Thursday, April 16, 2015

Patient-Centered Care: Generalities and Realities

In 2009, my book Obama, Doctors, and Health Reform (IUniverse, inc) was published. Its subtitle was A Doctor Assesses The Odds for Success, The Health System from the Top-Down to the Bottom-up, As Seen Through the Lenses of Complexity. I said odds for success were slim but wished Obama and its administration the best of luck and even gave a toast for their efforts.


The book’s unifying theme was reform-based improvement would be based on patient-centered care that was affordable, effective, and patient-friendly. Its success, I commented, would depend on patient responsibility and involvement.
That was 6 years ago, one year before ObamaCare passed.

How is ObamaCare doing so far?

Very well, in one sense. These days talk of a patient-centered health system is the rage , particularly in Republican circles, where the idea of a patient-centered, market-based with freedom of choice alternative to ObamaCare holds sway.

Not so well, if you consider the state of political controversy whirling around ObamaCare. It remains deeply unpopular with the American public. The GOP used ObamaCare as its main cudgel for capturing the House in 2012 and the Senate in 2014. And ObamaCare's continued existence may depend on a Supreme Court decision in June 2015.

And what about the patient-centered theme in the real world? How ‘s that going?

Again, not so well. In my book, I laid out 10 simple guides for patient-centered care, as set forth by the Institute of Medicine in its book Crossing the Quality Chasm, A New Health System for the 21st Century, (National Academy Press, 2001).

1. Care will be based on continuous healing relationships rather than on office visits. Sounds great, but health care continues to be based on episodic visits to different doctors in different settings rather than guidance from one primary care doctor.

2. Care is customized according to the patient needs and values rather than physician autonomy. This is slowly changing as patients gain more information from the Internet, but in most circumstances, doctors are still determining what patients need. “Values” remains a nebulous term based on the views of the beholder.

3. The patient is the source of control rather than the professional. This remains mostly pie in the sky because in a complex technological world only doctors have the information required to direct care, and patients for the most part still trust the doctor’s judgment.

4. Knowledge is shared and information flows freely rather than information remaining strictly in the record. This is beginning to change with the “open notes” movement, but patients still have trouble getting their records, and doctors are concerned patients may be unable to interpret information, and there are time constraints and privacy concerns in sharing information.

5. Decision making is evidence-based rather than on training and experience of the physician. In other words, decisions are based on data rather than on clinical intuition. Doctors are dubious about this proposition, because it takes experience to cut through the data clutter. Data may be an essential tool, but it is not the end game.

6. Safety is a system property rather than the individual responsibility of doctors even if doctors are dedicated to doing no harm. The idea that the “system” will take care of you and ensure your safety has a nice ring to collectivists, but I have doubts any “system” can effectively “protect “ patients against professional “harm.”

7. Transparency rather than secrecy is necessary. Of course, but there’s a thin line between transparency and confidentially and privacy.

8. Needs are anticipated rather than a reaction to needs. This is about maintaining health and preventing disease, which everybody agrees is needed, but it also about the reach of medicine. Medicine cannot control the culture or society or patient’s behavior once they leave the office, or the hospital or a health organization’s system. Only 15% of a nation’s health outcomes depend on medicine. The rest depends on the culture and patients’ life styles.

9. Waste is continually decreased and cost reduction is sought. This is obvious, but it isn’t always achieved by government regulations or not paying for care based on outcomes research. Too often, one person’s waste is another person’s hope for cure or life style betterment.

10. Cooperation among clinicians is a priority rather than preference being given to professional roles in the system. In short, two or more minds, acting cooperatively and collaboratively, are better than one. Or, to put it another way, organizational or team care decision-making , is preferable to individual care and individual decision-making.
In my book, I predicted health reform would have a mixed success and would not end with ObamaCare. The success of reform depends on patient freedom and choice and patient centered are and on American innovation and market experimentation, not on government regulation and guarantees of patient protection and affordability, which hve failed to date. Sometimes it is difficult to translate glittering generalities into the nitty-gritty realities .

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