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Patient-Center Care Finds "Extremist" Advocate in Berwick; Money-Centered Care Blasted in New Yorker PDF Print E-mail
Written by John Weeks   

Patient-Center Care Finds "Extremist" Advocate in Donald Berwick; Money-Centered Care Blasted in the New Yorker

Summary: Two recent articles underscore a key battleground in healthcare reform the conflict between patient-centered care and any other foci, whether MD interest, money-making, or some combination. The Institute for Health Improvement's Donald Berwick, MD, MPP, arguably the most influential physician of our time, offered a 10-page critique of prior health reform efforts in Health Affairs. He declares himself an "extremist" on behalf of a patient-centered and consumerist approach to care. Meantime, physician-journalist Atul Gawande, MD, writing in the New Yorker, explores the Texas town of McAllen, where healthcare costs are highest in the nation. He concludes that the culture of medicine has been systematically overrun by the money-making motives in McAllen's physician and delivery community. Gawande resists arguing for it, but makes clear that it is employed physicians, rather than for-profit physician entrepreneurs, who are more likely to put patients and teamwork, first. Late-breaking: The New York Times reported that Obama has made the Gawande piece mandatory reading.
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"In this paper I argue for a radical transfer of power and a bolder meaning of 'patient-centered care,' whether in a medical home or in the current cathedral of care: the hospital."
Donald Berwick, MD, MPP
So states Donald Berwick, MD, MPP, president and CEO of the Institute for Health Improvement (IHI) at Harvard University. The context is his paper, "What 'Patient-Centered' Should Mean: Confessions of an Extremist," in Health Affairs 28, no. 4 (2009). Patients could not have a better advocate than Berwick. It was Berwick who, through IHI, promoted the 100,000 lives campaign and its successor campaign to tackle problems of medical deaths, errors and waste revealed in the IOM's To Err Is Human.

Berwick argues that patient-centeredness is a secondary concern to both concerns over both safety and to effectiveness. In his view, statements from high-level teams regarding "patient centeredness" and that "'the patient is the source of control' are verbal analgesics ... that mask real pain." Berwick detects an enduring top-down approach. He levels a charge to a professional of any types:
" ... to whom has been reserved the right to judge the quality of their own work, to abdicate that monopoly and instead to bring a never-ending inquiry into those we serve: 'What do you want and need?' 'What is your way?' 'How am I doing at meeting your needs?' 'How could I do that better?' 'How can I help you?'"
ImageBerwick juxtaposes "professionalism" with "consumerism," finding that the former, a set of practices on which current defiitions of good medicine are predicated, is wanting. "Excellence is in the eye of the professional," in the present healthcare construct, while "in the more normal world of products and services, excellence is in the eye of the customer."  Concludes Berwick: "In the consumerist view, the current IOM definition of quality is defective."
"I eschew compromise words like 'partnership. For better or worse, I have come to believe that we - patients, families, clinicians, and the health care system as a whole - would all be far better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives."
Berwick tangles directly with a key counter argument on cost. On whether what a patient wants should override a physician's choice on a given test or service, Berwick states: "On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to that phrase 'a fully-informed patient.'" Here, as in much of Berwick's thesis, we see a radical deepening of the need for practitioners to truly meet patients.

Gawande: "Treating patients the way sub-prime lenders treated home-buyers"

Reporter Atul Gawande, MD
If anyone needs additional evidence that a huge transformation in the power-alignment of US medicine is needed, a convincing case is laid out in physician-journalist-policy consultant Atul Gawande's feature in the June 1, 2009 New Yorker entitled The Cost Conundrum: What a Texas town can teach us about health care."
Gawande, a former healthcare adviser to the Clintons, went to the U.S. town with the highest healthcare costs, McAllen, Texas, to find out why. Average Medicare expenditures there are at over $14,000 per person per year. At the other end of the  spectrum, in the Twin Cities of Minnesota, the average is less than half that, at $6,688. After a range of explorations of possible reasons, Gawande concludes:
"Here, along the banks of the Rio Grande, in the Square Dance Capital of the World, a medical community came to treat patients the way subprime-mortgage lenders treated home buyers: as profit centers."
Gawande reports that this huge shift has come since the early 1990s, when McAllen was precisely at the average for Medicare payments. In that interval, a "culture of money had taken over." One physician made uncomfortable by the changes "had often seen financial considerations drive the decisions doctors made for patients—the tests they ordered, the doctors and hospitals they recommended." Doctors who were unhappy about the direction medicine had taken in McAllen told Gawande the same thing: “It’s a machine, my friend.”

ImageWhile McAllen is precisely an extreme, Gawande notes similar patterns elsewhere. Cost are high in Florida and Southern California, and lowest in the Twin Cities of Minnesota and in Seattle, Washington. Gawande describes the role of the Mayo Clinic in the evolution of care in the Twin Cities. Interestingly, it is a place where there is a history of embracing Berwick's thesis :
"The core tenet of the Mayo Clinic is 'The needs of the patient come first'—not the convenience of the doctors, not their revenues. The doctors and nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients."
So what's the trick?
"I asked how the Mayo Clinic made this possible. 'It’s not easy,' [the administrator] said. But decades ago Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially possible."
(Notably, in Seattle, Washington, care has been significantly influenced by the role of Group Health Cooperative, a staff-model HMO with employed physicians, and University of Washington Physicians where doctors are also on salary.)

Gawande notes that this practice not only creates more opportunity to focus on patients rather than profits, it also promotes the kind of teamwork which benefits patients:
"As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems."
Gawande's conclusions are discomforting. Rather than focus cost-concernws on easy-to-hate insurers or other major, faceless economic stakeholders, he directs the inquisition on physicians and the hospitals and other medical businesses they run:
"Health-care costs ultimately arise from the accumulation of individual decisions doctors make about which services and treatments to write an order for. The most expensive piece of medical equipment, as the saying goes, is a doctor’s pen. And, as a rule, hospital executives don’t own the pen caps. Doctors do."

Comment: The ratio of cost differences between McAllen and the Twin Cities allows us to quickly, if simplistically, track the differential in the awful medical costs in the US versus those in other developed nations. If we were all at the level of the Twin Cities - ie, had a system shaped by employed physicians - we would be very close to the typical costs, and percentage of GNP, seen elsewhere. One of the concerns of giving patients more power in their care, noted by Berwick, can be quickly dismissed. The disaster of overuse from money-driven medicine totally overshadows potential cost problems if empowered patients, in Berwick's new medical consumerism, over-prescribe a few tests or procedures for themselves. Concern with what patient empowerment might do is a red herring given the whale of physician self-interest that is in the room.

These are two exceptional articles, the essences of which are not sufficiently highlighted in our present reform debate.

Late-breaking: The day after posting this Jacob Shor, ND, FABNO, one of those who sent me a link to the Gawande piece, the New York Times reported that Obama has made the Gawande piece "required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators."
(Thanks also to James Winterstein, DC, and Lou Sportelli, DC for sending me the Gawande piece.)

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