When doctors and patients share in decisions, hospital costs go up

May 28, 2013

Since the 1980s, doctors and patients have been encouraged to share decision making. Proponents argue that this approach promotes doctor-patient communication, enhances patient satisfaction, improves health outcomes, and even may lower cost.

Yet, a hospital-based study found that patients who want to participate in their medical decisions end up spending more time in the hospital and raising costs of their hospital stay by an average of $865.

The findings, published in JAMA Internal Medicine, came from the first hospital-based study to examine how patients' desire to participate in medical decisions affects their use of health care resources.

There are about 35 million hospitalizations each year in the United States. If 30 percent of those patients chose to share decision making rather than delegate that role to their doctors, it would mean $8.7 billion of additional costs per year, according to the study.

"The result that everyone would have liked, that patients who are more engaged in their care do better and cost less, is not what we found in this setting," said study author David Meltzer, MD, PhD, associate professor of medicine, economics and public policy at the University of Chicago. "Patients who want to be more involved do not have lower costs. Patients, as consumers, may value elements of care that the health care system might not."

The researchers approached all patients admitted to the University of Chicago's general internal medicine service between July 2003 and August 2011. Almost 22,000 people, about 70 percent of those asked, completed a wide-ranging 44-question survey.

The key multiple-choice item for this study was: "I prefer to leave decisions about my medical care up to my doctor." More than one-third of patients (37.6%) definitely agreed, one-third (33.5%) somewhat agreed, and a little less than one-third (28.9%) somewhat or definitely disagreed.

Patients who preferred not to delegate decisions to their doctors -- those who wanted to work with their caregivers to reach decisions -- spent about 5 percent more time in the hospital and incurred about 6 percent higher costs.

"Was I surprised?" asked Meltzer. "I wasn't shocked. It could have gone either way. Our results suggest that encouraging patients to be more involved will not, alone, reduce costs."

In fact, the authors note, "Policies that increase patient engagement may increase length of stay and costs."

Although this was a large study, it may not apply in every setting, the authors cautioned.

"We need to think harder and learn more about what it means to empower patients in multiple health care settings and how incentives facing both patients and caregivers in those settings can influence decisions," Meltzer said.

Indeed, the authors looked at "hospitalized patients, for whom providers have large incentives to decrease utilization due to Medicare prospective payment, low payment rates for Medicaid and uninsured patients, and utilization review for most patients."

They found that provider incentives were not the only predictors of care costs. Although the uninsured had slightly shorter stays and lower hospitalization costs, patients with public insurance such as Medicare or Medicaid, which pay less than the cost of care, had longer than average stays and higher costs.

As the principal tertiary care hospital on the South Side of the city, the University of Chicago Medicine provides care for a diverse population. Three-quarters of the patients in this study were black. More than half had a high school education or less. Nearly 80 percent were insured by Medicare or Medicaid or had no insurance.

"This isn’t about demographics," Meltzer said. Patients with the most education had lower costs than those with the least education, the study found.

Nonetheless, the authors expressed particular concern about the tendency for older, less educated, publicly insured and black patients to be less engaged in medical decision making. They warned this could increase health care disparities as empowered and engaged groups, who already are more likely to receive care, gain resources through shared decision making while the national movement toward accountable care organizations increases the pressure for cost reduction.

"We want patients to be more involved, to have the richest form of interaction," Meltzer said. "That can align preferences, prevent mistakes and avoid treatments patients don’t want. But we need to find ways to create functional doctor-patient partnerships that lead to good health as well as sound decisions about resource utilization."

The paper, "Association of patient preferences for participation in decision making with length of stay and costs among hospitalized patients," is in the May 27, 2013, issue of JAMA Internal Medicine. Additional authors were Hyo Jung Tak and Gregory Ruhnke of the University of Chicago Medicine. Funding for this work was provided by the Agency for Healthcare Research and Quality, the National Institute on Aging and the National Cancer Institute.

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