Friday, July 18, 2014

Informed Medical Decisions

At the California Coalition on Workers' Compensation 12th Conference in Anaheim yesterday, Department of Industrial Relations Director Christine Baker reviewed with the audience of mostly employer representatives the statistics arising out of SB 863's Independent Medical Review system.

As you likely are aware, the performance of the system has been questionable - and Baker was equanimous in spreading the blame for the lackluster numbers across the board, including her own agency.

Most everyone asked to examine how SB 863 is doing says that it's too early to tell, and while the Division of Workers' Compensation may be putting positive spin on the changes, realistically the early promises made of savings and better system performance have not come to fruition.

Be that as it may be, I wonder if all of this UR and IMR debate might be different if the injured worker were more involved in the medical decision making process.
Bowser: happy with SDM
A friend of mine pointed me to an organization in Boston, MA that espouses shared medical decision making, where the patient is centrally and actively  involved in all parts of the treatment process with greater knowledge and information about consequences and benefits of different options.

The Informed Medical Decisions Foundation says that Shared Decision Making is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.

The organization states on its website:

"Unfortunately, patients often make decisions about medical treatments without completely understanding their options. Decision aids present the various treatment options in an unbiased, balanced way to patients so they can make an informed choice. These tools, which are designed to complement, rather than replace, counseling from a health care provider, can be used to facilitate a shared decision making conversation between patient and provider."

As you might imagine, SDM requires greater interaction between patient and physician. It is described as "the process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives." (Emphasis original.)

The process involves informing the patient about the various evidence based options (evidence based medicine is critical to the process), the providing various tools that have been prepared in an unbiased manner to allow the patient to have a better understanding of the trade off of benefits and risks of any particular treatment option.

According to a 2010 survey conducted by the University of Michigan, the vast majority of people simply accept whatever treatment protocol their physician advises without exploring any alternatives. In fact, the study concluded that between 65% and 95% of the time the health care provider simply advises "just do it."

The studies promoted by the Foundation on SDM clearly reflect that the process is beneficial to the patient, reducing confusion about treatments, increasing patient satisfaction and decreasing risks with healthier outcomes.

But can this work in the industrial medicine setting? I've often opined that one of the problems with workers' compensation is that the injured worker, though the center of all sorts of activity and attention, completely lacks any participation in his or her treatment - seemingly blithely going along with whatever the doctors, the administrator and/or UR/IMR says is going to happen.

So it seems like SDM could work in the industrial medicine setting.

But while this sounds like medical treatment nirvana, in the volume based business of workers' compensation medical I have reservations about the ultimate effectiveness of this ideal.

Physicians already complain about unrealistically low reimbursement rates in the work comp world, and also complain about ridiculously long accounts receivables reconciliation. What SDM seems to propose is greater dialogue between physician and patient with more resources available to the patient along the decision making process.

I think most injured workers would gladly engage in SDM if promoted by the doctor but there's a caveat - how is the physician going to get paid to engage in this process, which is going to take up more professional time?

SDM is probably worth exploring further in the context of workers' compensation medical treatment, but along with it must come motivations for using it.

In the panel presentation that I participated at the CCWC Conference on Wednesday I opined that many of the incentives in workers' compensation defeat the ultimate goals of reducing treatment approvals and disability duration.

Look at what drives people to behave certain ways, fix the incentives and rewards, and processes should move more efficiently and effectively.

SDM could work, but legal and regulatory changes would first be needed to motivate its use.

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