Why We Aren’t Ready for Patient-Centered Care

March 31, 2012
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The follow is a guest post by Aanand D. Naik, MD  @empoweringpts.

We hear lots of discussion nowadays about Patient-Centered Care.  Most legislation for health care reform proposes innovative models of care such as Accountable Care Organizations and the Patient-Centered Medical Home (PCMH) with “Patient-Centered Care” at the core.  Given all the attention: Who could possibly be against Patient-Centered Care?

The follow is a guest post by Aanand D. Naik, MD  @empoweringpts.

We hear lots of discussion nowadays about Patient-Centered Care.  Most legislation for health care reform proposes innovative models of care such as Accountable Care Organizations and the Patient-Centered Medical Home (PCMH) with “Patient-Centered Care” at the core.  Given all the attention: Who could possibly be against Patient-Centered Care?

In this wake, I forward the controversial contention that many patients, probably a majority of health care providers, and every major health plan and health insurer really doesn’t believe in Patient-Centered Care.  Or at the very least, they aren’t ready to change the basic paradigms of health care to cultivate what Patient-Centered Care truly is and what its requires.  Simply put, we aren’t ready for Patient-Centered Care.

To clarify my argument, a clear understanding of Patient-Centered Care is needed.  The first consensus definition comes from the 2001 Institute of Medicine Report, Crossing the Quality Chasm.   The IOM report defines Patient-Centeredness as, “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”  The report clarifies several principles of health system redesign that will better align health care along 6 quality dimensions.  The principles most closely tied to the dimension of Patient-Centeredness include: a) customization of care based on patient needs and values; b) the patient as the source of control; c) shared knowledge and the free flow of information, and d) the need for transparency.

When fully realized, these are powerful principles–they can and will transform health care.  But, they must all occur together to ensure that transformation happens.  If only one or two of these principles are accomplished, especially if only the principles of free flow of knowledge and customization based on patient-need; then there will be little positive change at all.

Don Berwick wrote a wonderful essay in Health Affairs in 2009  in which he describes the lively debate that occurred on the IOM panel that defined Patient-Centered Care.  He defends the “extremist” position and adds his own parameters for patient centeredness: (1) “The needs of the patient come first.”(2) “Nothing about me without me.”(3) “Every patient is the only patient.”   These are compelling additions to the original IOM definition.  What I fear is that without the coexisting principles of transparency and patient control, the “needs of the patients” will be defined by doctors, providers, hospitals, health systems, and insurers rather than patients themselves.

My further belief is that the types of reforms gaining momentum, like PCMH, will actually precipitate and worsen the problems of supply-driven demand and hyperinflation because they will simply increase patients’ acceptance of doctors’ recommendations through “free flow of information and knowledge” and enhanced patient-centered communication.

Without truly making information transparent and giving patients real control of the ends and means of health care, then it’s simply patient-friendly talk and involvement in discussions related to what the doctor thinks is best.

Transparency is more than the free flow of information and patient-centered communication.  Transparency occurs when patients understand “in their gut” the meaning of the health problem and how health care will impact their daily lives.  Patients have control when they choose not to pursue a course of action the doctor might recommend because those outcomes are not consistent with their values or the desired course of their lives.  In the non-transparent form of PCMH, access to health care improves but health costs will continue to skyrocket.

What we need now is real discussion of patient control and transparency rather than platitudes about Patient-Centered Care.  What does it mean to give patients control and can control be helpful and lead to health outcomes that are consistent with our needs and values?  What does transparency really mean?  I wish Steve Jobs was still around to teach us a thing or two about the importance of design and the patient-interface in health care.  As a physician, I know the patient-doctor encounter is sacred and the doctor’s role is indispensible; but I am also fully ready to embrace transparency and patient-control over the ends and means of their health.

Aanand D. Naik is a medical geriatrician and health services researcher at the Michael E. Debakey VA Medical Center and Baylor College of Medicine in Houston, Texas.  Follow him on twitter @empoweringpts  The views expressed here have not been endorsed by either institution.

Sources:

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001, National Academy Press, Washington, D.C.

Berwick, Donald. What “Patient-Centered” Should Mean: Confessions of an Extremist. Health Affairs. 2009, 28:w555-w565.