shared decision-making program presented by betsy barbeau, scd, mph senior vice president, shared...

Shared Decision-Making Program

Presented by Betsy Barbeau, ScD, MPHSenior Vice President, Shared Decision-Making

Copyright © Health Dialog Services Corporation 2009. All rights reserved.

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A few thoughts

• Ideas that drive us

• A company built to deliver a vision

• How we help people

• Results for clients


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Geography is destiny

In November 2007,

Health Affairs named

Dr. Jack Wennberg

the most influential health policy

researcher of the past 25 years. . . Why?


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Geography is destiny

• Doctors practice medicine differently based on geography

• Much of this variation is unwarranted by medical evidence

• If unwarranted variation were eliminated, it would:

– Dramatically improve quality of care

– Reduce costs by 30%

• There are three sources of unwarranted variation . . .

The Dartmouth Atlas shows . . .


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Effective care

A diabetic Medicare patient

is 40% more likely to have

lipid testing in Royal Oak,

MI than in Sayre, PA


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Supply sensitive care

Medicare spending per enrollee

is 2.5 times greater in Miami, FL

than in Minneapolis, MN

. . . with no difference in outcomes

or life expectancy


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Preference sensitive care

A patient with a herniated disk

is 6 times more likely to have

back surgery in Santa Barbara, CA

than in Bronx, NY

A patient with heart disease

Is 3 times more likely to have

bypass surgery in Bloomington

IN, than in Albuquerque, NM


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Supply sensitive and preference sensitive careaccount for most of the waste

Mismatch of careto patient preference

Too littleeffective care

Too much supply-sensitive care

63%

25%

12%


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Preference-sensitive conditions include…

• Coronary artery disease (meds, angioplasty/stenting, CABG) • Prostate cancer (active surveillance, radiation, surgery) • Osteoarthritis (meds, surgery)• End of life care (‘curative/futile’, palliative, hospice, etc.)• Spinal stenosis (meds, PT, surgery)• Herniated disc (meds, PT, surgery)• Early-stage breast cancer treatment (lumpectomy/radiation,

mastectomy +/- reconstruction) • Benign uterine conditions (meds, D&C, ablation, hysterectomy)• Obesity (behavior change, meds, bariatric surgery)• Etc.


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What matters most depends on who you ask

Doctors and patientssee trade-offsin treatments

very differently

Women Doctors

High quality careis care patients wantwhen they are fully

informed

Keep breast

Live as longas possible

Look naturalwithout clothes

Avoid a prosthesis

7%

59%

33%

33%

71%

96%

80%

0%

Source: Karen Sepucha, MD, Massachusetts General Hospital


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What is Shared Decision-Making®?

• Taking an active role and participating in investigating the options, one’s preferences, and values as they relate to important healthcare decisions

• Actively working with provider to assure the communication flows both ways

“No fateful decisions in the face of avoidable ignorance.”

“The care patients need and no less, the carethey want and no more.”

– Al Mulley, MD


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A company built to deliver a vision

• Founded in 1995

• Our mission: improve healthcare by reducing unwarranted variation

• 1,700 employees

• 24 million lives


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A company built to deliver a vision

• Key external relationships:– The Dartmouth Institute for Health Policy and Clinical Practice– The Foundation for Informed Medical Decision Making

• Our clients:– Private health insurers– Public insurers: county, state, national governments– Large employers– Provider groups

• Why clients buy from us:– Lower claims costs – Better quality– Happier, healthier members


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Empowering patients to make quality medical decisionsOur Approach

The Patient Profiles Database (raw and derived data)

Outreach to individuals

Multiple data sources to identify individuals with PSC

Patient profile database

Analytics engine

Coaching system and patient decision aids

Reporting


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Targeting is driven by predictive models based on claims and by other data that we receive before claims are filed

Dartmouth Atlas data and clinical input from

Foundation for Informed Medical Decision Making

drive every model.

•Physician referrals •Pre-auth data•Future – EMR flags

Pre-claims identification

strategies


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Raising Member Awareness to Drive EngagementMember-Tailored Letters

• Members may also receive an SDM condition-specific mailer if identified in a decision window.

Note: Client logo replaces Health Dialog logo in materials.

Available Shared Decision-Making® Condition-Specific

Mailers:

• CAD Revascularization Letter

• Colorectal Cancer Screening Postcard

• Back and Joint Pain Letter

• Men’s & Women’s Health Letters

•Weight Loss Surgery Letter


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Raising Member Awareness to Drive Engagement RCT to assess Mail versus IVR

• Aim: To assess the impact of IVR outreach versus mail on reach, engagement with Health Coaching and medical care utilization for members with back and joint preference sensitive conditions.

• Study Population– Individuals covered by four different large insurer clients across the country– Identified as being at risk for Lumbar Back or Joint Replacement surgeries

by proprietary predictive models– Eligible for telephonic outreach

• Study Arms– IVR (AutoDialog™ Back/Joint Script): 25,816– Mailer (Back or Joint Condition specific postcard; One client received no

mailer): 20,588


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Raising Member Awareness to Drive Engagement RCT to assess Mail versus IVR

• Outcomes– AutoDialog™ arm had significantly higher rates of Health Coaching,

including distribution of decision aids (12.2% vs. 1.7%)– AutoDialog™ arm had 12% lower surgical rates and 16% lower

medical costs per member per month six months after start of study

Surgical Rate PMPM Costs

-12% -16%


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How we help people

Personal coaching

Inbound/outbound calls

At home

24/7/365

Nurses, respiratory therapists, nutritionists

On-call

Interactive tools edited by medical professionals

Self-guided health improvements

Shared decision-making videos, interactive wellness tools, health risk assessments

At home and at work

24/7/365

Online

Hands-on, face-to-face support

Biometric screening, educational programs, special events

At work

Working hours scheduled throughout the year

Onsite

Clinical field associates, nurses


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The most experienced coaches in the industry

Health Coach Orientation

PersonalCoaching

Report

Call Listening Skill

Enhancement

Advanced Health Coach

Training

Health Coach

ResourceLibrary

Model Call

Library

Peer CoachingProgram

Culture mirrors

Coaching philosophy

Shared Decision Making®

Certification

Health Coach

Specialist Program

Coaches avg. 10-15 years of

experience


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Chronic ConditionsEffective Care Opportunities

• Major Conditions: – Asthma– COPD– Coronary Heart

Disease– Diabetes– Heart Failure

• Medication Management• Clinical Quality Gaps• Post Hospital Discharge

Coaching approach: Information sharing Directional (not directive)

coaching Behavior change support

Preference-Sensitive Care Opportunities

• Hip Surgery• Knee Surgery• Back Surgery• Hysterectomy• Prostatectomy• Weight Loss

Surgery

Coaching approach: Information sharing Shared Decision-Making®

methodology

Lifestyle Coaching Opportunities

• Smoking • Weight• Stress • Nutrition• Exercise• Prevention & Screening

Coaching approach: Information sharing Combined primary and

specialist coaching Directional coaching Behavior change support

Decision SupportHow does coaching for SDM differ from other types of coaching?


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Decision SupportHealth Coaches

• Health Coaches trained and certified in Shared Decision-Making

• Augment decision-making skills of member– Help member frame decision to be made

– Listen for signs of decisional conflict

– Support awareness of healthcare choices and potential advantages and disadvantages

– Realign expectations

– Clarify values and preferences

• Prepare for doctor visits – Role play

– List of questions


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Empowering patients to make quality medical decisionsHow do decision aids help members?

• Decision aids improve– people’s knowledge of the options

– create accurate risk perceptions of their benefits and harms

– reduce difficulty with decision making

– and increase participation in the process

• Prevent use of options that informed patients don’t value, without adversely affecting health outcomes

• Summary measure of surgery vs. medical management across 8 randomized controlled trials RR (95% CI) = 0.75 (0.60-0.94)


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• Back, Hip, Knee– Herniated Disc: Choosing the Right Treatment

for You– Spinal Stenosis: Treating Low Back and Leg

Symptoms– Acute Low Back Pain: Managing Your Pain

Through Self-Care– Chronic Low Back Pain: Managing Your Pain

and Your Life – Treatment Choices for Knee Osteoarthritis – Treatment Choices for Hip Osteoarthritis

• End of Life– Looking Ahead: Choices for Medical Care

When You’re Seriously Ill • Heart Health

– Treatment Choices for Coronary Artery Disease

• Bariatric Surgery– Weight Loss Surgery: Is It Right for You?

• Cancer Screening– Colon Cancer Screening: Deciding What’s

Right for You– Is a PSA Test Right for You?

• Patient Empowerment– Getting the Health Care that’s Right for You

• Men’s Health– Treatment Choices for Prostate Cancer– Is a PSA Test Right for You?– Benign Prostatic Hyperplasia:

Choosing Your Treatment• Women’s Health

– Treatment Choices for Abnormal Uterine Bleeding

– Treatment Choices for Uterine Fibroids– Ductal Carcinoma In Situ: Choosing

Your Treatment – Early Breast Cancer: Hormone

Therapy and Chemotherapy– Early Stage Breast Cancer: Choosing

Your Surgery– Breast Reconstruction: Is It Right For

You? – Managing Menopause: Choosing

Treatments for Menopause Symptoms

Empowering patients to make quality medical decisionsDecision Aids Library


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Empowering patients to make quality medical decisionsShared Decision-Making® Decision Aids

• Frame the decision and the available options

• Explain what is and is not known about treatment options

• Share patient experiences of potential outcomes and common side effects or complications


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Empowering patients to make quality medical decisionsShared Decision-Making® Decision Aids

Short video explains herniated disc. Members can watch the video, or opt to read a description

Full length SDM video (streaming)

Full .pdf of SDM booklet

Anatomical illustrations can be enlarged by members for optimal viewing


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Impact of our Shared Decision-Making Program

Health Dialog internal data

Lower Utilization

4-10% reductions in medical costs for

the PSC population

0.5-1.5% cost reductions for total

population

Reduced Costs

Surgeries

Inpatient care

Outpatient care

Lab/Radiology

Increased Productivity

49%

27%

Moreproductive

Less time off

shared decision-making program presented by betsy barbeau, scd, mph senior vice president, shared...

Documents

decisionmaking slide

supplysensitive care

health affairs

quality of care

pa slide

nm slide

surgery osteoarthritis

life expectancy slide