13 August 2013
Patient-centered Care
The new management theme in health care is "Patient-centered Care." In a recent article in the LinkedIn.com group Patient-centered Care, a prominent physician-educator wrote a very supportive article to build up her colleagues who were feeling bashed by their patients. I did not consider her positive article went far enough for explaining why patients might feel antagonistic towards their physicians.
One reason for 'doctor bashing' is the process by which patients get access to a physician, however caring the physician may be. A patient has to establish his or her financial ability to pay for access, so financial stress can produce a negative reaction in the caller or at the registration desk. Second, the patient's financial resources, i.e. insurance coverage, must meet the requirements policed at the check-in window. Third, an empathetic, dedicated physician often cannot limit patient personal access to the time slot established by the practice or HMO, so patients may have to wait over 30 minutes-often more- for a 10-15 minute appointment. Patient waiting areas are not healthy places because no one knows what reasons for appointments the other occupants have. The lack of infectious disease controls in private practices and in most HMO registration, waiting and pharmacy facilities is appalling and unregulated by the UBC (Uniform Building Code) or accrediting agencies. Is it little wonder that the patient may not feel nurtured in the physician's office?
Dr. Rotering's supportive opinion piece most likely describes the best intentions of practicing physicians today. Of that I have no doubt. Patient-centered care, however, is less about the physician's expertise, attitude and empathy than it is about the environment within which the physician must practice. The members of the LinkedIn.com group are mostly health care professionals, not patients. Their perspective tends to focus on what to do for patients rather than to start from the patient's perspective of the patient expectations of them.
Patient-centered care is about nursing, about office staff and about financing of health care more than it is about the physician per se. Such a care model must include an awareness of the patient's time constraints, too. Working, single parents with an ill infant or child, a worker seeking access for a non-work related illness or injury, patients seeking psychological and other behavior/mood professionals and any patient without a working knowledge of English or with any cognitive impairment (such as with age) have not been the starting points for designing a patient-oriented care practice today.
The physician is the last person to encounter such patients and I believe that is a 180-degrees wrong design for health care. Imagine how differently our system might be if patients met first with the physician. The physician's ability to diagnose and to establish treatment modalities would determine the steps taken by the clinic or office staff on behalf of the patient as prescribed by the physician. Perhaps certain tests would be needed or medications prescribed for follow-up with the patient. If so, the tests might be chosen more specifically to the patient's state of health and initial medications might address symptoms while an underlying illness is being diagnosed. As I see it, the only reason physicians require testing results before seeing a patient is so that the physician can see more patients per shift. That is not patient-centered care. That is practice-centered care.
Physicians are bashed these days because the public sees the profession as having become greedy (remember, these are perceptions not reality); in charge of the entire health care system-other than the insurers-and, therefore, as able to make any changes physicians want in the delivery of health care. Yes, bashing for these reasons is not only unfair to individual physicians, it is also unfair to other patients' perceptions of their health care options. Patients requiring particularly expensive interventions often find themselves waiting for an insurance review of their physician's request for covering the procedure and patients may find themselves calling their insurer to speed up the approval process.
Certainly, insurers want to minimize patient care costs and insurers occasionally may prevent an unnecessary procedure. The role of private health care insurance providers, however, is to support the patient's ability to pay for services, not to function as a professional practice review board. Further, private insurers establish their reimbursement rules according to those promulgated by the public insurers. Public insurers like Medicare and Medicaid, though, seem to limit a physician's professional discretion through enforcement of the DCM-10 coding mechanism of reimbursement for services rendered. I think this effort to control health care costs by the Centers for Medicare and Medicaid Services (CMS) inhibits innovation in diagnosis and treatments and, rather, encourage physicians to find the best ways to help their patients get well and remain well.
And, part of this issue lies with each and every physician who tolerates sub-standard professional care by other physicians, who will not police their own ranks of bad actors, who subsume their medical ethics below financial support from third parties like pharmaceutical suppliers, and who refuse to criticize the judgment or actions of other physicians in formal arbitration and courts. If local and state medical boards were more pro-active in correcting unprofessional or inadequate performance by those they have licensed and granted membership to their medical societies, then I believe the public image of physicians would improve by a great amount. Physicians also need to know how their staff treat the patients.
The final part of patient-based health care models is the heretofore unrecognized fact that in health care, the primary stakeholder is the patient. Using a football analogy, the patient hires the team, the primary physician can be the general manager, head coach or quarterback. Consulting physicians or temporarily-designated attending physicians are the coaches. Nurses are the teams, often the special teams needed to make the quarterback successful and to make up for an embattled quarterback. I hope this concept is clearer using the analogy. The patient is the owner is patient centered care. QED
One reason for 'doctor bashing' is the process by which patients get access to a physician, however caring the physician may be. A patient has to establish his or her financial ability to pay for access, so financial stress can produce a negative reaction in the caller or at the registration desk. Second, the patient's financial resources, i.e. insurance coverage, must meet the requirements policed at the check-in window. Third, an empathetic, dedicated physician often cannot limit patient personal access to the time slot established by the practice or HMO, so patients may have to wait over 30 minutes-often more- for a 10-15 minute appointment. Patient waiting areas are not healthy places because no one knows what reasons for appointments the other occupants have. The lack of infectious disease controls in private practices and in most HMO registration, waiting and pharmacy facilities is appalling and unregulated by the UBC (Uniform Building Code) or accrediting agencies. Is it little wonder that the patient may not feel nurtured in the physician's office?
Dr. Rotering's supportive opinion piece most likely describes the best intentions of practicing physicians today. Of that I have no doubt. Patient-centered care, however, is less about the physician's expertise, attitude and empathy than it is about the environment within which the physician must practice. The members of the LinkedIn.com group are mostly health care professionals, not patients. Their perspective tends to focus on what to do for patients rather than to start from the patient's perspective of the patient expectations of them.
Patient-centered care is about nursing, about office staff and about financing of health care more than it is about the physician per se. Such a care model must include an awareness of the patient's time constraints, too. Working, single parents with an ill infant or child, a worker seeking access for a non-work related illness or injury, patients seeking psychological and other behavior/mood professionals and any patient without a working knowledge of English or with any cognitive impairment (such as with age) have not been the starting points for designing a patient-oriented care practice today.
The physician is the last person to encounter such patients and I believe that is a 180-degrees wrong design for health care. Imagine how differently our system might be if patients met first with the physician. The physician's ability to diagnose and to establish treatment modalities would determine the steps taken by the clinic or office staff on behalf of the patient as prescribed by the physician. Perhaps certain tests would be needed or medications prescribed for follow-up with the patient. If so, the tests might be chosen more specifically to the patient's state of health and initial medications might address symptoms while an underlying illness is being diagnosed. As I see it, the only reason physicians require testing results before seeing a patient is so that the physician can see more patients per shift. That is not patient-centered care. That is practice-centered care.
Physicians are bashed these days because the public sees the profession as having become greedy (remember, these are perceptions not reality); in charge of the entire health care system-other than the insurers-and, therefore, as able to make any changes physicians want in the delivery of health care. Yes, bashing for these reasons is not only unfair to individual physicians, it is also unfair to other patients' perceptions of their health care options. Patients requiring particularly expensive interventions often find themselves waiting for an insurance review of their physician's request for covering the procedure and patients may find themselves calling their insurer to speed up the approval process.
Certainly, insurers want to minimize patient care costs and insurers occasionally may prevent an unnecessary procedure. The role of private health care insurance providers, however, is to support the patient's ability to pay for services, not to function as a professional practice review board. Further, private insurers establish their reimbursement rules according to those promulgated by the public insurers. Public insurers like Medicare and Medicaid, though, seem to limit a physician's professional discretion through enforcement of the DCM-10 coding mechanism of reimbursement for services rendered. I think this effort to control health care costs by the Centers for Medicare and Medicaid Services (CMS) inhibits innovation in diagnosis and treatments and, rather, encourage physicians to find the best ways to help their patients get well and remain well.
And, part of this issue lies with each and every physician who tolerates sub-standard professional care by other physicians, who will not police their own ranks of bad actors, who subsume their medical ethics below financial support from third parties like pharmaceutical suppliers, and who refuse to criticize the judgment or actions of other physicians in formal arbitration and courts. If local and state medical boards were more pro-active in correcting unprofessional or inadequate performance by those they have licensed and granted membership to their medical societies, then I believe the public image of physicians would improve by a great amount. Physicians also need to know how their staff treat the patients.
The final part of patient-based health care models is the heretofore unrecognized fact that in health care, the primary stakeholder is the patient. Using a football analogy, the patient hires the team, the primary physician can be the general manager, head coach or quarterback. Consulting physicians or temporarily-designated attending physicians are the coaches. Nurses are the teams, often the special teams needed to make the quarterback successful and to make up for an embattled quarterback. I hope this concept is clearer using the analogy. The patient is the owner is patient centered care. QED
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