Is 'Patient Centered Care' the Jordan River for Health Reform? Thoughts on Dr. Berwick's Piece in Health Affairs & Implications for Disease Management

Ever hear of 'patient centered care?' You might think those are just the standard buzzwords applied to any healthcare initiative that means well. Like.... reducing rehospitalizations, promoting access to primary care, increasing immunization rates and expanding coverage to the uninsured. They’re all ‘patient centered,” right?

Wrong.

The ever insightful and occasionally contrarian Don Berwick of the famous Insitute of Healthcare Improvement takes up the topic in a Health Affairs 'web exclusive.' It's worth a look for anyone interested in treading on the less traveled paths of health reform. While there is a surprising amount of policy history behind the idea, patient centeredness ultimately means that the patient is in charge. Period. That means it's the responsibility of the health care system to meet the patient's needs as defined by the patient - not the professionals, not HIPAA weenies, not pencil headed administrators and certainly not picayune insurers hiding behind reductionist definitions of medical necessity.

Wow.

Before you snort derisively at such a naïve notion and decide to surf on over to the Health Care Blog for more tiresome reruns on the virtues of single payer systems, the wonderfulness of EHRs and the evils of AHIP, pause and think about walking on this wild-side. Then realize Dr. Berwick has already anticipated the three biggest objections from us know-it-alls in the healthcare expert class:

1) Patients may override evidence-based medicine. Dr. Berwick thinks that is a small price pay in exchange for responding to a population of patients that are far better informed than we give them credit for. It is very possible to rely on education coupled with lots of provider dialogue to help patients choose wisely. While some may make unwise decisions, that’s more likely a function of the quality of the education and the dialogue. Last but not least, a few crazy and demanding patients should not hold the rest of the medical world hostage.

2) Patients may use up precious resources. Dr. Berwick asks 'as defined by who,' especially when you consider that demand for health care services doesn't drive supply, rather it's vice versa. Paradoxically, if persons were truly allowed to make their own decisions, the overall demand for health care services could go down.

3) Patients may lose out on the two-way doctor-patient relationship. Dr. Berwick points out that it is far more common for docs’ to tell patients what they can’t have, coupled with emotional distancing. This is a way out of the ‘no, because…’ Desert to the Promised Land of 'yes, if....' Patient Centeredness is our way of getting over the Jordan River.

And he has some simple suggestions. For patients, care needs to be customized, transparent and fully under their control. The training of young physicians needs to be retooled. Older physicians need to be reassured. Finally, providers of health care services can measure performance on patient centeredness using long established and validated surveys created for that very purpose.

The DMCB is intrigued. While Dr. Berwick can be forgiven for restricting his perspective to the patient-physician axis, that doesn’t mean those of us in the population-based care business can’t go further in thinking about this outside the box:

First off, disease management organizations need to approach the topic with cautious optimism. Veterans will recall that the earliest underpinnings of the industry was "patient empowerment." It sounded good at the time, but we were accused of undercutting the physicians' authority. The DMCB appreciates the irony, but doubts a word switch from 'empowerment' to 'centeredness' - even if embraced by Dr. Berwick - will make it any more palatable. That doesn't mean our colleagues in the population-care business shouldn't be prepared to speak to the topic. After all, we are experts.

A small minority of self insured employers and their broker-consultants would be the most likely to embrace a yet-to-be developed 'patient-centered health benefit.' If they can be found (and if the Obamacare blob doesn't impede innovation in commerical employer-based settings), these brave souls could end up being the vanguard of a new chapter in health care reform. An innovative disease management organization could help. Medicare will be struggling on how to sponsor a demo on the topic years from now.

The DMCB thinks the industry-wide focus on ‘evidence-based’ discreet HEDIS measures is a barrier to patient centered care. One way to dispatch this is for insurers to think about a) waiving any and all utilization review and b) pay full P4P to any provider group that convincingly demonstrates they adhere to patient centeredness. Why not? If a patient doesn’t get a mammogram, it’s because the educated patient chose not to. If a high dollar MRI is ordered, it’s because the educated patient wanted it. To go even further, insurers could offer up their own X-Prize to any physician group that develops the criteria and delivers on the promises of the patient centered care approach. Disease management organizations could provide the necessary support for a patient centeredness initiative and help sponsor the Prize.

Why not?

Patient Centered Medical Care and Disease Management

The Disease Management Care Blog is ashamed to admit that 'Patient-Centered Medical Care' (PCMC) has been treated by it as something of an afterthought. What is this concept and what are the implications for disease management?

It turns out that the famous Crossing the Quality Chasm report has included ‘patient centeredness’ as one of the six pillars for the reform of healthcare. In order to achieve this, health care delivery should be customized based on the patient’s values, have open sharing of information, be evidence based and placed under the ultimate control of the patient. There is a good review on the topic here.

This has several important implications:

1) health care delivery will need to be far more flexible and accommodate a range of patient preferences, including doing nothing to being highly aggressive.

2) variation, that bane of the Dartmouth Atlas, the NCQA and quality improvement weenies everywhere could turn out to be a good thing if it is the result of truly empowered patients using their own values and preferences.

3) measurement of 'quality' will be a heluva lot more difficult, since the ‘denominator’ will need to be based on what a reasonable fully informed patient would have chosen for treatment of their back pain, management of their diabetes or use of the ICU with life threatening illness at the age of 90. That reasonableness includes getting an MRI anyway, opting for an A1c of 7.2 and having everything done even if the chance of survival is less than 1%.

4) insurers should embrace it because, in balance, when reasonable patients are fully informed about the risks, benefits and alternatives to various treatment options, proportionately more opt for less invasive (and therefore less expensive and possibly higher value) treatment.

5) once again, disease management should have a huge role to play because it has the resources and institutional intelligence to pull off fully informed patient empowerment. In fact, the DMCB believes disease management organizations should not only emphasize 'PCMC' as part of its suite of services and embrace it as part of its policy advocacy.

PCMC is not an afterthought. It's what disease management has been doing all along.