1. Shared Decision-Making: Using Patient-Centered Decision Aids to Improve Outcomes and Reduce Overuse Debra L. Ness Co-Chair, Consumer-Purchaser Disclosure Project President, National Partnership for Women & Families Peter V. Lee Co-Chair, Consumer-Purchaser Disclosure Project Executive Director, National Health Policy Pacific Business Group on Health Invitational Working Session July 1, 2009

2. 1 Agenda Welcome and Introductions –Debra L. Ness, Disclosure Project and NPWF Setting the Context for Shared Decision-Making –Peter V. Lee, JD, Disclosure Project and PBGH Overview of Shared Decision-Making Aids and Effect on Outcomes –Lyn Paget, Foundation for Informed Medical Decision Making –Catharine Clay, Ctr. For Shared Decision-Making, Dartmouth- Hitchcock Medical Center Public and Private Policy Options for Implementing SDM –Eva DuGoff, Office of Senator Ron Wyden (D-OR) –Elizabeth Barbeau, Health Dialog Roundtable Discussion –Peter Lee and Debra Ness

3. 2 Health Reform Elements Major Policy AreaCritical Value Policies Coverage expansion and Financing 1. Align public and private policies 2. Connector or Exchange promoting value Benefits 3. Assure core benefits promote affordable “right care” System Reforms 4.Full measures and public reporting (including release Medicare data) 5.Promote wellness and care coordination 6.Consumer and provider incentives for shared decisions 7.Payment reform – Change payments AND the decision process Infrastructure 8. Patient-centered comparative effectiveness 9. HIT that promotes better care 10. Foster innovation

4. 3 Shared decision-making should encompass four key elements in which a patient working with their clinician: Understands the disease or condition (its risk and seriousness); Understands the treatment/prevention options (including the risks, benefits, alternatives, and uncertainties); Has weighed his or her values regarding the potential benefits and harms associated with the treatment options; and Has engaged in decision-making at a level at which he or she desires and feels comfortable. Adapted from Task Force on Community Preventive Services definition as described in “How Might Clinicians Facilitate Patient Participation in Decision-making?,” Agency for Healthcare Quality and Research, http://www.ahrq.gov/clinic/3rduspstf/shared/sharedba2.htm#5

5. 4 Why Shared Decision-making (“SDM”) is Core to Reforming Care Delivery SDM and use of Patient Decision Aids (“PtDAs”) are at the heart of making care patient-centered. They recognize that for preference-sensitive care, variation should be driven by patient not provider preferences SDM has the potential of reducing unwarranted variations in the use of preference-sensitive health care options Numerous randomized trials indicate that Patient Decision Aids (PtDAs) prevent overuse of options that informed patients do not value Shared decision-making provides a patient-centered foundation for the use of comparative effectiveness research

6. 5 Challenges to Expanding Shared Decision-making History of “informed consent” being uninformed and non-consensual (signing long legalese document prior to procedure) Clinicians rarely trained or supported in engaging patients/caregivers as partners Evidence gaps: –Risks, benefits and alternative treatments –What types of SDM or patient aids make the most difference No standard definitions of share decision-making Misaligned incentives – big money for DOING procedures, no money for helping patients decide what’s right for them

7. 6 Private Sector SDM Adoption: Wide Variation in Employer Demand and Health Plan Support General Support: Responding to patients and/or providers’ requests for information; wide support for incorporating SDM features as part of nurselines or general counseling programs Specific Support: Growth in strategies to facilitate SDM tools in clinical settings; using data to identify patients who would benefit

8. 7 Purchasers Expectations of Health Plans for SDM “Purchasers expect plans to provide well- researched and objective resources to support members in making treatment decisions. Plans are encouraged to incorporate benefit coverage and Plan/network-specific cost information. Purchasers also expect Plans to promote and evaluate use of their treatment option support services.” eValue8 RFI Standard, 2009

9. 8 Examples of Health Plan Support of SDM Nurse call centers providing decision support for preference-sensitive treatments in response to questions/concerns of patients. But, many challenges, including: –Linking nurse services to how decisions are actually carried out at point of service; –Still very dependent on provider; providers need training in “assess, advise, agree, assist, arrange” methodology. Targeted outreach (“push” strategies) to reach out to individuals who may be considering preference sensitive care: –Data mining from claims to ID and reach out to individuals who may be considering treatment options

10. 9 State Legislative Activity to Promote Shared Decision-making StateMajor ProvisionsTarget PopulationBill Status WADirects the Health Care Authority (HCA) to establish SDM demonstration pilots at group practice sites; Gives providers legal protection by formally recognizing SDM within informed consent context, and defines what constitutes SDM. Basic Health Plan members SB 5930 signed into law, May 2, 2007 VTSDM pilot programs to increase patient awareness of treatment alternatives, with a goal of reducing variation. Public and privately insured S. 129 signed into law, May 28, 2009 MNRequire providers to actively participate in SDM process before referral is approved or reimbursement is paid. State employees and Medicaid enrollees LD-1358 proposed MEProvide reimbursement to providers for engaging in Shared Decision-Making. MaineCare and Private Health Plan members SF-696 proposed

11. 10 Federal Proposals to Expand SDM Senate Bill 1133: Establish shared decision-making standards, requirements, and a pilot program for the implementation of shared decision making under the Medicare program. Financial assistance for the establishment and support of Shared Decision-Making Resource Centers Bonus payments to eligible providers participating in the pilot program who achieve high quality shared decision making Program would evolve to reducing payments for preference sensitive care where patient did not previously receive SDM Senate HELP Committee – Affordable Health Choice Act: Many elements parallel Senate Bill 1133 (Section 217) Expands measurement development of effective use of SDM, but: –Does not make SDM covered benefit or establish a pilot program –Does not expand to potential of non-payment where SDM does not occur

12. 11 Potential Roles for Consumer, Labor and Employers in Expanding Shared Decision-making As Purchasers: hold plans accountable; develop benefit design incentives; Negotiate with health plans to provide incentives to employees/providers for using PtDAs Utilize Support Tools to educate employees Public advocacy for payment reform that pays for SDM or pays less for preference sensitive care when SDM not provided Support for development of standards or certification for SDM and PtDAs

13. 12 The Consumer-Purchaser Disclosure Project is an initiative that is improving health care quality and affordability by advancing public reporting of provider performance information so it can be used for improvement, consumer choice, and as part of payment reform. The Project is a collaboration of leading national and local employer, consumer, and labor organizations whose shared vision is for Americans to be able to select hospitals, physicians, and treatments based on nationally standardized measures for clinical quality, consumer experience, equity, and efficiency. The Project is funded by the Robert Wood Johnson Foundation along with support from participating organizations. Previous Discussion Forums are available at: http://healthcaredisclosure.org/activities/forums/ For More Information Contact: Tanya Alteras, MPP Associate Director 202-238-4820 talteras@nationalpartnership.org About the Disclosure Project