementing a program for shared decisionmaking. Report to legislature by 2012.

18 Federal Health Care Reform HR3590 Section 3506/936 Program to Facilitate Shared Decision Making Purpose is to facilitate collaborative process between pti patients t and dproviders... if info about ttradeoffs and options and to incorporate patient preferences and values into medical plan. AUTHORIZED but not APPROPRIATED

19 Key Aspects of Legislation 3506 Priority it - preference sensitive care Produce patient decision aids to understand treatment options- focus on preference sensitive care Set quality standards & certify decision aids- delegated to NQF to establish endorsement process AUTHORIZED but not APPROPRIATED

20 Key Aspects of Legislation 3506 Priority - preference sensitive care Secretary shall consult with CDC and NIH to develop, update and create patient decision i aids Test to ensure that they are balanced Educate providers on use of materials Ensure that aids produced under grant or contract are available to public AUTHORIZED but not APPROPRIATED

21 Section 3021 CMS Innovation Center Test innovative payment models to reduce costs Enhance quality. To design, implement and evaluate 18 different models 9) Assisting applicable individuals in making informed health care choices by paying providers for using patient decision support tools that improve individual understanding of medical options AUTHORIZED AND APPROPRIATED 15 Billion 5 Billion FY 2010 and 10 Billion FY

22 Patient Decision Aids Can Help! Patient decision aids are tools designed to help people participate in decision making about health care options. They provide information on the options and help patients clarify and communicate the personal value they associate with different features of the options. (The International Patient Decision Aid Standards Collaboration )

23 Patient Decision Aids Can Help! Patient decision aids do not advise people to choose one option over another, nor are they meant to replace practitioner consultation. Instead, they prepare patients to make informed, values-based decisions with their practitioner. (The International Patient Decision Aid Standards Collaboration )

24 Cochrane Review of Decision i Aids In 55 trials of decision aids addressing 23 different screening or treatment decisions, use has led to: Greater knowledge More accurate risk perceptions Greater comfort with decisions Greater participation in decision-making Fewer people remaining undecided Fewer patients choosing major surgery, PSA tests (O Connor et al. Cochrane Database ( of Systematic Reviews 2009, Issue 3. Art. No.: CD001431)

25 Education Literacy Numeracy Language Rural Technology access Alameda County Public Health Department