Paradigm, Not Pill: The New Role of Patient-Centered Care

Michael L. Millenson

In the years since the Institute of Medicine (IOM) pronounced patient-centered care one of six core aims of a high-value system, its definition has broadened and become more prescriptive. The 2001 IOM report spoke loftily of “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”¹ In contrast, a February 2013 IOM workshop called for “strategies and policies for activities to be undertaken at multiple levels to advance patients, in partnership with providers, as leaders and drivers of care delivery improvement through the protected use of clinical data, informed, shared decisions and value improvement.”²

The difference in tone reflects a substantive shift in the role of patient-centeredness in health system reform. What began as an adjuration to physicians about values has progressed to a prescriptive guide incorporating activities and objectives that reverberate well beyond the individual clinical encounter. As the 2013 IOM meeting put it: “Prepared, engaged patients are a fundamental precursor to high-quality care, lower costs and better health.”

In this essay I explore the sometimes conflicting roles that have become part of the real-world definition of patient-centered care, describe evidence of the concept’s economic and clinical impact, and examine the opportunities and barriers involved in making patient-centeredness an integral part of U.S. health care.

Evolving and Overlapping Roles

While the 2001 IOM definition is oft-quoted, “patient centered” is commonly used today to describe three distinct ideas that can be synergistic but can also clash: patient-centeredness as an ethical responsibility, an economic relationship and a clinical partnership. Though intertwined, each role comes with its own rules and expectations.

Ethical Responsibility

The term patient-centered care originated as an ethical critique, with activists from the civil rights and feminist movements rejecting the idea of patients as passive objects. The IOM built on that foundation by positioning patient autonomy and self-determination as basic human rights.³

Economic Relationship

The economic as-pects of patient-centered care play out in mar-ket-places frequented by consumers. It is con-sumers, for example, who compare co-verage and puzzle out co-payments when buying in-surance. However, the role of con-sumerism in a clinical context is less clear. Though the terms patient and consumer are in-creasingly used interchangeably, they de-scribe very different relationships that may be complementary or conflict.

The individual in a high-deductible health plan (HDHP) could be motivated to avoid an unneeded test or procedure both as a consumer seeking savings and a patient wanting to ward off unneeded interventions. But HDHP enrollees trying to economize could also eschew necessary care that would prevent greater expense later on (a consumer benefit) or personal suffering (patient benefit). Or, in another scenario, the consumer “bargain” of a free screening test could lead to false positives that go against the patient’s interest.

Roles and expectations switch back and forth. The consumer may choose a high-value hospital, but it is the patient who waits anxiously for the procedure to begin. The woman who uses a smartphone app to select her doctor assumes the marketplace mantra of caveat emptor will not replace the clinical imperative of primum non nocere when she walks into the exam room as a patient – but should she? Policy discussions about patient-centeredness and consumerism must directly address these emerging dilemmas.

Clinical Partnership

The third concept em-bodied in patient-centered care is that of clinical partner. This concept has many labels, including person-centered care, patient activation, shared decision-making and parti-cipatory medicine. By whatever name, a part-nership between patient and clinical team is the key to improving clinical and economic out-comes. That’s par-ticularly true in an era when chronic disease accounts for three-quarters of costs. While a surgeon can perform a bypass, it may take a clinical partnership to control the hypertension that made the surgery necessary.