n particular, given the shortage of primary care providers,1 affordable, high-quality health care for increasing numbers of elderly, chronically ill people may not be available without adopting new ways of delivering care. The growth in chronic illness will continue to spiral upward, with a 40 percent increase in heart disease and a 50 percent increase in cancer and diabetes projected for 2023.2 Baby boomers are just beginning to enter their high-maintenance health care years of sixty-five-plus,3⇓⇓–6 while workforce statistics show that physicians and nurses are both in short supply.7,8 The Centers for Medicare and Medicaid Services (CMS) predicts that health care costs could reach almost 20 percent of gross domestic product (GDP) by 2022 without interventions.9 Policy makers, payers, providers, and patients are actively exploring ways to control the cost of health care through value-based purchasing plans, innovative care delivery systems, and novel means of empowering patients to manage their own illnesses.Another approach is the development of accountable care organizations (ACOs), through which providers may be financially rewarded for controlling costs and improving outcomes but assume some measure of financial risk if they fail to do so. ACOs thus will have incentives to use specialist physician care for patients in the most efficient manner. For example, providing remote dermatology or radiology consultations to primary care providers instead of referring patients to additional (and expensive) specialty visits may become a safe and recommended practice.
These forces are coming into play at a critical moment. By 2050 the US population will grow from the current 314 million to nearly 400 million.1 The number of Americans age sixty-five and older will nearly double, growing to eighty-four million or one in five US residents.1 Right now we spend approximately 84 percent of our health care dollars on patients with chronic conditions—a cohort that is expected to grow.2More chronic illness means more-intensive use of health care resources. Nearly 20 percent of gross domestic product (GDP), or more than $2.6 trillion, is already devoted to health care.3 We cannot afford more. The only answer is to demand greater value.Previous SectionNext Section
^ President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998). "Quality First: Better Health Care for All Americans".Jump up ^ Engel GL (May 1980). "The clinical application of the biopsychosocial model". Am J Psychiatry137 (5): 535–44. PMID 7369396.Jump up ^Levenstein JH (1984). "The patient-centred general practice consultation". South African Family Practice5: 276–82.
Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D.N Engl J Med 2013; 368:6-8January 3, 2013DOI: 10.1056/NEJMp1209500Share:Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D.N Engl J Med 2013; 368:6-8January 3, 2013DOI: 10.1056/NEJMp1209500Share:
Several Initiatives have been
• MEDICAL HOME
• SHARED SAVINGS
• BUNDLED PAYMENT
• PAY For PERFORMANCE
• ACAs … BUT
SUPPLY /DEMAND Asymmetry
• Growth in chronic illness will continue to spiral upward,
• 40 percent increase in heart disease and a
• 50 percent increase in cancer and diabetes projected for 2023.
• Baby boomers are just beginning to enter their high-maintenance
health care years of sixty-five-plus ( non debatable)
• physicians and nurses- (Clinicians) are both in short supply. (
workforce statistics data)
• Scope of practice regulations are restrictive for non physician
SO HOW DO WE GET THERE
• MAJOR IMPEDIMENT: SHORTAGE OF CLINICAL EXPERTISE and COST
HAMPERING SCALABILITY OF PILOT SOLUTIONS.
IMAGINE IF THIS WERe FASTER….
FASTER CURES.. What about FasteR
• The first group, "The Alarmed," is made up 16% of the public. They believe health change is an
urgent problem but have no clear idea of how to fix it. (Aging Baby boomers)
• The second group (30%) is "The Concerned." They believe it is your neighbors problem no theirs..
They are in control! (millennial, currently healthier baby boomers)
• The third group, "The Cautious" (23%), are people on the fence. (Enlightened baby boomers,
quantified self folks, ).
• The fourth group, "The Disengaged" (10%), doesn't know anything and does not want to know (
consumed by life issues or lack thereof)
• The fifth group, "The Doubtful" (12%), do not believe there is away to solve it. ( the sky is falling
and the cup is half full)
ONE SIZE FITS ALL – Not a Reality in
Patients: The recent
advancements in technology
have ushered in an era of patient
patients were largely reliant on
doctors for any knowledge or
information regarding their
health; now, patients have the
tools to track and monitor their
health at home or on-the-go,
allowing them to be active
members of their own health
Only 10–15 percent of an individual’s health status is attributable to the health care services he or she
receives. The rest is driven by behavior, genetics, and social determinants including living
conditions, access to food, and education status.
That means that the trillions of dollars the United States spends on health care
services contribute to only one-tenth of the nation’s health.
An individual’s behavior is by far the single most important contributor to his or
her overall health. It is also a substantial driver of health care costs.
SHARED DECISION MAKING NOT A
NEW PHENOMENON:• In a 2001 report, Crossing the Quality Chasm, the Institute of
Medicine recommended redesigning health care processes
according to 10 rules, many of which emphasize shared
• One rule, for instance, underlines the importance of the
patient as the source of control, envisioning a health care
system that encourages shared decision making and
accommodates patients' preferences.
IN Fact WE have RECONGNISED IT FOR
More than 3 decades• One of the first instances where the term ‘shared decision making’ was used was in a
report entitled the ‘President's Commission for The Study of Ethical Problems in Medicine
and Biomedical Research. This work built on the increasing interest in patient-
centredness and an increasing emphasis on recognising patient autonomy in health care
interactions since the 1970s.
• Charles described a set of principles for shared decision making, stating “that at least two
participants, the clinician and patient be involved; that both parties share information; that
both parties take steps to build a consensus about the preferred treatment; and that an
agreement is reached on the treatment to implement. ”These principles rely on an
eventual arrival at an agreement but this final principle is not fully accepted by others in
the field. The view that it is acceptable to agree to disagree is also regarded as an
acceptable outcome of shared decision making.
• ^ Charles C, Gafni A, Whelan T (March 1997). "Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango)". Soc Sci Med
44 (5): 681–92. doi:10.1016/S0277-9536(96)00221-3. PMID 9032835.
NOT FAR ENOUGH in our journey
• The care patients receive doesn't always align with their
preferences. For example, in a study of more than 1000 office visits
in which more than 3500 medical decisions were made, less than
10% of decisions met the minimum standards for informed decision
• Braddock CH III, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back
to basics. JAMA 1999;282:2313-2320
• Similarly, a study showed that only 41% of Medicare patients
believed that their treatment reflected their preference for palliative
care over more aggressive interventions.
• Covinsky KE, Fuller JD, Yaffe K, et al. Communication and decision-making in seriously ill patients: findings of the
SUPPORT project: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am
Geriatr Soc 2000;48:Suppl:S187-S193
SHARED DECISION MAKING AND
• A 2011 Cochrane Collaborative review of 86 studies showed
that as compared with patients who received usual care,
those who used decision aids had increased knowledge, more
accurate risk perceptions, reduced internal conflict about
decisions, and a greater likelihood of receiving care aligned
with their values. Moreover, fewer patients were undecided
or passive in the decision-making process — changes that are
essential for patients' adherence to therapies.
SHARED DECISION AND OPTIMAL
• Consistently, as many as 20% of patients who participate in shared
decision making choose less invasive surgical options and more
conservative treatment than do patients who do not use decision aids
• Stacey D, Bennett CL, Barry MJ, et al. Decision aids for
people facing health treatment or screening
decisions. Cochrane Database Syst Rev
Why payers see alignment
• In 2008, the Lewin Group estimated that implementing shared decision
making for just 11 procedures would yield more than $9 billion in savings
nationally over 10 years.
• In addition, a 2012 study by Group Health in Washington State showed
that providing decision aids to patients eligible for hip and knee
replacements substantially reduced both surgery rates and costs — with
up to 38% fewer surgeries and savings of 12 to 21% over 6 months.4 The
myriad benefits of this approach argue for more rapid implementation of
Section 3506 of the ACA.
Source: Veroff D, Marr A, and Wennberg DE. Enhanced support for shared decision making reduced costs of care for patients with preference-
sensitive conditions. Health Aff 2013;32(2):285–293.
NOTES: Medical costs were capped at $200,000 per year. Advanced imaging includes magnetic resonance imaging, X-ray computed
tomography, and positron emission tomography. Standard imaging includes standard X-rays and ultrasound.
**p < 0:05 ***p < 0:01 ****p < 0:001
WHERE DOES ACA FIT IN
• Section 3506 of the Affordable Care Act directly relates to Shared Decision
Making. Specifically it would offer funding resources to an independant
organization to develop standards for Shared Decision Making, and tools to
assist in the implementation of Shared Decision Making.
• Additional funding in the form of grants may be available to providers who are
willing and able to show effective implementation of these tools in the practice
• Finally, there is authorization from the Center of Medicaid and Medicare to
begin testing the impact of Shared Decision Making Models across metrics that
take into account both cost, quality and satisfaction.
WHAT DO PATIENTS/CONSUMERS
HOW IMPORTANT IS IT FOR YOUR PHYSICIAN PROVIDE YOU OPTIONS FOR SDS
THE FORGOTTEN ASSET
• We have positioned patients as passive
recipients of care, not fully recognizing that
• they have tremendous insights, expertise and
experience that can help us build cost-efficient,
high-quality, safe systems of care,”
• Bev Johnson, president and CEO
• of the Institute for Patient- and Family-Centered Care.