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Patient-centered medicine (PCM) is becoming a catchphrase in medical practice. The Institute of Medicine includes PCM as one of its aims of quality,1 and many professional associations and other groups are getting behind the concept.
"The simplest way to view this is that our job is to meet the needs of the patient, an obvious statement in every industry except health care," says Rushika Fernandopulle, MD, cofounder of Renaissance Health, a practice in Arlington, Mass. "The current model is that I, the doctor, will manage your chronic disease for you."
Fernandopulle views this as "silly" since physicians may see the patient for 2 hours a year, and the patient manages his or her own disease for the remaining 8,700-plus hours. The real job of the primary care practice is to give patients the tools they need to take care of themselves.
Research by Anne-Marie Audet, MD, vice president for quality improvement at the Commonwealth Fund in New York City, indicates that PCM models share several concepts:
"I have seen how fragmented health care has become," says Teresa Shupe, MD, who is currently setting up her solo practice in Haymarket, Va. "Nobody is coordinating the whole person, so things get missed, or patients get frustrated because they don't know whom to call or what they are supposed to do."
TIPS FROM PROFESSIONAL ORGANIZATIONS
Many professional organizations have programs that give pointers on developing patient-centered models (see "FYI"). Shupe is involved in a pilot program with the American Academy of Family Physicians called TransforMED that is testing PCM models at 36 practices nationwide.
The hardest changes may be cultural in nature and are among the first that should be addressed. Experts interviewed agree that if the culture is right, the rest will follow. "You must be particularly careful about whom you employ," Fernandopulle says. "Hire for personality and train for skills."
A practice should look not only at its own culture but also at the expectations and cultural requirements of the patient. Although most patient-centered practices adhere to the physician-patient partnership model, some patients may feel more comfortable when the doctor tells them what to do and how to do it.
Instituting these changes can be expensive, and payers do not appear eager to increase reimbursements to practices that pursue them. However, PCM may be able to offset some of the extra expenses.
"There is increasing pressure on practitioners for outcomes accountability," Audet says. "Emerging data suggest that patient-centered practices have more satisfied patients, better adherence to treatment, less patient turnover, and higher volume, as well as fewer malpractice claims."
Most practices already have many PCM attributes in place. Audet cites unpublished data from the Commonwealth Fund's work showing that three of every four practices already make same-day appointments available, 70% get timely feedback from referrals, and about half have patient reminder systems. She notes that the transition seems less formidable when it is recognized that most practices already have a "fairly good start."
A few tools make it easier for practices to make the transition, Audet says. "Electronic medical records [EMRs] with registries allow for a better idea of a practice's population so it can develop programs for all patients with diabetes, for example, making sure that there is continuity and helping match needs to resources."
FINANCIAL IMPACTS
Finding a way to help solo or small group practices invest in the systems and staff needed to implement PCM is a major challenge. "To keep a practice financially viable, knowing how to code for proper reimbursement is essential," Shupe notes. "If you are careful, you can include counseling and similar services in your notes and bill as a higher-level visit. EMR systems make it easier to do complete notes and also remind you what you need to talk about during visits."
Another way to increase efficiency and limit impact on a practice is to provide group services when possible. Basic teaching on heart risk factors for patients with high cholesterol is the same whether directed toward 1 person or 10. Providing this information to a number of people at the same time, with individual follow-up for questions and additional teaching, is both effective and patient-centered.
Shupe uses assets available in the community when possible. A hospital in her area provides dietary teaching for her patients with diabetes, for example.
ONE MODEL AMONG MANY
No one knows the ultimate impact of PCM. Fernanodopulle, for one, suggests that patient-centered medicine may not be entirely compatible with other currents in American health care.
"In many ways the pay-for-performance metrics being pushed are not patient-centered," he says. "I am doing the right thing from a patient-centered perspective when I work with my patient to get her A1C [glycated hemoglobin] levels down as far as they can go, given the way she wants to live her life. But I am going to be docked on pay-for-performance because her A1C isn't to standards."
But he also believes the trend is moving toward consumer-driven health care. "I can see a day where a practice that differentiates itself on patient care will not only attract more patients, but may get a higher price for its services."
Fernandopulle's practice has added a small monthly fee to help cover PCM functions, such as spending additional time with patients, instituting procedures that result in more comprehensive between-visit followups, and increasing patient education. The fee is affordable for most patients and can be waived if a patient's situation warrants, distinguishing Fernandopulle's office from so-called "concierge" practices.
Since much of his practice's revenue comes directly from patient payments instead of through insurance companies, the reward cycle is about keeping patients happy, which makes the practice more patient-centered, according to Fernandopulle.
"Currently, the doctor doesn't really work for the patient," he
says. "At the end of the day, the health plans sign the doctor's
paychecks. Until the payment system changes, it is going to be hard to get
true patient-centered practice. If any other industry treated its customers
the way we do in health care, it would be out of business very fast."
Footnotes
For more perspectives on patient-centered medicine, check out the following:
• Information about TransforMED, an initiative of the American Academy of Family Physicians focused on transformative practice redesign, is available at www.aafp.org/x40604.xml.
• The American Board of Internal Medicine Foundation offers a free DVD, "Putting Quality Into Practice: Physicians in Their Own Voices," available at www.abimfoundation.org/pqip_video.htm.
• The American Hospital Association's Strategies for Leadership: Patient- and Family-Centered Care toolkit, which offers resources for hospital leaders, medical staff, and governing boards, is available at www.aha.org/aha/key_issues/patient_safety/resources/patientcenteredcare.html.
• The Institute of Medicine publication, Educating Health Professionals to Be Patient-Centered: Current Reality, Barriers, and Related Actions, is available at www.iom.edu/Object.file/master/10/460/patient.pdf.
• Information about the Institute for Healthcare Improvement program, Patient-Centered Care: Advancing Patient-Centered Care to the Next Level, is available at www.ihi.org/ihi/topics/patientcenteredcare.
• Information about the Foundation for Informed Medical Decision Making, which aims to strengthen patients' role in selecting treatments for their medical conditions, is available at www.fimdm.org.
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