Finding Solutions

With chronic disease on the rise, U.S. health care costs skyrocketing and the old model of medicine failing to provided solutions, many are calling for a 'patient-centered' approach to health care.

The Promise of Patient-Centered Medicine

With chronic disease on the rise, U.S. health care costs skyrocketing and the disease-based, doctor-centered model of medicine failing to provide solutions, many practitioners in the medical community are calling for a “patient-centered” approach to health care. The idea of patient-centered care is a growing trend in the U.S. and has been embraced by organizations such as the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association.

Wait, isn’t all medicine patient-centered?

On the face of it, yes. A doctor is ultimately supposed to serve the patient’s best interests. However, in the quest to conquer disease, the fact that the patient is a person can often get overlooked. In the predominant U.S. healthcare model, people are often treated as a collection of diseases that episodically rear their ugly head and require drastic, increasingly expensive medical interventions. Practitioners of patient-centered medicine hope to change this, focusing on the overall well-being of the patient from day one with a combination of prevention, early detection and treatment that respects the patient’s goals, values and unique characteristics.

BirdInHand

What defines patient-centered medicine?

Patient-centered medicine is a term that can be fuzzy and hard to pin down. It isn’t one thing, it is applied by different practitioners in different ways and complicating matters are competing terms such as integrative and person-centered medicine. Whatever you call it, there are three broad themes that run through this way of thinking about health care:

Personhood

Patient-centered medicine acknowledges that the patient is a person and that their mind, culture, family, environment, financial situation and other factors all have important roles to play in health. It recognizes that the ultimate objective of medicine is not only to improve the patient’s physical health but their overall well-being. Because this approach is multidimensional, providers often work in teams to address the many factors that impact health. When someone visits a patient-centered clinic they may meet with a primary care doctor, mental health counselor, nutritionist, social worker and dentist. This team of health professionals is often referred to as the ‘patient-centered medical home’ even though the team members aren’t necessarily in one geographical location.

Partnership

The patient is treated as an equal partner in their own healthcare and is allowed a voice in all decisions. Instead of acting as a final authority, the physician acts more as a guide, dispensing information and lending advice and support where needed. Communication is key here as the doctor must elicit the patient’s preferences, goals and values. In cases of terminal illness, the physician must respect the patient’s right to withdraw from treatment if the benefits do not clearly outweigh the costs to the patient’s dignity and well-being.

Continuity

Continuity means that there is an on-going, personal relationship with a physician (or other primary care provider) who is familiar with the patient’s unique circumstances. Instead of seeing a doctor only when faced with acute illness the relationship is on-going. This also means that if the patient is unable to visit the doctor, the doctor will visit the patient in their own home.

What is the role of technology in patient-centered medicine?

When we think of new technology in regards to healthcare, it brings to mind images of cutting edge medical treatments like robotic surgery or gene therapy. However, information technology in particular, is empowering individuals to take ownership over their own health and aiding continuity of care. For example, face-to-face video chat allows patients in remote communities to talk directly to doctors on a regular basis. In Mississippi, a pilot project has patients using electronic tablets to manage their diabetes. The tablets are outfitted with medical probes that feed health information back to doctors in real time. In many health centers around the country electronic health records are enabling patient-centered teams to share information about patients in a more efficient and seamless way.

Dr. David Loxterkamp sees patients at his practice. Caption to come.

Patient-centered physician David Loxterkamp sees patients at his practice in Belfast, Maine.

Why is patient-centered medicine thought to be more effective at dealing with chronic illness?

Chronic diseases are long-lasting conditions that can’t be cured, only controlled. According to the CDC, they are among the most prevalent and costly of all health problems. It is estimated that roughly half of U.S. adults suffer from at least one chronic disease and they are responsible for 70 percent of all deaths, 75 percent of all health care costs and have a total impact on the economy of $1.3 trillion annually. These numbers are only likely to increase as our population ages and obesity, a prime driver of diabetes and heart disease, continues to become more widespread.

The good news is that many chronic diseases are preventable and can be headed off entirely. The CDC identifies four modifiable risk factors that are responsible for “much of the illness, suffering and early death” related to chronic diseases: lack of physical activity, poor nutrition, excessive alcohol use and tobacco use. In addition, catching and stopping highly-treatable cancers, such as breast, colon and cervical cancer, through screening prevents them from becoming chronic diseases which can only be held at bay with toxic and often expensive chemotherapy regimens.

If not entirely prevented, the worst effects of chronic illness can be mitigated with the right care. Obstacles to this include socioeconomic factors, disabilities, management of multiple diseases and the patient’s adherence to treatment. Because of the predominant health care model’s laser-like focus on treating acute, episodic bouts of illness, these issues often go unaddressed.

With its attention to the team-based treatment of the whole person, continuous care throughout a patient’s lifetime and engagement with people as partners in their own health, patient-centered medicine can only be better at both preventing and mitigating the worst effects of chronic conditions.

What evidence do we have that patient-centered medicine works?

It is certainly easier to test the effectiveness of disease-based medicine rather than patient-centered medicine. The gold standard is the randomized case-control clinical trial. A treatment is tested in a very homogenous population against a placebo, a dummy treatment that has no effect (or in rare cases is mildly beneficial). Neither the doctor or patient are allowed to know who is receiving the treatment or the placebo. This devastatingly effective approach has laid waste to many ineffective and pointless treatments and identified the ones that are most effective.

But we can’t measure the effectiveness of patient-centered medicine in the same way. First of all, patient-centered medicine’s strength is that it is personalized and considers the patient’s unique circumstances and preferences. A homogenous population simply doesn’t exist when it comes to patient-centeredness. Secondly, patient’s often have multiple chronic diseases. Obesity, especially in an older patients, is often accompanied by diabetes and heart disease. Having multiple conditions, what scientists call comorbidities, would complicate any standard clinical trial.

If we can’t measure patient-centered care directly, we can still look for signs that it’s working. Are costs going down? Is quality of care improving? Do patients visit the emergency room less? Are patients themselves reporting more satisfaction? Some of the hospitals and clinics that have implemented patient-centered medicine have seen dramatic results. For example, the Alaska Native Medical Center (which is jointly owned by the Southcentral Foundation featured in the Rx film), reported 50 percent fewer urgent care and emergency room visits and 53 percent fewer hospital admissions overall. Group Health, a non-profit health organization in Seattle, Washington, reported 15 percent fewer hospital readmissions and in 2009 estimated costs savings at $15 million dollars compared to previous years.

However, it is important to note that there may not be a one-size-fits-all model of implementing patient-centered care. A 2014 study conducted by the RAND Corporation recruited 32 small to mid-size primary care practices in Southeastern Pennsylvania to be trained and certified in the Patient-Centered Medical Home model of care. They compared the volunteer practices to 29 control practices that did not receive any training. While the study found some improvement in the quality of diabetes care, there was no significant reduction in hospital visits or cost. The authors note that the problem may not be with the model itself, but with how it was introduced, writing: “These findings suggest that medical home interventions may need further refinement.”

<<Click here to learn about doctors and organizations that are seeing results with a patient-centered approach>>

Further Reading:

Nation Conference of State Legislatures: The Medical Home Model of Care.
Accessed on March 11, 2015 at:

http://www.ncsl.org/research/health/the-medical-home-model-of-care.aspx

Joint Principles of the Patient-Centered Medical Home (PDF).
Accessed at: http://www.acponline.org/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf

Bridging the gap: The Separate Worlds of Evidence-Based Medicine and Patient-Centered Medicine.
Accessed at:
http://www.ncbi.nlm.nih.gov/pubmed/11013544

Defining Patient-Centered Medicine. New England Journal of Medicine. March 8, 2012.
Accessed at:
http://www.nejm.org/doi/full/10.1056/NEJMp1200070

Is Patient-Centered Care the Same As Person-Focused Care? The Permanente Journal.
Accessed at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140752/

CDC: The Power of Prevention.
Accessed at:
http://www.cdc.gov/chronicdisease/pdf/2009-power-of-prevention.pdf

Meeting the Needs of Chronically Ill People.
Accessed at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121493/

Barriers to Care in Chronic Disease: How to Bridge the Treatment Gap.
Accessed at:
http://www.fafp.org/pdf/31.pdf

Patiented-Centered Primary Care Collaborative: Results & Evidence.
Accessed on March 11, 2015 at:
https://www.pcpcc.org/content/results-evidence

Association Between Participation in a Multipayer Medical Home Intervention and Changes in Quality, Utilization, and Costs of Care.
Accessed at:
http://jama.jamanetwork.com/article.aspx?articleid=1832540#joi140007t3

Defining Challenges

A disease-based, doctor-centered medicine served us well for the first half of the 20th century, but economic pressures and a changing population are revealing its shortcomings.

  • Abbey Leigh Wall

    Could someone tell when my story will show up please submitted yesterday