Advocacy groups shout it from the rooftops. Research careers are built around it. And medical education has integrated it into many curricula. I’m talking about shared decision-making—the idea that medical decisions should be made in partnership with the patient. In theory, it makes a lot of sense. If I, as a clinician, educate the patient about a decision, or if a patient reads every Up-To-Date article on their condition, that patient should make a more informed decision that reflects the best possible care. And that best care should be evidence-based and of the highest value. Right?
It seems obvious that if we arm patients with knowledge, they are more likely to receive high-value care, and receipt of that high-value care is important for patients—not just to improve their outcomes, but to reduce the strain on their pocketbooks. This is particularly important in the current era of greater cost sharing and coverage denials for low-value care. But do we know whether more medical knowledge increases use of high-value care and decreases use of low-value care?
Does More Knowledge Equal Better Care?
This question was addressed in an interesting study by Michael Frakes, Jonathan Gruber, and Anupam Jena published recently as a working paper by the National Bureau of Economics Research (the authors have also written a STAT News article that boils down some of their main findings). In their study, they place an “upper bound” on how much medical knowledge can improve care quality by using physician-as-patient (and their dependents) as proxies for the most medically informed patients, and compare the care they receive to non-physician patients (and their dependents). The authors looked at avoidance of low-value interventions (cesarean delivery, and use of pre-operative testing for low-risk surgeries such as cataract removal), and exposure to high-value care (adherence to diabetes and cardiovascular care guidelines, adherence to medications, and receipt of immunizations).
The findings—surprisingly—confound the conventional wisdom that more medical knowledge leads to better (i.e., higher-value) care. As far as avoidance of low-value care, the authors found that for physicians and their dependents, C-section deliveries were reduced in the range of 6 percent to 15 percent compared with non-physicians, and unnecessary preoperative testing was reduced only by 1 percent. In other words, as the authors note, “even the best-informed patients do not make less use of low-value health services.”
And what about high-value care? It also turns out that doctors and their dependents were not any more likely to follow guidelines for cardiovascular or diabetes care than non-physicians. They were only about 2 percent more likely to take medications as prescribed, and slightly more likely to have their children immunized based on guidelines. Overall, the impact of medical knowledge on receiving value-based care was negligible or nonexistent.
Why Is this Study Important?
This study by Frakes, Gruber, and Jena gives insight into the limits of patients’ medical knowledge in promoting value-based care. This insight extends from medical decisions to medical coverage, as well. As Caitlin Owens writes in Axios, “[T]his is the theory behind high-deductible insurance. One possible explanation for why it hasn't been very effective in improving patient health is because consumers aren't knowledgeable enough to steer themselves toward high-value care.”
So, maybe something else other than knowledge explains why high-deductible insurance is not very effective. Hence, the utility of more informed, shared decision-making impacts not just receipt of care but coverage of care, which ultimately impacts access, cost, and…(wait for it)…value.
Should We Do Anything Different with these Results?
Maybe medical knowledge doesn’t have as much of an impact on value-based care as we thought, but this absolutely does not mean should we stop educating patients. I have to believe that more information is always better, and even the incremental improvements make a difference in the long run.
Yet maybe we need to shift our focus a little. Maybe we need to be careful with our growing faith in shared decision-making as a solution to our current healthcare crisis. As the study authors write: “Perhaps one interpretation of these findings is that patients remain generally deferential to the care recommendations of their treating physicians, even in the case of near fully-informed patients.”
As much as we try to avoid (and should avoid) paternalism in medicine, we must accept that it is to some degree inherent in the physician’s role. Patient education is and always should be a priority, but we will need more than just that to introduce greater value into healthcare.