The collaborative, led by The Dartmouth Institute for Health Policy and Clinical Practice, focuses on the analysis and dissemination of the best practices in health care. The grant, awarded by the Center for Medicare and Medicaid Innovation, is intended to increase the human capacity to realize more efficient and ethical medical care in a way that could transform the status quo for medical institutions, Weeks said.
"When people are informed well about decisions regarding treatment, they tend to choose less costly procedures," Weeks said. "There is substantial waste in the health care system by virtue of the fact that when people are rushed to surgery, they're rushed to get the most expensive procedures available, but they don't need it or want it."
The grant provides funding to train and hire "family and patient activators" to equip patients with the tools they need to make decisions about their health care, Weeks said. The activators will be trained according to a curriculum developed at Dartmouth. The family and patient activators are complementary to the physician-patient dialogue, according to Benjamin Moulton, the senior legal advisor for the Informed Medical Decisions Foundation.
"A high-quality decision aid is a mechanism to give a patient a full plate of information broken down by narratives from other patients who had similar choices to make, where absolute risk is described, where there is reference and comments by various medical experts and reference to a robust library of further articles that can assist that patient, in conjunction with the physician, to make the choice that's right for them," Moulton said in a video posted on the foundation's website.
The grant will allow the collaborative to hire activators at 15 hospitals in order to help overcome hospitals' reluctance to make the initial investment in the human resources necessary for operationalizing shared decision-making. A major barrier to the concept, however, will be the inevitable decline in revenue resulting from the expansion of less costly treatments, according to Weeks. The current fee-for-service structure incentivizes hospitals to offer expensive treatments that shore up their revenue base but may not be the most appropriate for a particular patient, Weeks said.
"If you're investing in something that costs you money and decreases your revenue, it's a double hit," he said.
The potential of shared decision-making to bring greater social equity to the health care system makes it an ethical imperative despite the decreased hospital revenue, he said. Whereas the strength of a health insurance plan has long determined access to a particular medical procedure, a system centered on the patient's needs and values goes a long way toward minimizing such a disparity.
Building a health care system that makes the most efficient use of its human resources must guide the growing social justice-oriented calls for increased health care access, Al Mulley, the director of the Dartmouth Center for Health Care Delivery Science, said. This requires having practitioners trained for procedures at a particular level of complexity, which would ensure that the compensation to the provider is appropriate for that treatment, Mulley said.
The challenge is to scale up low-cost interventions internationally, taking into account differences in economic and social contexts, Mulley said.
The ultimate goal of the High Value Health Care Collaborative is to implement its findings beyond the 15 institutions that are currently engaged in the program, according to Weeks. The Dartmouth Institute is the home base for the collaborative's data analysis, comparing health care efficiency and outcomes among the 15 sites.
Given that the sites have achieved varying degrees of performance in these categories, they offer a microcosm to explore how effectively best practices can be transmitted among hospitals on a nationwide scale, Weeks said.
