Do smarter patients create cheaper care?

Whenever researchers compare drugs or treatments to see which works best, somebody's ox gets gored (in the words of BusinessWeek magazine).

Such "comparative effectiveness" studies have already cast doubt on new blood pressure and schizophrenia drugs, as well as spinal fusions and other surgeries.  And the latest case involves a very expensive ox: the heart procedure angioplasty.

A series of studies — the newest published in the June 11 issue of The New England Journal of Medicine — finds that stable patients with chronic heart disease who have the angioplasty procedure get little benefit compared with similar patients treated only with drugs, such as Pfizer's cholesterol-lowering Lipitor and other statins, plus aspirin.

That's why there's a growing effort led by physicians, health insurers and even state legislatures to make sure patients truly understand the medical evidence about angioplasty and other treatments and procedures.  Once informed, the patients are encouraged to make their own choices.  This idea is shared (or informed) decision-making.

Studies show that this process, using comprehensive videos and other materials prepared by groups such as the non-profit Foundation for Informed Medical Decision Making (FIMDM), leads patients to choose conservative options more often.  Put into widespread use, the approach has the potential to trim hundreds of billions of dollars from the nation's $2.4 trillion healthcare bill.

Some health insurers are modifying their strategies.  Pennsylvania's Highmark tries to contact patients when a claim comes in for an MRI for back pain, showing that they may be facing a choice.  "We may send a card saying, 'Do you know you can call in for materials?'" says Chief Medical Officer Dr. Donald R. Fischer.

So far, these efforts reach only a tiny percentage of patients.  When FIMDM was set up in 1989, "we totally minimized the difficulty of getting this used," says Massachusetts General's Mulley.  One reason is that people are naturally suspicious of information from insurers or employers.  "The tension in this is whether it is just another way to talk patients out of something expensive," says Kaiser's Wallace.

There's another obstacle in getting information out: It's hard to reach patients before they've seen their specialists and gotten a perhaps incomplete picture of the risks and benefits of a procedure.  That problem is particularly acute with angioplasty, because patients are typically whisked in for the procedure immediately after having diagnostic tests, according to BusinessWeek.

To get more information to patients, advocates are pushing to change the incentives in the healthcare system.  The Washington State law, for instance, mandates demonstration projects in shared decision-making and raises malpractice protections for doctors who use the approach.  Other ideas include adding reimbursements for the decision-making process itself or paying a flat rate for an episode of, say, back pain, regardless of the treatment.

The field is also expected to get a boost from new comparative effectiveness research. The Obama Administration is now pumping $1.1 billion into trials that will compare treatments.

What do you think will drive shared decision-making:  politics, economics, or good medicine?