Many of us at The Commonwealth Fund, along with numerous colleagues elsewhere, spend a lot of time analyzing how best to expand health care coverage to all Americans. We feel passionately about the need to address this difficult problem in whatever way turns out to be most realistic and sustainable. But while we work hard on how to expand coverage, we spend an increasing amount of time thinking about the kind of care provided. Because even if you are well insured, you may not be able to get the care you need, when you need it, in a way that works for you.
I experienced this problem some years ago when I couldn't get an appointment to see my primary care doctor for what turned out to be pneumonia. The office receptionist told me there were no open appointments for eight weeks, even though I felt sicker than I had ever felt in my life. I found another physician and have been a loyal patient for a decade. But I didn't find the route to my new physician easy or pleasant.
Compare this with another primary care system, Denmark's, which I observed firsthand not long ago. Denmark has an unusual system that blends primary-care patient panel fees and fee-for-service payment. Each physician has an enrolled patient population of about 1,500. Physicians own their practices, many of them small group arrangements. The system is set up to handle same-day appointments and walk-ins. Electronic prescribing networks linking physicians and pharmacies have been in place since the late 1990s. Physicians still make the occasional house call. When the doctor's office closes, an "off-hours service" kicks in, staffed by physicians who handle patient questions by telephone, informed by computerized patient health registries, electronic prescribing, and clinics set up to promote off-hours primary care. Off-hours telephone consulting is reimbursed and the patient's main doctor briefed on the off-hours physician's advice and care.
Real Patient-Centered Medicine
I call this truly "patient-centered" medicine, and I'm a convert. I'm not suggesting the Danish system is perfect—Danish hospitals have a long way to go to meet American standards and the waiting times for specialist care would be intolerable to most of us, for example. Nor do I think the Danish health care financing and delivery system, which no doubt is what allows the primary care system to do so much for patients, can be transferred to this country easily or perhaps at all. But there is ample evidence that patient-centered care can be, if not achieved, as least vigorously pursued in this country right now.
The Institute of Medicine has included patient-centered care as one of six domains of quality. Assessing patient experiences with physician care is not as well developed, but it can be done. Dana Safran, Sc.D., of Tufts–New England Medical Center has conducted surveys of patient experiences with primary care on 11 summary measures covering two broad dimensions of patients' experience: quality of interactions with primary care physicians and organizational features of care (access, visit-based continuity, integration of care, clinical team, and office staff). Safran and her colleagues, in part with Fund support, have demonstrated that valid and reliable measures of patients' experiences with individual physicians and practices can be obtained.
Other leading researchers have shown that the benefits of patient-centered primary care include patients' adherence to medical advice, improved clinical status, loyalty to a physician's practice, and reduced malpractice litigation. But from an economist's point of view, patient-centered primary care is important in and of itself—as a reflection of the patient's utility gained from the receipt of the care. One of the basic tenets of economics is that consumption of goods or services should maximize the utility or satisfaction of consumers as perceived by those consumers. From this perspective, whether care given to patients maximizes their satisfaction for the revenue spent should be the ultimate test of whether the health system is doing a good job. A transformed primary care system would ensure that all patients have access to the kind of care that works for them.
Quality is often defined as providing the right care in the right way at the right time. But a patient-centered vision would define quality as providing the care the patient wants in the way the patient wants at the time the patient wants it. Since both patients and physicians want good health outcomes, sometimes these goals are identical. Economists have talked about the physician as the patient's agent—providing the care the patient would want if the patient had the information that the physician has. But increasingly patients want direct access to that information and the ability to be active partners in their care. That will require listening to patients much more and reorienting primary care practice to provide care that works for patients.
A Wish List for Patient-Centered Care
In a recent article in the Journal of General Internal Medicine, colleagues Stephen C. Schoenbaum, M.D., Anne-Marie Audet, M.D., and I proposed, for research and discussion, that a patient-centered primary care practice have the following characteristics: