As the lead author of a policy paper entitled, “Will the Affordable Care Act Move Patient-Centeredness to Center Stage?” I admit to a certain guilty thrill when I read this precise demand coming as the climax of a letter sent by 80 hard-right representatives to House Speaker John Boehner (R-OH). You don’t get much more “center stage” than shutting off the federal money spigot, which is what the letter – discussed in a recent article in The New Yorker – threatened unless the ACA was defunded.
Having said that, patient-centeredness was a truly odd choice to occupy a central role in the conservative casus belli that ended up disrupting the entire U.S. economy until the right wing finally caved.
To begin with, the term is a minor piece of jargon likely to draw blank stares from pretty much the entire American public. Even for us health policy mavens, the GOP letter linking James Madison on the redress of grievances to defunding Obamacare to a “restoration” of patient-centeredness required major mental gymnastics.
Then there’s the unintentional linguistic irony. The term “patient-centered medicine” originated after World War II with a psychoanalyst who urged physicians to relate to patients as people with physical and psychological needs, not just a bundle of symptoms. “Patient-centered care” further defined itself as exploring “patients’ needs and concerns as patients themselves define them,” according to a book by the Picker/Commonwealth Program for Patient-Centered Care, which coined the term in 1987. Patient-centered care was adopted as a “goal” by the Institute of Medicine, which added its own definition, in 2001.
But here’s where the irony kicks in. Obamacare opponents assert that the ACA undermines the traditional doctor-patient relationship – although I suspect that being able to pay your doctor because you have health insurance actually improves it quite a bit.
Yet in calling for “patient-centered healthcare” instead of the more common “patient-centered care” or even patient-centered medicine, conservatives unwittingly abandoned doctor-patient language in favor of business-speak.
“Healthcare” as one word was pioneered by Modern Healthcare, a business magazine for hospital executives. The one-word version has become a business standard, whether used by the “healthcare” systems that own hospitals, like Tenet Healthcare, or by corporate entities such as GE Healthcare.
Doctors, on the other hand, “care for” patients. It is that rootedness in caring that explains why major medical journals spell “health care” as two words and professional societies focus on “patient-centered care,” not “healthcare.” In other words, those hard-right House Republicans putatively working to “restore” the traditional doctor-patient relationship are talking in language whose corporate overtones would make a traditional doctor bristle. “Patient-centered care,” the language of patients, is the term employed in the ACA.
However, what is oddest about the conservative demand for “patient-centered healthcare” is neither its obscurity nor its spelling, but its substance. The ACA can be fairly accused of many failures, but there has never been any major law anywhere that focuses so explicitly on patient-centeredness.
A simple search of “patient-centered” in the final version of the ACA on the GovTrack.us website turned up 43 mentions. Among the most prominent was a mandate to establish a national strategy for quality improvement that includes “patient-centeredness of health care for all populations, including children and vulnerable populations.” As my co-author Juliana Macri and I wrote in our Urban Institute paper: “The law repeatedly refers to patient-centeredness, patient satisfaction, patient experience of care, patient engagement and shared decision-making in its provisions.”
We even listed specific programs where the ACA requires use of “patient-centered” quality measures, including Medicare Advantage, the favored conservative alternative to fee-for-service Medicare, and the Patient-Centered Medical Home, an effort to strengthen primary care.
In its approach to the doctor-patient relationship, Obamacare might better be seen as incorporating this piece of wisdom from a Republican with impeccable conservative credentials: “The provision of medical care has become one of the largest industries of the country…[That has] created issues from which society cannot escape merely through its own optimism or through confidence in the high character of medical practitioners.”
That was Dr. Ray Lyman Wilbur, an American Medical Association president and member of President Herbert Hoover’s cabinet, assessing why medical care costs were going up. He offered that opinion in 1933. Thinking about what patient-centeredness truly means, today’s conservatives would do well to listen.
Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, IL and the Mervin Shalowitz, MD Visiting Scholar at the Kellogg School of Management. This post originally appeared in Forbes.