Karen Merrikin, JD Senior Policy Advisor Group Health Cooperative

1. Shared Decision Making: Promoting patient centered care through health policy changes Karen Merrikin, JD Senior Policy Advisor Group Health Cooperative Alliance for Health Reform February 14, 2011

2. A member governed, non-profit health plan and care delivery system with 650,000+ members in Washington State and N. Idaho Our members come to us via Medicare, employer plans, individual plans, and low income programs. Two primary models of care: Integrated Group Practice (GH owned clinics with GH salaried providers) Network (contracted clinics and providers) Group Health Cooperative: Background

3. Patient-centered care at Group Health Implementation timeline 2011 2009 2007 Evaluation of decision aids continues Decision aids for shared decision making 2005 Medical home pilot Shared electronic medical record

4. Why Focus on This Type of Variation? Spokane Seattle Community wide, variation not explained by people’s health needs or preferences.

5. Even within Group Health, geography is destiny (for your knees) Statewide Rate 2005

6. What Solutions? For Group Health? For Communities We Serve?

7. Health Policy Rationale for SDM Expansion • Ethical imperative - to do the right thing • Improved Informed Consent-Aligning preferences, values and lifestyle with individual’s clinical decision • Better Decisional Quality • Reduced Malpractice exposure • Bridging Health Disparities • Generally More Conservative utilization of surgical interventions

8. How Did We Engage our Community?Washington State Legislation, 2007 • “Just do it” – and measure results • A multi-site, coordinated demonstration project and evaluation of the use of decision aids for elective surgeries, focused on state purchased healthcare and coordinated through state agency. • Raise the bar on informed consent • A change in the state’s informed consent laws to recognize that prevailing community practice patterns may not always be the “right” benchmark when it comes to informed patient choice. • Bi-partisan Interest and Support

9. What’s in the Legislation: A New Approach to Informed Consent

10. The Collaborative Structure & Practice Sites Wa. State Health Care Authority WA OFM The Everett Clinic Puget Sound Health Alliance Shared Decision Making Collaborative Stakeholders Group Virginia Mason Medical Center University of Washington Evaluation, Coordination Group Health Cooperative & GH Research Institute Multicare Medical Center

11. SDM Collaborative: A Focus on Six Critical Areas with High Variation in Washington State 1 2 3 4 5 6

12. Group Health’s Approach System-wide implementation 2-year research project Foundation support

13. 12 Preference-sensitive Conditions • Hip osteoarthritis • Knee osteoarthritis Coronary artery disease Benign prostatic hyperplasia Prostate cancer Uterine fibroids Abnormal uterine bleeding Early stage Ductal carcinoma in situ Breast reconstruction Spinal stenosis Herniated disc

14. Distributing Decision Aids DVDs can be ordered for mailing or viewed on the Web

15. What are We Learning?

16. Decision aid distribution Number of videos distributed, by month Total: 8,808* *As of 12/31/2010; does not include decision aids viewed on the web after Oct 2009 Jan Apr Jul Oct Jan Apr Jul Oct 2009 2010

17. Fewer missed opportunities Percentage of procedures for preference sensitive conditions where patient did not receive the video 2009 2010

18. Patient assessment Overall rating of decision aid videos Patient survey, September2010, 950 responses Helped you understand the treatment choices Helped you prepare to talk with provider

19. Patient assessment Overall rating of decision aid videos Patient survey, September 2010, 975 responses How important is it that providers make programs like this available?

20. Next Steps at Group Health • Preliminary findings from Group Health’s 2 year evaluation, likely complete in late Spring, 2011. • Patient satisfaction, cost impact, strategies to improve usage rates. • However, Group Health is not waiting for the formal results. • We are accelerating our efforts to implement SDM, focusing on ways to incorporate shared decisionmaking into standard workflows, and broadening adoption among our network providers. • We now measure “defect rate” around SDM.

21. Where Must We Go From Here? • National Certification Standards and Processes for Decision Aids • Assures Decision Aids are High Quality, Unbiased, Up to date. • Activates Informed Consent Law Provisions. • Policy Strategies that Promote Widespread Adoption • Payment, certification, collaboratives, measurement • Patient and Purchaser Demand • CMS & Employers • Satisfied Patients • “Authorized AND Appropriated”

22. So, Why Shared Decision Making? Because we care about better value Because care should be centered around patient’s values. And because we can take our experience in working collaboratively on SDM and apply it to broader health reform challenges.