NIHCR Policy Analysis No. 5
Ann S. O'Malley, Emily Carrier, Elizabeth Docteur, Alison C. Shmerling, Eugene C. Rich
Major discrepancies exist between patient preferences and the medical care they receive for many common conditions. Shared decision making (SDM) is a process where a patient and clinician faced with more than one medically acceptable treatment option jointly decide which option is best based on current evidence and the patient’s needs, preferences and values. Many believe shared decision making can help bridge the gap between the care patients want and the care they receive. At the same time, SDM may help constrain heath care spending by avoiding treatments that patients don’t want. However, barriers exist to wider use of shared decision making, including lack of reimbursement for physicians to adopt SDM under the existing fee-for-service payment system that rewards higher service volume; insufficient information on how best to train clinicians to weigh evidence and discuss treatment options for preference-sensitive conditions with patients; and clinician concerns about malpractice liability. Moreover, challenges to engaging some patients in shared decision making range from low health literacy to fears they will be denied needed care. Adding to these challenges is a climate of political hyperbole that stifles discussion about shared decision making, particularly when applied to difficult end-of-life-care decisions.
The 2010 health reform law established a process to encourage shared decision making, including setting standards for patient-decision aids (PDAs) and certification of these tools by an independent entity. However, Congress has not appropriated funding for these tasks. Along with ensuring the scientific rigor and quality of patient-decision aids, liability protections and additional payments for clinicians are other policy options that may foster shared decision making. In the longer term, including SDM as an important feature of delivery system and payment reforms, such as patient-centered medical homes, accountable care organizations and meaningful use of health information technology, also could help advance health system changes to improve care and contain costs.
This article is available at the National Institute for Health Care Reform Web site by clicking here.