karen merrikin, jd senior policy advisor group health cooperative shared decision making: promoting...

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

Group Health Cooperative: Background

A member governed, non-profit health plan and care delivery system with 650,000+ members in Washington State and N. Idaho

Our members come to us via Medicare, employer plans, individual plans, and low income programs.

Two primary models of care:

Integrated Group Practice (GH owned clinics with GH salaried providers)

Network (contracted clinics and providers)

Patient-centered care at Group Health

Shared electronic medical record

Medical home pilot

Decision aids for shared decision making

20052005

20072007

20092009

Implementationtimeline 20112011

Evaluation of decision aids continues

Why Focus on This Type of Variation?

Spokane

Seattle

Community wide, variation not explained by people’s health needs or preferences.

Even within Group Health, geography is destiny (for your knees)

6

8

10

12

14

16

18

20

22

King Co GHCentral

GHEastside

GHSouth

Spokane

Statewide Rate2005

What Solutions? For Group Health? For Communities We Serve?

Health Policy Rationale for SDM Expansion

Ethical imperative - to do the right thing

Improved Informed Consent-Aligning preferences, values and lifestyle with individual’s clinical decision

Better Decisional Quality

Reduced Malpractice exposure

Bridging Health Disparities

Generally More Conservative utilization of surgical interventions

How Did We Engage our Community?Washington State Legislation, 2007

“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.

Raise the bar on informed consent

A change in the state’s informed consent laws to recognize that prevailing community practice patterns may not always be the “right” benchmark when it comes to informed patient choice.

Bi-partisan Interest and Support

What’s in the Legislation: A New Approach to Informed Consent

Wa. StateHealth Care Authority

Shared Decision MakingCollaborative

Stakeholders Group

Group HealthCooperative &GH Research Institute

The Everett Clinic

Puget Sound Health Alliance

Virginia MasonMedical Center University of

WashingtonEvaluation,

Coordination

WA OFM

The Collaborative Structure & Practice Sites

Multicare Medical Center

SDM Collaborative: A Focus on Six Critical Areas with High Variation in Washington State

1

2

3

4

5

6

Group Health’s Approach

System-wide implementation

2-year research project

Foundation support

12 Preference-sensitive Conditions

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 stage9. Ductal

carcinoma in situ

10. Breast reconstruction

11. Spinal stenosis

12. Herniated disc

Distributing Decision Aids

DVDs can be ordered for

mailing or viewed on the

Web

What are We Learning?

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

Jan Apr Jul Oct Jan Apr Jul Oct2009 2010

2009 2010

Percentage of procedures for preference sensitive conditions where patient did not receive the video

Fewer missed opportunities

Overall rating of decision aid videosPatient survey, September2010, 950 responses

Helped you understand the treatment choices

Helped you prepare to talk with provider

Patient assessment

Patient assessment

Overall rating of decision aid videosPatient survey, September 2010, 975 responses

How important is it that providers make programs like this available?

Next Steps at Group Health

Preliminary findings from Group Health’s 2 year evaluation, likely complete in late Spring, 2011.

Patient satisfaction, cost impact, strategies to improve usage rates.

However, Group Health is not waiting for the formal results.

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.

We now measure “defect rate” around SDM.

Where Must We Go From Here?

National Certification Standards and Processes for Decision Aids

Assures Decision Aids are High Quality, Unbiased, Up to date. Activates Informed Consent Law Provisions.

Policy Strategies that Promote Widespread Adoption

Payment, certification, collaboratives, measurement

Patient and Purchaser Demand

CMS & Employers

Satisfied Patients

“Authorized AND Appropriated”

So, Why Shared Decision Making?

Because we care about better value

Because care should be centered around patient’s values.

And because we can take our experience in working collaboratively on SDM and apply it to broader health reform challenges.