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Robert E. Litan Headshot

Ending Health Care Pinball

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Right now, the debate over American health policy is understandably focused on the Affordable Care Act -- and the possibility that the Supreme Court might overturn it.

The legal and political uncertainties surrounding the health care law seem to have paralyzed our efforts to rein in the runaway growth of health costs and improve the quality of care. The end-users of our health care system -- patients -- will pay the price for policymakers' dithering.

Patients today are like pinballs. Those seeking treatment bounce through a complex series of obstacles while the players in the system -- insurers, doctors, and hospitals -- rack up costs rather than points.

That needs to change. Instead of pinballs, patients need to be players -- empowered with more information, more options and more control over their care.

Of course, the pinball effect is sometimes unavoidable. In emergencies, for instance, patients aren't really equipped to make informed decisions about their care. In these cases, doctors really do know best.

But patients frequently have decisions to make. About a third of health care is preference -- sensitive or elective. In other words, patients choose what sort of treatment to pursue -- or in some cases, whether to pursue treatment at all.

Early-stage prostate cancer is one example. These patients can currently select from at least four possible courses of treatment.

The story is similar for women with early-stage breast cancer. A patient can have her entire breast removed in a mastectomy. Or she might choose to have a lumpectomy -- an invasive surgical procedure that removes only the tumor -- and then proceed with post-surgical radiation therapy. The clinical evidence on both procedures indicates that they are equally effective -- that they give women the same chance of survival. The difference, then, is the impact on each woman's life and well-being -- how she feels about what's required to go through each treatment.

But how are those choices made? Too often, patients simply leave decisions to their doctors and end up pinballing through the health care system. That framework has yielded trends in treatment protocols that vary widely across the country for no apparent reason other than individual doctors' preferences.

Research shows that doctors tend to emphasize the benefits of surgery, for instance, and downplay its risks. By abdicating their decision-making responsibilities, patients may end up undergoing treatment plans that align with their doctors' interests -- but perhaps not their own.

What we need is a new system -- one that relies on shared decision making.

This calls for patients to take an entrepreneurial approach to their health care -- to take charge of the business of their health by demanding access to additional information. Doctors also will need to take initiative by providing patients with options rather than orders -- and then helping them weigh the relative merits of those options.

Patients taking greater control over their care is a worthwhile end unto itself. But empowerment strategies can produce real results, too.

Better-informed patients are better decision makers. Studies have found that "patient decision aids" -- which can include everything from DVD guides to questionnaires -- improve knowledge of health care choices, increase the proportion of patients with realistic perceptions of benefits and harms and lower decisional conflict. They also reduce the number of patients passively involved in decision making or undecided after counseling.

Better information has produced better results -- at lower cost. Patients given decision aids were 20 percent less likely, on average, to choose more invasive options -- with medical outcomes that were just as good.

Decision aids are growing more and more common. Since 1997, their use has increased roughly one-hundredfold. And shared decision making is becoming de rigueur in states from Washington to Maine.

Still, there are additional savings to be realized. The Lewin Group, a health care consultancy, estimated in 2009 that fully implementing shared decision-making in the Medicare population for 11 conditions that could be treated with surgery could save Medicare $50 billion over a decade.

Patients need incentives and information to make cost-effective health care choices. Raising co-payments might give patients reason to look for better value, but what they need most to make smart decisions is information about the underlying costs of treatments and the relative effectiveness of medical care.

Patients taking charge of their health care choices, like business owners take charge of their companies, will not in and of itself solve the entire magnitude of our nation's health-cost crisis, but it is one essential component. If even a fraction of America's 300 million patients turned into entrepreneurial patients -- making informed decisions, sharing in productivity gains, and taking ownership of their care -- the health care system would experience a tsunami of cost savings and quality care would skyrocket.

Robert Litan is vice president for Research and Policy at the Kauffman Foundation. Litan co-edited a report released today titled, "Valuing Health Care: Improving Productivity and Quality."