“Patient-Centered Care” and What Patients Want

Today , September 13, Doctor Donald Berwick, the new head of CMS and President Obama’s controversial recess appointee, gives a much awaited maiden speech before a Medicare and Medicaid audience.

A lot is riding on his presentation. He must convince Americans that the Affordable Care Act, now often referred to as “Obamacare,” is a good thing.

If you look at the latest polls, so far the Obama administration’s efforts to sell the new health reform law have failed. The latest polls indicate Americans against/for Obama’s health plan are: USA/Gallup +17%, Rasmussen Reports +22%, CNN/Opinion Research +16%, CBS/NBC +13%, and Pew/National Journal +12%. In other words, an average of 16% more Americans oppose the plan than favor it. In public polling, this is considered a huge margin.

And in political campaigns to date, Democrats running for November re-election are either shunning, running away from health reform. or bragging about opposing the health reform law.

Enter Doctor Berwick. He has long been a champion of “patient-centered care.” According to an abstract of a 2009 article ,” What 'Patient-Centered' Should Mean: Confessions Of An Extremist,” he wrote for Health Affairs,

“ ‘Patient-centeredness’ is a dimension of health care quality in its own right, not just because of its connection with other desired aims, like safety and effectiveness. Its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it. Such a consumerist view of the quality of care, itself, has important differences from the more classical, professionally dominated definitions of 'quality.' New designs, like the so-called medical home, should incorporate that change.”

The key phrase, which I have italicized, is "radical, unfamiliar, and disruptive shifts in control and power, out of those who give care and into the hands of those who receive it."

In Berwick’s past actions since the 1991 founding the Healthcare Improvement Institute, based in Boston, and serving it as its CEO through 2010, this phrase has come to mean improving hospital safety, avoiding unnecessary deaths, looking at care from the patient’s point of view, and ridding the system of health care waste, i.e. procedures and tests with no proof of benefits. These are admirable goals.

What rankles critics is his insistence upon “shifts in power and control, “ in most cases means shifts from current market-based practices to government-based regulations, and away from physicians and hospitals. To many, Doctor Berwick is a liberal, even a socialist, idealogue.


As a Time Magazine piece today says,

“Interest in his remarks will be high because Berwick is perhaps the single most powerful person in American health care, overseeing a 2011 budget of $759 billion — larger than the Pentagon's — and a bureaucracy that includes 4,500 employees providing health coverage for some 100 million Americans. As part of the new Affordable Care Act, Berwick will begin the process of cutting some $500 billion from Medicare — largely by eliminating subsidies for the private insurance program known as Medicare Advantage — and lay the groundwork for adding 16 million Americans to the Medicaid rolls.”

For me, “patient-centered care” boils down to what patients want and fear from government control. This is what I hear on the streets and from fellow physicians.

• Patients want relief from pain, which is why so many hip and knee replacements are being done. Patients fear government will limit joint replacements.

• Patients want good vision. They fear government will ration cataract surgeries, perhaps restricting them to one eye.

• Patients want protection from higher costs and medical bankruptcies, which so far government has not provided. Quite the reverse is occurring.

' Patients want something to happen now, rather than waiting until 2014 and thereafter.

• Patients want quick access to doctors, who will be in short supply when 78 million baby boomers become eligible for Medicare starting in 2011 and 16 million Medicaid recipients become insured in 2014.

• Patients want hope for cures, particularly of cancer, which may involve treatment with expensive cancer drugs which they fear will not be authorized or paid for by government.

• Patients want their medical care to be safe, an area of expertise or Dr. Berwick and perhaps his biggest selling point.

• Patients want their doctors to be on time and for medical care to be convenient and accessible 24/7, which is why retail clinics and urgent care clinics are popular, and why emergency rooms are crowded.

• Patients fear government bureaucrats, not their doctors, will be making clinical decisions on what can and cannot be done. Thia directly contradicts Berwick's philosophy.

• Patients fear what they want and what they will get will be radically different.