nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Wednesday, June 30, 2010

What "Patient-Centered" Health Care Means...And Doesn't

 
The term "patient-centered" gets tossed around a lot, and sounds like an obviously good thing, but people who are promoting the concept can have radically different views of what it means.

Most people will read the words "patient-centered" and adopt a common sense definition:  the health care is there to benefit the patient...the patient, and their needs, are at the "center" of what gets done and how.

But take a look at one description of what Patient-Centered does:
Respect patients’ values, preferences and expressed needs. Coordinate and integrate care across boundaries of the system.  Provide the information, communication, and education that people need and want. Guarantee physical comfort, emotional support, and the involvement of family and friends.
All great-sounding words, but notice that the patient is not involved in directing how the health care comes about.  Behind the high-minded words is an agent that makes sure things are respected, coordinated, provided and guaranteed.  In a word, the government (or an insurer, government or private).

What would Patient-Centered care look like if the patient was not only at the center, but also directing the process?

Consider this definition of how to keep the patient at the hub of the health care wheel:
Consumers [patients] will work with their physicians and health care providers to create a better health care outcome for themselves and their families.  Health care usage is more cost efficient with empowered and knowledgeable consumers who use information tools.  Price and quality transparency about health care professionals is a key method for effective consumer health care choices.

Also great-sounding words.  But... although both definitions keep the patient as the focus, the difference is who's in charge?    The former is plan-directed and patient-centered.  The latter is patient-directed and patient-centered.

Plan-directed care, as exemplified by Medicare and the new government-regulated health care exchanges, will make some decisions for you, in your best interest, as they best see it.  Patient-directed care puts you in the driver seat, preserving freedom to choose, but--and make no mistake--the patient incurs responsibility along with the freedom.  You get to decide, but you take responsibility for your decisions.  All the stuff in the first system, you do yourself:  get the information, compare cost and quality, make a judgment about your unique needs.

Each approach has its own kitbag of tools, and there are examples to illustrate how they work.

The former, plan-directed care is how the Obama Administration and Congress saw health care improvement.  The President's nominee to run Medicare and Medicaid is Dr. Donald Berwick, who is CEO of the Institute for Healthcare Improvement.  The first quotation above is from IHI, and encapsulates how he sees a high-quality, cost-effective system should run.  He also loves the British National Health Service, which in my opinion, is a disaster.  Their tools are comparative effectiveness, price controls, government-regulated health plans, denial of payment for complications, incentivizing primary care payment, etc.

The latter, patient-directed care, can be implemented in different ways.  The two most prominent are HSA's and HRA's.  The second of these, Health Reimbursement Accounts, are employer-funded plans that reimburse employees for incurred medical expenses that are not covered by the company's standard insurance plan. Because the employer funds the plan, any distributions (money the employee gets to keep) are considered tax deductible (to the employer). Reimbursement dollars received by the employee are generally tax free.

Put simply, HRA's have an insurance plan that covers high-cost care, and prevention vists.  For routine and acute care, the employer gives the employee a bag of money and says, "go find the best and most cost-effective care; if you don't spend it all, you get to keep the rest."

This incentivizes people to take the time to judge who's the best doctor, and what's the best price.  All this information is available online (as I've written before here).  Critics of HSA's and HRA's have said people will not seek care when they need it.  This has been disproven; actually they seek care ONLY when they really need it, unlike plan-directed care.*  Other critics have claimed the employer can decide not to fund the employee's account.  This has also not occurred.  In fact, the savings the employer incurs from having employee's make good choices have been so substantial it saves money overall for the company, even while rewarding good decisions by employees.

The state of Indiana is reaping the benefit of patient-directed care.  Enrollment is voluntary, but has grown rapidly to 70% of state employees.  Unused funds in the account, about $30M, are the property of the workers.  The state expects to save about $20M this year (an 11% reduction), and premiums are about half of what employees pay in traditional plans.

The bad news:  Provisions in ObamaCare regulate what health plans must cover, and may force these patient-controlled, cost-savings plans to disappear.

Quelle horreur!

Doc D
 
*As one academic put it, supporters of HRA's "believe, as do a fair number of health economists, that people use too much health care, and use too much health care of little value...[with HRA's] people will think twice. If I have a sore throat, instead of going to my physician, I'll have a cup of tea instead."
  
 

1 comment:

Massage Therapist Insurance said...

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