Where Shared Decision-Making and Payer Return-on-Investment Calculations Align

Published 2020.7.28

I believe that patients and providers can make better healthcare decisions to improve health using health information. Unfortunately, the healthcare evidence base has not shown a consistent linkage between knowledge or shared decision making with higher healthcare value. A 2017 Cochrane review around decision aids found that patients exposed to a decision aid were less likely to choose major elective surgery (risk ratio 0.86 [95% CI 0.75-1.00], n=17 studies). Most included studies did not find a meaningful increase in medication adherence or improved cost-effectiveness. A 2018 Cochrane review including 87 studies found low certainty that studied interventions led to increased shared decision making among healthcare professionals. The authors thought the studies’ methodology did not allow the reviewers to measure the risk of bias, many studies included diverse measures of shared decision-making and challenges with validity and reliability of included patient-reported outcome measures.

Payers can divide healthcare costs into diagnostic evaluations (testing before a formal diagnosis), episodes linked to an acute procedure and ongoing costs for chronic care (e.g., surveillance to monitor for disease progression or recurrence, risk factor control). Diagnostic evaluations may be driven by providers’ and patients’ perceptions of diagnostic certainty and ability to reduce morbidity or risk of dying. Procedures and their short-term complications could also be included within a commercial payer’s return-on-investment interval (18-24 months). The costs for managing chronic conditions usually have lower variation than costs to perform acute interventions, but chronic care monitoring costs might shift if a new technology or approach to monitoring a condition or set of conditions was developed (e.g., telehealth, remote patient monitoring, e-visits).

When I think about shared decision-making and avoidable healthcare costs, I tend to gravitate toward those symptom constellations or disease presentations that lead to higher-than-average long-term follow-up (end-stage kidney disease) or a series of acute procedures to try to remedy the symptoms (low back pain). For patients with no clear diagnosis after initial testing, payers might facilitate second opinions to help identify the disease(s) causing the patient’s symptoms. After the diagnosis is clear, advocating for the highest-value intervention should align the payer, employer and individual. For advanced kidney disease, the decision to pursue home peritoneal dialysis instead of in-facility hemodialysis could save thousands of dollars in the short term (from a societal perspective) with no discernable effect on infection rates or death when compared to in-facility hemodialysis. For conditions like back pain with some likelihood of pain resolution (albeit with a higher risk of recurrence) regardless of the procedure(s) performed, payers may suggest stepped therapy starting with those interventions that are least likely to create long-term adverse sequelae.

This framework would suggest payers do more work evaluating if a procedure is reliably curative (e.g., cataract surgery) or unlikely to lead to an improved quality-of-life (e.g., decompression with spinal fusion for low back pain). Those procedures that reduce the risk of long-term surveillance or chronic management should be embraced and those procedures with a lower likelihood of resolving a patient’s symptoms should be avoided.

Here’s a list of the most frequently performed surgeries by type of payer in America back in 2014:

Five most common ambulatory invasive, therapeutic surgeries performed in community hospitals in the United States, by payer type, 2014
Payer Produre (volume) Generally curative
Commercial Muscle, tendon, and soft tissue procedure (496,400) Unknown
Commercial Cholecystectomy and common duct exploration (461,900) Yes
Commercial Incision or fusion of joint, destruction of joint lesion (413,500) Unknown
Commercial Excision of semilunar cartilage of knee (331,500) Unknown
Commercial Lens and cataract procedures (318,600) Yes
Medicaid Cholecystectomy and common duct exploration (176,700) Yes
Medicaid Tonsillectomy and/or adenoidectomy (147,800) Yes
Medicaid Muscle, tendon, and soft tissue procedure (131,800) Unknown
Medicaid Myringotomy (128,400) Yes
Medicaid Lens and cataract procedures (76,700) Yes
Medicare Lens and cararact procedures (985,400) Yes
Medicare Vascular stents and operating room procedures, other than head or neck (688,500) Unknown
Medicare Insertion, revision, replacement, removal of cardiac pacemaker or cardioverter/defibrillator (389,200) Yes
Medicare Muscle, tendon, and soft tissue operating room procedures (306,200) Unknown
Medicare Inguinal and femoral hernia repair (151,200) Yes

In some cases, the categories labeled “Unknown” reflect the fact that the category may include procedures that are curative as well as those that are not curative. In other cases, the indication for the procedure might increase the odds the procedure is curative, even if the procedure is not generally curative for all indications.

Payers would benefit from focusing their review authority with generally curative procedures in ways that encourage the highest value site-of-service (ambulatory instead of inpatient) rather than denying the procedure. The payers might highlight those procedures without a reliable improvement in health for prior authorization. But in both instances, shared decision-making might be helpful to activate patients to make high-value healthcare decisions.

If a payer demands additional justification for a procedure the patient and the provider believe is necessary, the payer may be at a disadvantage to shift the conversation to a higher-value outcome for the patient. Rather than intervening just after a high-cost or low-value procedure is recommended, payers may be more likely to enlist the member’s support if reaching out earlier in the patient’s medical journey. Reframing shared decision making as an ongoing process as more information becomes available may be more useful than a single intervention at one point in time.

Many have given up on shared-decision making entirely and focused efforts on more systemic interventions that have led to higher healthcare value (e.g., reference pricing, bundled payments). Deploying shared decision-making as an ongoing process may increase the likelihood that patients get activated earlier in their treatment course when they may be open to hearing about other diagnostic or treatment options and reducing the likelihood that prior authorization might even be required. Starting shared decision making on those scenarios that lead to higher short-term costs or procedures with low rates of success might be more appropriate than focusing on other types of healthcare decisions.