Shared decision-making works well, but requires time
by Joyce Frieden, News Editor, MedPage Today September 26, 2017

WASHINGTON — Paying doctors more for simply sitting and talking with their patients — rather than basing payment more on quality measures — would be a great way to improve the doctor-patient relationship, Andy Lazris, MD, said here Tuesday.
Today, “if you discuss something with the patient, you lose on quality measures” because you’re not spending the time performing a recommended test or procedure, said Lazris, who is co-chairman of the Right Care Alliance Primary Care Council. “That’s antithetical to [good] decision-making.” He spoke at a briefing on the doctor, patient, and government relationship sponsored by Politico, Center Forward, the Doctor-Patient Rights Project, and the Galen Institute.
Lazris works in an accountable care organization with many elderly patients, so a lot of the regular quality indicators don’t apply, he said.
“To me, quality measures should be ‘You’ve had that discussion’,” he continued. “I don’t want to lower my 85-year-old patient’s blood pressure too low, but if I lower enough that they faint and break their hip, I would have passed that [hypertension] quality measure.”
Part of the difficulty in trying shared decision-making with patients is lack of time, said Yalda Jabbarpour, MD, assistant professor of family medicine at Georgetown University in Washington. “Expanding that time in the office … would help the patient.”
Talking with patients has “almost a metaphysical aspect” to it, according to Sen. Bill Cassidy, MD (R-La.), a gastroenterologist. “Imagine you’re with a friend and another friend has died. As you speak to your friend, you measure in their body language and their eyes how they’re receiving it … That is the key to the doctor-patient relationship,” he said.
Even when a physician is tired and supposed to go home, “when a patient has cancer, but she can’t hear you say, ‘There’s hope’ because all she hears is ‘cancer’ — let me take a little more time, let me not tap away on the computer which the government tells me I have to do or I don’t get paid,” he continued. “We need to take the time to look in the patient’s eyes and say, ‘There’s hope.'”
There is data that shows that taking this kind of approach — with patients involved in medical decision-making — works well, said Sen. Jeanne Shaheen (D-N.H.). “Data show that if you implement this model, not only do patients tend to choose the less invasive procedure, they are happier, physicians are more satisfied working with that kind of model, and costs go down … There are all kinds of reasons why we should encourage this model.”
The ongoing battle over healthcare reform makes trying to implement this type of change in reimbursement a challenge, Shaheen said. “We can never get to those discussions … unless we get over this Groundhog Day we’re in now where we continually decide whether to repeal the Affordable Care Act or go forward with it. We have got to get to that point where we can talk long-term about what we want to do with healthcare.”
Transparency about healthcare costs and tradeoffs also will be key to encouraging shared decision-making, said David Barbe, MD, president of the American Medical Association. “As physicians and patients are discussing treatment options, it may be impossible as the family physician to know which [specialist] physicians are on the patient’s network and how much hospitalization might cost. There may be ways [to get that information] and help people make informed decisions.”
This should extend to physician outcomes as well, to include outcomes and patient satisfaction data, said Rep. Roger Marshall, MD (R-Kan.), a retired ob/gyn. “Medicare would collect data on me and compare me to other doctors at similar hospitals … ‘This is what Dr. Marshall spends on average hysterectomy; this is his average length of stay, this is his readmission rate.'”
Another issue is making sure to include patient-reported outcomes in quality measures, said Kim Templeton, MD, immediate past president of the American Medical Women’s Association. “When looking at quality, it should not just be ‘Did you order a specific test?’ but also ‘How did the patient do?'” she said. “This is where we really need to engage the patient … Unfortunately, while process measures are easy to measure, patient-reported outcome measures are not available for all conditions and are some of the most challenging things to measure.”
For one thing, men and women are very different when it comes to medical care, “and process measures don’t necessarily take that into account, and a lot of patient-reported measures don’t [either],” Templeton said. For instance, “depression manifestation is different in women than in men but that’s something you don’t necessarily get in a process measure.”
The speakers had some definite ideas about what Congress might do to help solve some of these problems. “One thing … is to pay doctors as much to talk to patients as to do something,” said Lazris. “You’ll get more primary care physicians, the healthcare system will be saved, and patients will be saved.”
“Align measures to make them more simple, and give things time to mature,” said Jabbarpour. “It’s hard for physicians to keep adapting to more measures.