CMS Initiatives to Test Shared Decision Making

Ken Terry

December 12, 2016

The Centers for Medicare & Medicaid Services (CMS) announced Thursday that its Innovation Center is launching a pair of 5-year demonstration projects aimed at evaluating different approaches to shared decision making between physicians and patients.

The Shared Decision Making (SDM) Model will focus on integrating this approach into clinical workflow in accountable care organizations (ACOs). The Direct Decision Support (DDS) Model, to be tested in the other project, will use outside "decision support organizations" to educate patients about their treatment choices so they can have informed conversations with their doctors.

Both demonstrations will include fee-for-service Medicare beneficiaries who have one of the following "preference-sensitive" conditions: stable ischemic heart disease, hip or knee osteoarthritis, herniated disk or spinal stenosis, clinically localized prostate cancer, and benign prostate hyperplasia. A preference-sensitive condition, as defined by CMS, is one for which there are multiple treatment options and no clear evidence on which approach is best. The decision support organizations — which CMS has not fully described — will also be encouraged to provide decision support for "a broader range of acute and chronic conditions."

The SDM Model, expected to engage over 150,000 Medicare patients annually, will use patient decision aids in a four-step process. The ACOs can do three of the steps, including identification of SDM-eligible beneficiaries, distributing patient decision aids to these patients, and tracking and reporting the effects of shared decision making. However, a physician or other provider must furnish the SDM service, which involves discussing the treatment options in depth with patients.

CMS plans to operate the SDM Model in an intervention group of practices participating in 50 ACOs nationwide, along with an equal number of comparison ACOs. To qualify, ACOs must participate in the Medicare Shared Savings Plan or the Next Generation ACO program. The ACOs must commit to 2 years of participation and will be offered up to three year-by-year renewals if they meet performance criteria.

The ACOs will receive $50 per SDM service delivered by their practitioners. It is possible, but not required, that they will pass this money onto physicians who engage in shared decision making discussions.

Not many physicians are doing so currently, CMS noted. "Despite the inherent value of shared decision making, the literature indicates that practitioners have found it difficult to integrate shared decision making into their routine workflows," the agency said. Among the reasons CMS cited are heavy workloads, insufficient training, inadequate information systems, and lack of consistent methods to measure whether shared decision making is taking place.

Glyn Elwyn, MD, director of the shared decision making research lab at the Dartmouth Institute for Healthcare Policy and Clinical Practice, Hanover, New Hampshire, told Medscape Medical News that doctors "vary tremendously in their willingness to discuss treatment options with patients. The incentive to use a comparison tool in primary care is low when you're under time pressure."

So primary care physicians often refer patients with serious medical problems to specialists, who are more likely to perform a test or procedure than engage in shared decision making, he said.

However, if primary care doctors were paid $50 per service, he added, they might spend the necessary time with patients to discuss their choices in depth.

Decision Support for Patients

In the DDS demonstration, each decision support organization will have a population of least 100,000 Medicare beneficiaries in a specific geographic area. "Engaged beneficiaries will interact with decision support mechanisms, such as web-based PDAs [patient decision aids] and tools, telephonic decision support, and/or mobile e-health applications," CMS said.

Beneficiaries assigned to a decision support organization will receive a letter informing them they have been enrolled in the program. They will also be told they can opt out of the initiative.

CMS will partner with up to seven decision support organizations, which must commit for at least 2 years. After that, if they meet performance goals, they will be offered up to three 1-year contract renewals. They will receive a fixed monthly payment for each assigned beneficiary.

CMS did not explain exactly what a decision support organization is in its online materials, and a CMS spokesman did not respond to a request for clarification at press time. However, some health plans have used outside firms to educate patients about evidence-based care; Aetna even bought one of these companies, ActiveHealth Management.

Dr Elwyn is skeptical about the DDS model, although he thinks it's a step in the right direction. Even if the decision support organizations use the best patient decision aids, he said, "The research shows that the informed or empowered patient doesn't necessarily translate into the ability to ask questions or disagree with a practitioner." Patients are often afraid to ask doctors about treatment options or to disagree with their physician, he said, because they're afraid it will lead to worse care in the future.

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