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Saturday, May 22, 2010

How to create a patient centered system

I would like to thank my fellow medical blogger notes from RW http://doctorrw.blogspot.com/2010/05/donald-berwick-im-extremist.html, citing a very interesting article written by Donald Berwick in Health Affairs last year. http://content.healthaffairs.org/cgi/content/full/28/4/w555 . The piece is entitled:
"What patient Centered Should mean: confessions of an extremist."
Abstract: 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 piece is very provocative for a host of reasons and could serve as the source of blog commentary for weeks on end. It identifies that initiatives to achieve the generally agreed upon goals of quality, value, safety, efficiency, professionalism, and patient centered care create conflicts where you can achieve one or more only at the expense of one or more of the other goals. Overall the achievement of any of these goals will be restricted by the same thing that restricts the achievement of any other goal;


1. Scarcity of resources
2. Competing priorities and agendas - which desirable outcomes take priority?
3. Uncertainty regarding how interventions will be translated into outcomes 


Berwick, in claiming to be an extremist, admits this and comes down on the side of radical consumerism in health care.  I must say that I am sympathetic to his radical health consumer agenda. I still maintain a reasonably active practice and my conscience prevents me from being anything from completely honest and transparent with any patient I deal with. If they (patients) were not my priority, I would  feel obligated to tell them so. I can not in good conscience tell them that and since I desire to remain active in patient care, I choose to make them my priority. However, in taking on such a health care consumer advocacy position, you need to realize that there must still be a brake the consumption of resources needed to fulfill patient wants. Ultimately, someone needs to say no. 


Each individual physician can choose how to allocate their individual scarce resources. No individual physician has infinite hours or energy. We all limit the numbers of patients with whom we create therapeutic relationships and which specific patient wants we choose to fulfill.   However, how policy makers react to devise system-wide approaches is an entirely different story. Fundamentally, it is a paper, scissors, rock problem. To be patient centered as a system we must be responsive to what patients want. In the world outside of health care, patient wants are are essentially unlimited and the limits of fulfillment are based upon decisions made by individuals deciding how they want to allocate their limited personal resources.


In the Alice in Wonderland world of health care, patient wants are also unlimited. In contrast to the world outside of health care, resources are commonized and the agencies responsible for allocation of scarce resources are charged with making decisions to optimize efficiency, quality, value, safety, and patient centered care. To deliver efficiency and value to the system, they must say no to some patient wants and fail to be patient centered.  To not say no requires us to infinitely commonize and direct more and more resources toward health care, ultimately bankrupting our economy.


In the very consumerist world outside of health care people deal with their infinite wants within the context of their limited personal resources by creating personal priorities. Vendors strive mightily to deliver value, competing for the scare consumer dollars.  The net effect is the relentless drive to value, with goods and resources of increasing quality becoming available more broadly at less cost. Where specific consumer breakthroughs happen is unpredictable but what is certain is they happen.  As an alternative to this consumerist vision outside of health care, we are offered a professionalism model to deal with the competing priorities and conflicts of interest inherent in the doctor (health care worker) - patient relationship. 




"Professionalism" versus "consumerism." The sociologist Eliot Freidson, in his classic study of health care, Profession of Medicine, defines a profession as a work group that reserves to itself the authority to judge the quality of its own work. Freidson posits that society cedes this authority to a profession because of three beliefs: (1) altruism—that professionals will work in the best interests of those they serve, rather than their own interests; (2) expertise—that professionals are in command of a special body of technical knowledge not readily accessible to nonprofes-sionals, and (3) self-regulation—that professionals will police each other.
It appears that in order to embrace such a model, we will need to model our behavior on Plato's philosopher-Kings, who are to act as guardians of the general good and are immune to the pitfalls of their non-rational appetites. This is simply unrealistic and a denial of human history. Utopian schemes based upon altruism and self regulation have  a perfectly consistent track record. They always fail.  Optimal achievement of the system goals of quality, value, safety, efficiency, and patient centered care can neither be planned nor accomplished through a command and control environment with decision making and controls delegated to non-self interested elites. I would argue that to create a truly patient centered  health care system can only be created through a market based health care system where patients (medical consumers) define the priorities and push for quality and value by controlling allocation of their own scarce resources. A system which is truly patient-centered is one where the primary agent saying no is the patient themselves, based upon their decision that their own resources would be better spent on something else.  It may not be perfect but it has proven to be the best model of optimal allocation of scarce resources and fulfillment of consumer needs in all human realms. 





1 comment:

  1. According to Dr. Berwick, patient participation and input are vital to make the appropriate clinical decisions. But I'm a little confused. Donald Berwick was recently selected by Pres Obama to head CMS. Medicare will soon be basing reimbursements on the ability of providers to strictly adhere to quality guidelines deemed by CMS as best for the patient!!

    Also, what happens when a patient deems a certain guideline as inappropriate for him/her?

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