1. Karen Merrikin, JD Senior Policy Advisor Group Health Cooperative Shared Decision Making: Promoting patient centered care through health policy changes Alliance for Health Reform February 14, 2011

2. Group Health Cooperative: Background n A member governed, non-profit health plan and care delivery system with 650,000+ members in Washington State and N. Idaho n Our members come to us via Medicare, employer plans, individual plans, and low income programs. n Two primary models of care: Integrated Group Practice (GH owned clinics with GH salaried providers) Network (contracted clinics and providers)

3. Patient-centered care at Group Health Shared electronic medical record Medical home pilot Decision aids for shared decision making 2005 2007 2009 Implementation timeline 2011 Evaluation of decision aids continues

4. Why Focus on This Type of Variation? Spokane Seattle Community wide, variation not explained by peoples health needs or preferences.

5. Even within Group Health, geography is destiny (for your knees) Statewide Rate 2005

6. What Solutions? For Group Health? For Communities We Serve? Increased knowledge More active patient participation Better alignment between values & choices 34 randomized controlled trials Lower surgery rates No evidence of harms from not having surgery 7 RCTs Higher patient knowledge & satisfaction Lower surgery rates with similar outcomes 2 Group Health studies

7. Health Policy Rationale for SDM Expansion Ethical imperative - to do the right thing Improved Informed Consent-Aligning preferences, values and lifestyle with individuals clinical decision Better Decisional Quality Reduced Malpractice exposure Bridging Health Disparities Generally More Conservative utilization of surgical interventions

8. How Did We Engage our Community? Washington State Legislation, 2007 n Just do it – and measure results A multi-site, coordinated demonstration project and evaluation of the use of decision aids for elective surgeries, focused on state purchased healthcare and coordinated through state agency. n Raise the bar on informed consent A change in the states informed consent laws to recognize that prevailing community practice patterns may not always be the right benchmark when it comes to informed patient choice. n Bi-partisan Interest and Support

9. Whats in the Legislation: A New Approach to Informed Consent

10. Wa. State Health Care Authority Shared Decision Making Collaborative Stakeholders Group Group Health Cooperative & GH Research Institute The Everett Clinic Puget Sound Health Alliance Virginia Mason Medical Center University of Washington Evaluation, Coordination WA OFM The Collaborative Structure & Practice Sites Multicare Medical Center

11. SDM Collaborative: A Focus on Six Critical Areas with High Variation in Washington State Orthopedics Cardiology Urology Womens health Breast cancer Back care 1 2 3 4 5 6

12. Group Healths Approach System-wide implementation 2-year research project Foundation support

13. 12 Preference-sensitive Conditions OrthopedicsCardiologyUrology Womens Health Breast Cancer Back Care 1.Hip osteoarthritis 2.Knee osteoarthritis 3.Coronary artery disease 4.Benign prostatic hyperplasia 5.Prostate cancer 6.Uterine fibroids 7.Abnormal uterine bleeding 8.Early stage 9.Ductal carcinoma in situ 10.Breast reconstruction 11.Spinal stenosis 12.Herniated disc

14. Distributing Decision Aids DVDs can be ordered for mailing or viewed on the Web

15. What are We Learning? Ordering & viewing Provider interviews Patient survey link link

16. Decision aid distribution Number of videos distributed, by month Total: 8,808* *As of 12/31/2010; does not include decision aids viewed on the web after Oct 2009 JanAprJulOctJanAprJulOct 20092010

17. 20092010 Percentage of procedures for preference sensitive conditions where patient did not receive the video Fewer missed opportunities

18. Overall rating of decision aid videos Patient survey, September2010, 950 responses Helped you understand the treatment choices Helped you prepare to talk with provider Patient assessment

19. Overall rating of decision aid videos Patient survey, September 2010, 975 responses How important is it that providers make programs like this available?

20. Next Steps at Group Health n Preliminary findings from Group Healths 2 year evaluation, likely complete in late Spring, 2011. Patient satisfaction, cost impact, strategies to improve usage rates. n However, Group Health is not waiting for the formal results. n We are accelerating our efforts to implement SDM, focusing on ways to incorporate shared decisionmaking into standard workflows, and broadening adoption among our network providers. n We now measure defect rate around SDM.

21. Where Must We Go From Here? n National Certification Standards and Processes for Decision Aids Assures Decision Aids are High Quality, Unbiased, Up to date. Activates Informed Consent Law Provisions. n Policy Strategies that Promote Widespread Adoption Payment, certification, collaboratives, measurement n Patient and Purchaser Demand CMS & Employers Satisfied Patients n Authorized AND Appropriated

22. So, Why Shared Decision Making? Because we care about better value Because care should be centered around patients values. And because we can take our experience in working collaboratively on SDM and apply it to broader health reform challenges.