Policy Options to Encourage Patient-Physician Shared Decision Making

Originally published by the Center for Studying Health System Change (HSC) as NIHCR Policy Analysis No. 5, September 2011.

Shared Decision Making: Bridging the Gap Between Patient Preferences and Medical Care

Significant discrepancies persist between what patients prefer in terms of medical treatment and the care they actually receive for many common conditions. Shared decision making (SDM) is a clinical process in which a patient and clinician, faced with more than one medically acceptable treatment option, work together to determine which option best fits the patient's needs, preferences, and values in light of the available evidence.

This Policy Analysis, authored by Ann S. O'Malley, Emily Carrier, Elizabeth Docteur, Alison C. Shmerling, and Eugene C. Rich, examined the promise and challenges of shared decision making as both a strategy for improving the quality of medical care and a potential mechanism for containing health care costs. The authors found that SDM could help close the gap between the care patients want and the care they receive, while potentially reducing spending by steering patients away from treatments they do not actually want once they are fully informed about the options, risks, and benefits.

Barriers to Wider Adoption

Several obstacles impeded broader use of shared decision making in clinical practice. The prevailing fee-for-service payment system rewarded higher service volume rather than time spent counseling patients about treatment options. Physicians had limited financial incentive to invest the additional time required for meaningful shared decision making conversations when they could generate more revenue by seeing additional patients or performing more procedures.

There was also insufficient information about the best ways to train clinicians to weigh evidence and discuss treatment options for preference-sensitive conditions with their patients. Malpractice liability concerns added another layer of complexity, as some physicians worried about legal exposure if patients chose less aggressive treatment options through a shared decision making process and later experienced poor outcomes.

Patient-side barriers existed as well. Low health literacy made it difficult for some patients to engage meaningfully in treatment discussions, even with well-designed decision aids. Some patients feared that shared decision making was a mechanism to deny them care rather than a genuine effort to align treatment with their preferences. The political climate further complicated matters, as public discussion of shared decision making, particularly when applied to end-of-life care decisions, had become entangled in politically charged rhetoric that stifled productive dialogue.

Patient Decision Aids and Quality Standards

Patient decision aids (PDAs) are tools designed to help patients understand their treatment options, the likely outcomes of each option, and how their own values and preferences should factor into the decision. These tools take various forms, including printed materials, videos, and interactive web-based programs. Research has shown that when patients use well-designed decision aids, they tend to make more informed choices and, in many cases, choose less invasive or less expensive treatment options than patients who do not use such tools.

The 2010 health reform law established a process to encourage shared decision making, including setting standards for patient decision aids and creating a mechanism for certifying these tools through an independent entity. However, Congress had not appropriated funding for these tasks at the time of the analysis, leaving the implementation pathway uncertain.

Policy Options for Advancing Shared Decision Making

The authors identified several policy options that could foster greater adoption of shared decision making. Ensuring the scientific rigor and quality of patient decision aids through a credible certification process was a foundational step. Liability protections for clinicians who use certified decision aids and document the shared decision making process could help address physicians' malpractice concerns. Additional payments or adjustments to the fee schedule that compensated clinicians for the time spent in shared decision making conversations could remove a significant financial barrier.

Over the longer term, incorporating shared decision making as a core component of emerging delivery system and payment reforms could accelerate its adoption. Patient-centered medical homes, accountable care organizations, and meaningful-use requirements for health information technology all represent potential vehicles for embedding shared decision making into routine clinical practice. By making SDM an expected element of these reform models rather than a standalone initiative, policy makers could help build the infrastructure, training, and cultural change needed for shared decision making to become standard practice rather than an occasional add-on.

Sources and Further Reading

O'Malley, Ann S., Emily Carrier, Elizabeth Docteur, Alison C. Shmerling, and Eugene C. Rich, "Policy Options to Encourage Patient-Physician Shared Decision Making," NIHCR Policy Analysis No. 5, Center for Studying Health System Change (September 2011).

Stacey, Dawn, et al., "Decision Aids for People Facing Health Treatment or Screening Decisions," Cochrane Database of Systematic Reviews.