A growing trend in healthcare is the concept of shared decision making (SDM), whereby patients with medical conditions that have more than one clinically appropriate treatment take an active role in selecting their medical care. By giving patients more authority over their own care, SDM allows patients to supplement a physician’s recommendations with information from others who have undergone similar procedures and obtain information on outcomes, possible complications, and alternative treatments. SDM may promote quality and offer greater value, but it is also likely to significantly impact physicians’ and hospitals’ fee-for-service reimbursement, and reactions from the industry are likely to be mixed as the concept gains traction.¹

Although SDM has gained more publicity following recent announcements concerning a spate of unnecessary surgeries performed across the country, enlisting greater patient involvement in healthcare decisions is not entirely new.² A seminal report issued by the Institute of Medicine (IOM) in 2001 declared “patient-centeredness” one of the six core goals of the U.S. healthcare system, and though the term’s meaning is still evolving, patient-centeredness today is defined “through the patient’s eyes.”³  SDM includes tools and support that enable patients to “assess the merits of various treatment options in the context of their own ‘values and convictions,’” and is a component of the broader concept of “patient-centeredness” promoted by the Patient Protection and Affordable Care Act (ACA).⁴ Through the use of “decision aids,” physicians and other providers can help patients understand their medical conditions; the screening and treatment options available to them; and, the various potential outcomes.⁵ Decision aids are intended to supplement the information provided by healthcare professionals and help patients make an informed medical decision in concert with their providers, taking into account patients’ individual values and preferences that may not be adequately addressed in the traditional informed consent process.⁶ Instead of being referred directly to a surgeon, patients could attend a class, use an online tool, or view a DVD with information on their hospital’s or physician’s performance records, a procedure’s infection rates, or post-surgical complications.⁷ SDM can also help patients make other decisions about their care, such as the range of end-of-life treatments desired.⁸

Research suggests that, when armed with additional information, a substantial number of patients are likely to forgo the suggested surgery or treatment, which in turn is likely to negatively affect physician reimbursement.  Some in the industry are likely to reject the SDM concept, as it may imply that physicians may be recommending procedures that are unlikely to benefit their patients, and primary care physicians may not want to accommodate the additional burden involved with referring patients to alternative sources of information or treatments. Others in the industry welcome the concept as long overdue, asserting there is an extensive amount of unnecessary medical care currently being rendered, with little evidence of better outcomes. The Dartmouth Institute endorses patients being more involved in making decisions about non-emergency surgeries at the primary care physician level, and for several orthopedic procedures it has removed surgeons from the decision making process entirely in order to eliminate conflicts of interest. Other systems, including the clinically integrated health systems of Mayo Clinic and Intermountain Healthcare, are expected to implement similar models in their hospitals.  The concept is expected to receive a more favorable response in systems that employ their surgeons, as these physicians’ compensation is not contingent on the volume of surgeries they perform.⁹

One study found that SDM was associated with lower healthcare costs because of the reduction in over-diagnosis and over-treatment of conditions, and the study estimated that implementing SDM for 11 procedures would produce national savings of more than $9 billion over a ten-year period.¹⁰ The Center for Medicare and Medicaid Innovation (CMI) provided Dartmouth with a $26 million grant to implement SDM models in healthcare systems covering 50 million patients across 17 states.¹¹ Other groups, e.g. the Informed Medical Decisions Foundation; the American College of Surgeons; and, the professional societies comprising the Choosing Wisely collaboration, are each developing tools and strategies to promote a process by which patients and doctors arrive at a treatment decision that is in accordance with individual patients’ preferences and medical needs.¹² Despite resistance by some industry stakeholders, SDM is gaining popularity among patients and providers, and the concept appears poised to dramatically change the way healthcare is rendered.