Shared Decision-making’s Place in Health Care Reform Peter V. Lee Executive Director National Health Care Policy, PBGH Co-Chair, Consumer-Purchaser Disclosure Project Foundation for Informed Medical Decision Making Research and Policy Forum January 28, 2010

Health Care Reform Isn’t Dead © Consumer-Purchaser Disclosure Project, Health Care Reform

Reforming Health Care Delivery Core “Reform” Elements © Consumer-Purchaser Disclosure Project, Major Policy AreaDisclosure’s Critical Value Policies Coverage Expansion and Financing 1. Align public and private policies 2. Connector or Exchange promoting value Benefits3. Assure core benefits promote affordable “right care” System Reforms 4.Full measures and public reporting (including release Medicare data) 5.Promote wellness 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

Patient & Payer Consensus on Key Delivery Reform Elements Groups representing consumers, patients and purchasers developed recommendations that identify the best provisions of the House and Senate health reform provisions to improve quality and slow cost growth in health care:  Payment reform  Comparative Effectiveness Research  Performance Measurement  Public Reporting For complete report, recommendations and broad list of endorsers go to: © Consumer-Purchaser Disclosure Project,

Why Shared Decision-making is Core to Reforming Care Delivery Shared decision-making and use of patient decision aids 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. Shared decision-making has the potential of reducing unwarranted variations in the use of preference-sensitive health care options. Numerous randomized trials indicate patient decision aids 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. © Consumer-Purchaser Disclosure Project,

Shared Decision-making in Federal Reform 2010 House of Representatives (HR 3962):  Shared decision-making demonstration program. Senate (HR 3590):  Support and technical assistance for shared decision-making.  Shared decision-making as a CMS Innovation Center activity. © Consumer-Purchaser Disclosure Project,

House: Shared Decision-making Demonstration Program (HR 3962) Purpose: To improve Medicare beneficiaries’ understanding of their medical options. Program:  Providers to schedule “follow-up consulting visit” for Medicare beneficiaries after they view a patient decision aid. Providers to be reimbursed for visits through creation of new payment code.  Includes collection of outcomes and quality data.  No more than 30 providers (groups). Must have experience implementing, and have invested in infrastructure to implement shared decision-making. Structure: Operated through CMS Innovation Center. Evaluation & Expansion:  Within 12 months Secretary to submit report to Congress with recommendations for legislation and administrative action.  Report includes evaluation of impact on health quality, utilization of health care services, and improving quality of life.  No explicit expansion path. © Consumer-Purchaser Disclosure Project,

Senate: Support and TA for Shared Decision-making (HR 3590) Purpose: Help clinicians engage patients and caregivers through information about trade-offs among treatment options, and incorporating patient preferences and values into the medical plan. Program:  Secretary of HHS to contract with an entity to: (1) establish measures; (2) endorse measures; and (3) certify patient decision aids.  Secretary to award grants: To develop, update, and produce patient decision aids for preference sensitive use; test materials; educate providers on use. Fund Shared Decision-making Resource Centers to supply TA to providers. Support health care providers for development and implementation of shared decision-making techniques. Structure: Funding to begin in FY No $ specified. Evaluation & Expansion: Not addressed. © Consumer-Purchaser Disclosure Project,

Senate: Shared Decision-making as CMS Innovation Center Activity (HR 3590) Purpose: Assisting eligible individuals make informed health care choices. Innovation Center serves Medicare and Medicaid beneficiaries. Program: Pay providers of services and suppliers for using patient decision- support tools. Budget neutral. Structure: Shared decision-making is one of the broad roster of potential programs identified for the Innovation Center, BUT the Center is not required to test shared decision-making (or any of roster of programs). Evaluation and Expansion:  Secretary has authority to expand duration and scope of model that improves care and/or lowers costs and terminate or modify models that do not.  Secretary to submit to Congress report in 2012 and annually thereafter. Report has recommendations on payment models. © Consumer-Purchaser Disclosure Project,

Quick Comparison of House & Senate © Consumer-Purchaser Disclosure Project, TopicHouse Demo Pilot Senate TA and Support Senate Innovation Center PopulationMedicare Medicare (and Medicaid?) Program elements defined in detail Yes No Provider financial incentives YesNoYes Consumer financial incentives No Set standards for patient decision aids NoYesNo Funding for development of patient decision aids NoYesNo Evaluation YesNoYes Provides for potential expansion UnclearN/AYes

Shared Decision-making Advocates: Recommendations to Improve Provisions Clarify focus of shared decision-making on “preference sensitive care”. Ensure robust conflict of interest provisions (patient decision aids used are developed in a way to be balanced, evidence based, and free of bias and conflict of interest). Ensure shared decision-making is extended into other payment pilots. Ensure (for Senate support and TA function) clarification of distinct roles relative to:  Development of measures for patient decision aids  Endorsement of measures  Certification of patient decision aids © Consumer-Purchaser Disclosure Project,

Is Changing Medicare Enough? © Consumer-Purchaser Disclosure Project,

© Consumer-Purchaser Disclosure Project, Changing Medicare: Necessary but NOT Sufficient The full story: Medicare represents only 19% of total health spending. Medicare IS the largest single payer. Medicare CAN have an important sentinel effect. Many efforts need to promote consistency across payers.

To Learn More and Additional Resources 14  — Consumer Purchaser Disclosure Project, good source for background and resources on the value agenda  — an overview of PBGH programs and initiatives, commentaries and policy positions  — Center for Payment Reform, multi-stakeholder collaborative working to reform public and private payment to promote quality and cost containment © Consumer-Purchaser Disclosure Project, 2010 To subscribe to the PBGH E-Letter, go to