The power of shared decision making to control healthcare costs

A new Institute of Medicine report estimates the healthcare industry wastes $750 billion a year. Couple that with research showing a third of all healthcare spending is unnecessary, and everyone can agree healthcare costs are out of control.

Such astronomical figures were on my mind as I watched a screening this week of Money and Medicine, a new PBS documentary airing Sept. 25 that examines soaring healthcare costs through the lens of overdiagnosis and overtreatment.

In addition to identifying areas that drive excessive healthcare (e.g., end-of-life care, diagnostic testing and screenings), it offered some strategies to help keep escalating healthcare costs in check.

Like the IOM report, the film points to patient engagement and, more importantly, shared decision making as key to delivering more cost-effective care.

The film featured Utah's Intermountain Healthcare for its success at reining in runaway healthcare expenditures. It attributes some of that success to participation in a collaborative with Dartmouth-Hitchcock and the Mayo Clinic that uses a formal set of shared decision-making tools and then measures their impact, Brent James, M.D., Intermountain's chief quality officer, told FierceHealthcare.

"The other place where I've seen real success with shared decision making within our system is at the level of ICU care and hospice, which starts on an outpatient setting," James said, noting that even though provider-patient conversations take time, they need to happen. And after they happen, those shared decisions must be carried forward every time the patient comes into contact with the system.

Another key ingredient to shared decision making, according to James, is family involvement. Including the family in the decision-making process has helped Intermountain and Utah achieve one of the highest hospice rates in the country--which is associated with care that is must cheaper and much more receptive to patient wishes, not to mention, longer life expectancies, James noted.

But what the film fails to address is that a lot of overtreatment and excessive costs stem from defensive medicine.

In countless surveys, doctors have admitted to providing too much medical care. They cite malpractice concerns, current reimbursement systems and clinical performance measures as the main forces behind more aggressive healthcare.

"The term I like to use for it is 'rescue care.' And it's an attitude as much as anything--if it might work, let's do it. It's the hope for the miracle," James said. "But maybe only 1 in 100 will get the miracle, and the other 99 are going to get a little bit of harm, at massive expense."

Even if providers practice defensive medicine to avoid medical errors, those extra procedures and screenings actually increase the likelihood of error and additional complications, according to Sanjay Gupta, the associate chief of neurosurgery at Grady Memorial Hospital and the chief medical correspondent for CNN.

With such stats, healthcare needs a culture change--one that moves providers away from the mindset that more care means better care.

"It's this real aggressive disposition to do more--even when more is not better. How do we deal with that, and how do we get better service to our patients in terms of what really works," James said.

Some would say the solution must include tort reform. For Gupta, short of abolishing defensive medicine, simply asking fellow doctors to justify the procedures they order and perform can help providers rethink care decisions.

Meanwhile, James is hoping for a more "old-school" approach to improve efficiency and eliminate waste. "The primary role of a good clinician is to be a wise counselor, a trusted advisor--that's the thing patients value more than any other thing."

But, he noted, as the science of medicine advanced during the past 50 years, the basics of caring have fallen by the wayside. "Maybe it's going home to our roots and getting much better in that role of wise counselor, trusted advisor."

So how do you think the industry can take control on escalating costs? What will it take to set a culture change in motion? - Alicia (@FierceHealth)