Moderator: David Lansky, PhD, President and CEO, Pacific Business Group on Health
Are patient advocacy groups prepared to acknowledge the scope and severity of this problem? How do we achieve a consensus on controversial tests and treatments (such as PSA testing and vertebroplasty)? What role can employers play now that health care costs are increasingly being shifted to unions, employees, and the government? The knowledge about what third-party payers have accumulated over the decades may be valuable, but is it politically too toxic? What forces have stymied their efforts to curb overutilization? How can we recruit employers and patients to this issue, get them up to speed, and guide them toward effective action?
Leaders from the consumer, patient, and purchaser communities recognize and support the growing professional commitment to identify and better manage avoidable care. We see a number of opportunities to collaborate with professional societies, provider and payor organizations, and our own physicians to put more attention on avoidable care. We recognize that patients need to alter their expectation of medical care and be engaged in a dialogue with health professionals to select appropriate treatments.
We also caution against oversimplifying the roles that patients or purchasers can play in the pursuit of more appropriate utilization of health care resources. Our discussions recognize several roles – and that these roles will vary under different circumstances.
At a broad level, we will encourage consumers and patients to recognize that more care is not necessarily better, and that honest dialogue with their doctors is important to good decision making. To avoid “avoidable care”, we will need to challenge traditional roles and messages from traditionally authoritative sources. It is unlikely that most of us will begin to question this “conventional wisdom” until we know for sure that:
a. It is important: that we can be harmed by overuse; that our health and that of our families may be at risk.
b. It is possible to do something about it: it is easy to find evidence to help us understand the trade-offs of different tests; our clinicians are knowledgeable and discuss those trade-offs when making decisions with us about our care.
c. It is safe: we are confident that we will not be punished by clinicians for questioning their recommendations.
In specific treatment circumstances, we recognize that various decision aids can be helpful ways to engage patients in the dialogue about appropriate care. These can include ‘shared decision making’ tools such as interactive videos and computer aids, or consultations with independent advisors, or thorough conversations with personal physicians. For some treatments, the ‘informed consent’ process can be designed to ensure greater patient understanding and participation in treatment choices.
However, there are many treatment circumstances where it is not reasonable or appropriate to expect patients to be full partners in the decision. Among the “Choosing Wisely” catalogue, for example, many of the treatments and tests are technical and involve multiple, complex factors. We expect highly trained and compensated professionals to understand the current evidence base and the individual patient’s needs, risks, and capabilities and then make treatment recommendations consistent with that knowledge. Many patients – elderly, with dementia, with limited health literacy – may have great difficulty evaluating which care is “avoidable” and will appropriately rely on a health professional for those judgments. Patients should be given understandable information about the treatment choices they face, and the opportunity to engage in shared decision making approaches, but they should not feel burdened by the need to make complex technical judgments.
In these situations, one way to reduce inappropriate care is to encourage patients to seek care from doctors and care systems that are diligent in bringing practice into conformity with standards of appropriate care, such as those described in the Choosing Wisely campaign or some professional societies’ “appropriate use criteria”. This approach will require systematic measurement of appropriateness and treatment outcomes, and transparency about those results to payers, purchasers, and patients. Purchasers are likely to develop preferred networks, benefit designs, and payment programs that recognize and reward providers who conform to professionally-defined standards of appropriate care.
Both patients and professionals will need to change their expectations – and change the culture of patient-physician interaction. Above all, we will need opportunities for candid, evidence-based discussions of what works, for which patients, in which circumstances – both as a society and in individual patient care.
Rethinking informed consent – Ben Moulton, JD, MPH
The role of patients and families – Jessie Gruman
“The Story of Michael Skolnik” – Patty Skolnik