Since there are few medical conditions for which there is usually one and only one drug treatment, patients should understand the trade-offs involved with using one drug versus another and should engage their doctors in a process of shared decision making.
. How they are managed accounts for significant variations in care and costs.
As defined by the Dartmouth Atlas of Health Care, "Preference-sensitive care comprises treatments that involve significant tradeoffs affecting the patient’s quality and/or length of life. Decisions about these interventions — whether to have them or not, which ones to have – ought to reflect patients’ personal values and preferences, and ought to be made only after patients have enough information to make an informed choice. Sometimes, as with the options for treating early stage breast cancer, the scientific evidence on the main outcome – survival – is quite good; other times, as with treatment options following prostate cancer, the evidence is much weaker."
As such, they should be approached using shared decision making.
The same concept applies to drug prescribing. Since there are few medical conditions for which there is usually one and only one drug treatment, patients should understand the trade-offs involved with using one drug versus another and should engage their doctors in a process of shared decision making. But, it does not happen for many reasons:
1. Partial or incomplete access to the right information.
2. Differences in what is important to doctors versus what is important to patients.
3. Not enough time during the visit to discuss.
4. Doctors don't get paid to do it.
5. Patients don't have enough incentive to do it are incapable of making the decisions on their own.
6. Conflict of interest for employed physicians or those being paid under risk sharing agreements.
7. Unwillingness to address rationing in a rational and transparent way.
8. Legal and regulatory constraints concerning cost effectiveness.
9. Workflow disruption and not the right people on board to implement the results.
10. Pressure on drug companies to maximize profits.
The rising cost of drugs, particularly boutique drugs costing upwards of a thousand dollars a month, represents a potential existential threat to bundled payments and other risk sharing models. We can manage the problem overtly or covertly, selling or telling patient-customers, or, we can march forward as we are doing now until we get to the edge of the cliff.