Article written by Pamela Menard, MBA, MS, NP, Health System Strategist for Maxcess Managed Markets


Background:

Shared decision making refers to a collaborative, patient-directed process that helps patients, together with their caregivers and healthcare team, set goals and priorities and make choices that meet the patient’s needs while honoring his or her values and preferences. This process is often focused on those conditions for which multiple treatment options are shown to have similar outcomes (eg, prostate cancer). Shared decision making includes the use of educational aids such as written materials and video. There are many tools certified to be “evidence based” that can be shared in person or through online channels.

In December 2016, the Centers for Medicare & Medicaid Services (CMS) announced a pilot testing of its own shared-decision-making model. The goal was for Accountable Care Organizations (ACOs) to test how clinical practice could be adapted into a 4-step decision-making process:

  1. Identify eligible beneficiaries
  2. Distribute patient decision aids
  3. Offer an in-person collaborative process to understand treatment options
  4. Track adherence and report results.

Participating ACOs would receive $50 for each decision-making service provided.

The pilot focused on 6 conditions for which clinical evidence doesn’t support one treatment option over another. These conditions were stable ischemic heart disease, hip osteoarthritis, knee osteoarthritis, herniated disk and spinal stenosis, clinically localized prostate cancer, and benign prostatic hyperplasia.

In November 2017, CMS announced that it would not proceed with the pilot, as too few ACOs expressed interest in participating.

 

Analysis:

Why was there little interest in this pilot? First, pilot participation was extended only to ACOs participating in the Medicare Shared Savings Program or the Next Generation ACO Model, limiting the pool of potential shared-decision-making participants to approximately 525 organizations. Second, physician practices struggle to keep up with requirements that place demands on their limited resources. These requirements may include maintaining strong participation in multiple quality incentive programs for multiple payers; achieving and maintaining accreditation as a patient-centered medical home (PCMH); facilitating and reporting on overall performance to multiple entities; optimizing the use of electronic medical records to advance population health management (PHM); performing clinical practice redesigns in pursuit of goals of the Triple Aim: affordability, improved quality, and enhanced patient experience of care.

According to an American Medical Association survey, nearly 1 of 5 physicians wants to cut back their clinical hours to part-time status within a year, while others are thinking of retirement, pursuing a different kind of practice, pursuing employment, or leaving healthcare altogether. These results, published in the November 2017 issue of Mayo Clinic Proceedings, were strongly tied to feelings of burnout and dissatisfaction with work-life balance.

One ACO in upstate New York, when asked why it had chosen not to participate, responded that this pilot “didn’t even hit [our] radar screen.” They were concerned about the burden of implementing new processes on practice sustainability, as well as the impact that additional administrative processes would have on patient access to care. Most practices in ACOs are PCMH certified, and shared decision making is inherent in that team-based care approach as a standard of care. In addition, practices may think CMS is too prescriptive and see the reporting as burdensome.

ACOs may find it beneficial to collaborate with other knowledgeable organizations, such as pharmaceutical manufacturers, when looking to improve patient care. Many key pharma-ACO partnerships for improved patient outcomes have been developed, leveraging the strengths of each organization. For instance, Merck, a global pharmaceutical company, and the Heritage Provider Network–a Southern California–based managed care organization with affiliates in Arizona and New York and the largest of the Pioneer Model ACOs–engaged in a collaborative process to identify novel solutions in disease areas of shared interest: diabetes and heart disease. The partnership list goes on, but they and their positive results get little recognition.

 

Implications:

While all sides have good intentions, the inability of many provider practices to take on the additional work burden of shared decision making might inhibit them from achieving the very goals all parties are striving for: providing high-quality patient care that achieves optimal outcomes at a reasonable cost.

 

Conclusions:

Although the CMS pilot is no longer moving forward, the practice of shared decision making is still embraced by many practices, especially in the new world of the Merit-Based Incentive Payment System (MIPS). The challenge is how providers can best provide this service within the constraints of their workflows and general office practices. Pharmaceutical manufacturers have the opportunity to do more than sell product—with their industry knowledge and presence, they can help bridge value provider practice partnerships, thus becoming a trusted advocate for quality, innovation, health information technology (HIT), and process/workflow improvements. This may help decrease the administrative burden in a way that allows prescribers to do what they are trained to do: provide the best possible care to optimize patient outcomes.

 

Sources

Alston C, Berger Z, Brownlee S; National Academy of Medicine. Making Strategies for Best Care: Patient Decision Aids [discussion paper]. https://nam.edu/perspectives-2014-shared-decision-making-startegies-for-best-care-patient-decision-aids/. Published September 18, 2014. Accessed December 20, 2017.

Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-781.

Bhandari A, Chatterjee A, Holoubek S, Powers B, Gluck J, Jain SH. A novel pharmaceutical-ACO collaboration: the Merck/Heritage Provider Network open innovation challenge. http://www.ajmc.com/printer?url=/journals/ajac/2014/2014-1-vol2-n1/a-novel-pharmaceutical-aco collaboration-the-merckheritage-provider-network-open-innovation-challenge. Accessed December 13, 2017.

Centers for Medicare & Medicaid Services. Beneficiary engagement and incentives models: shared decision making model. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-12-08-2.html. Published December 8, 2016. Accessed December 13, 2017.

Centers for Medicare & Medicaid Services. Beneficiary engagement and incentives: shared decision making (SDM) model. https://innovation.cms.gov/initiatives/Beneficiary-Engagement-SDM/. Published November 13, 2017. Accessed December 13, 2017.

HealthIT.gov; National Learning Consortium. Shared decision making [fact sheet]. https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf. Published December 2013. Accessed December 20, 2017.

Institute for Healthcare Improvement. The IHI Triple Aim. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed December 13, 2017.  

National Association of ACOs. NAACOS joins CMS in welcoming 525 ACOs in 2017! [press release]. https://naacos.memberclicks.net/naacos-joins-cms-in-welcoming-525-acos-in-2017. Published January 18, 2017. Accessed December 13, 2017.

Olson KD. Physician burnout—a leading indicator of health system performance? Mayo Clin Proc. 2017;92(11):1608-1611.