Pay attention when the pundits and legal poohbahs start prattling about the “severability” of the individual mandate provision that’s the focus of the much-anticipated Supreme Court hearings on the constitutionality of health reform. What the partisan obloquy about “Obamacare” too often obscures is that the Patient Protection and Affordable Care Act is mostly about patient protection and affordable care.

Case in point: the law’s landmark provisions regarding “patient-centeredness.”

Is anyone against patient-centeredness? Those elitists at the Institute of Medicine, drawing on work by suspect Massachusetts liberals at the Picker Institute, defined patient-centeredness back in 2001 (when George W. Bush was president) this way: “Care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” The IOM also made patient-centeredness one of six aims for U.S. health care.

Wait. Couldn’t Ron Paul and the Libertarians endorse that same individual-centric definition, which also has roots in religious teachings? (Hey, the original Tea Party was in Boston.)

If you’re a free-market conservative, patient-centeredness fits the concept of health care as a marketplace filled with consumers and providers. Interestingly, as early as 1974, under another Republican president, those IOM elitists endorsed publishing outcomes measures “so consumers can be informed of the relative effectiveness of various health providers and make their choices accordingly.”

Finally, if you think actual medical care has nothing to do with politics – which makes you normal – then patient-reported outcome measures such as physical functioning have a clinical role when reported in a manner that can provide feedback about ongoing treatment decisions.

The ACA supports all of these aspects of patient-centeredness. Its provisions repeatedly refer to patient-centeredness, patient satisfaction, patient experience of care, patient engagement and shared decision-making. Even when the law uses the more general term “quality measures,” patient-centered assessments are required in the implementing regulations.

These ACA patient-centeredness requirements, built on a long history of bipartisan accord, support and supercharge similar efforts in the private sector and represent an unsung transformation of health care. My colleague Juliana Macri and I write about it in a just-published Urban Institute paper sponsored by the Robert Wood Johnson Foundation, entitled, “Will the Affordable Care Act Move Patient-Centeredness to Center Stage?

It will – as long as the ever-unpredictable Justices of the Supreme Court don’t bring down the curtain too soon.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age.

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13 Responses for “What the Supreme Court (and You) Won’t Hear About Health Reform”

  1. Nate Ogden says:

    “If you’re a free-market conservative, patient-centeredness fits the concept of health care as a marketplace filled with consumers and providers.”

    Not if it is part of a large federal bill doling out billions of dollars. Patient-centered primary care would be great. Right now the biggest problem is healthcare is hospitals. The impact of PPACA and patient-centerdness is hospitals buying up primary care quicker then you can update your directory.

    So while the market is looking for PC to keep patients away from the hospital and when they do need to go to steer them towards the most efficient hospital this bill spends billions to compound and extend our biggest problem.

    We don’t need government to achieve patient-centerdness, we surly don’t need them adding 1 trillion to the deficit the next 10 years to accomplish it. The market can do this just fine on its own if government would get out of the way and stop distorting the market.

  2. john irvine says:

    What does patient-centredness mean, anyway? Does anybody know?

    It’s sounds like something Stephen Colbert invented ….

    • The first use of the term was in 1969 in the psychotherapy field.

      The original intent in the current context and how it came to be, is best left to Dr. Berwick himself
      http://content.healthaffairs.org/content/28/4/w555.full
      and summarized by him as “The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care” ( note the “without exception” clause).

  3. Actually, patient-centeredness, as I note in the blog, comes out of the patients’ rights movement, which itself came out of the Civil Rights movement, which itself didn’t really work when the Eisenhower Administration let the states take care of it (I’m looking at YOU, Alabama), but somehow did work when the federal government got involved. Not that I’m drawing any analogies, but, in fact, if you look at the economics of the marketplace, there’s a reason why it has not been efficient in this direction.

    (Hint: EVEN Milton Friedman and EVEN Adam Smith were not as doctrinaire as some of today’s so-called conservatives. Real conservatives are…conservative.)

    In any event, patient-centeredness — not to be confused with Colbert’s “truthiness” — is giving way to even more awkward phrases, like “patient- and family-centered care.” Me: I’m a fan of “participatory medicine” (and on the board of the Society for Participatory Medicine). The truth (not truthiness) of medicine is that despite the ethical and caring nature of individual doctors, the system itself has not been patient-friendly. That’s what needs to change. And there’s been bipartisan support for Medicare, as a prudent buyer, doing so.

    • Nate Ogden says:

      “That’s what needs to change. And there’s been bipartisan support for Medicare, as a prudent buyer, doing so.”

      Isn’t that the problem? Medicare = Buyer. If the patient is not the buyer will it ever be centered around them? If we want to get more patietn centric get Medicare and Government out of the exam room.

  4. Mr. Millinson suggests that if the government names a policy with a pleasant label, then that which the label describes will surely come to pass. Thus, Iraqi Freedom resulted in Iraqi freedom. The assorted Bush/Obama housing bailouts have resolved the mortgage crisis. And the American Reinvestment and Recovery Act (ARRA aka stimulus) resulted in reinvestment and recovery. If only the real world would behave as it ought.

  5. Gosh, I don’t recall making that suggestion at all. Although John Graham is even more correct than he may know. These days, most pieces of legislation, by both parties, are named with various acronyms or full legislative names that suggest wonderful things will occur if only they pass. See the recent bipartisan example, the JOBS bill.

  6. MD as HELL says:

    “Patient-centered” violates the Golden Rule: The man with the Gold makes the Rules.

    Furthermore, if the patient knew what to do, they would by a doctor.

    If a patient in the exam room needs a doctor, the more important person in the room is the doctor. The guardian of patient rights has always been the doctor. Most people ignore the fact that a patient is not a customer.

    Obamacare is government-centered, all the way.

  7. Interestingly, as early as 1974, under another Republican president, those IOM elitists endorsed publishing outcomes measures “so consumers can be informed of the relative effectiveness of various health providers and make their choices accordingly.”

  8. All I’m stating is that it is very easy to write a law that purports to do good things. However, when the government actually tries to execute it, it usually goes upside down.

  9. To say government laws “usually” don’t work to their intended purpose is as absurd as saying that capitalism “usually” hurts consumers. Common sense, and common observation, show that there’s a balance. Unbridled capitalism leads to abuses, as any student of history knows. Over-regulation can stifle initiative. The original Medicare law passed because traditional charity care failed, and Medicare has worked very well in its main purpose. One can argue about this or that aspect, but NO law — just plain charity care — left doctors poor (you can look it up) and patients uncared for.

  10. Nate Ogden says:

    “The original Medicare law passed because traditional charity care failed, and Medicare has worked very well in its main purpose.”

    What a load of revisionist BS. You are aware of the internet are you not? 13% of seniors needed assistance with medical bills in 1964. Mainly due to serious prolonged illness. Medicare was passed so Grandma would not lose the shirt off her back. The actual bill that was passed turned out to not even cover prolonged illness. So from the day it was enacted it has been a failure in regards to the reason it was passed.

    Further 19% of seniors are now on Medicaid, for those not shoveling BS that means we could have skipped Medicare all together and probably been further ahead with just providing a good Medicaid plan to the 13%.

    It has been a failure by every conceivable measure.

    Amazes me the out right BS people think they can get away with saying and no one will check them on. Have you even read the transcripts from the hearings?

  11. Nate Ogden says:

    The most pressing rationale for compulsory health insurance continually put forward by government officials and echoed by the public was the specter that responsible older people could be ruined financially by catastrophic illness. Yet neither the 1963 nor the 1965 proposal provided coverage for catastrophic illness. During the 1965 Senate Finance Committee hearings, Chairman Russell Long (D., La.) asked HEW Secretary Anthony Celebrezze, whose department had written the bill, “Why do you leave out the real catastrophes, the catastrophic illnesses?” (U.S. Senate Hearings 1965: 182). When Celebrezze replied that it was “not intended for those that are going to stay in institutions year-in and year-out,” Senator Long countered: “Well, in arguing for your plan you say let’s not strip poor old grandma of the last dress she has and of her home and what little resources she has and you bring us a plan that does exactly that unless she gets well in 60 days.”

    Celebrezze concurred, stating that means-tested public assistance would provide “additional help.” (U.S. Senate Hearings 1965: 182-83). Long added that “Almost everybody I know of who comes in and says we ought to have medicare picks out the very kind of cases that you and I are talking about where a person is sick for a lot longer than 60 days and needs a lot more hospitalization” (U.S. Senate Hearings 1965: 184). [14] Yet the very element that government officials continued to cite to win public support for Medicare was deliberately omitted from the administration’s bills.

    Ya Medicare great F’n success, best 40 trillion I ever borrowed

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