Michael Millenson

There appears to be a broad consensus that patient-centeredness is important to the future of healthcare, according to a new report from the Urban Institute. But peeking under the surface of that apparent consensus reveals that the term means many things to many people, and that not all patient-centric initiatives are complementary.

"While the umbrella term 'patient-centered care' attracts near-universal acclaim, it encompasses three separate concepts that can overlap, be synergistic or even conflict with each other," co-authors Michael Millenson, president of Health Quality Advisors, and Robert Berenson, an Institute fellow, write. "The ethical aspect of patient autonomy relies heavily on notions of individual rights and free choice founded on more than a century of legal decisions establishing every person’s right to be fully informed about a proposed treatment. The economic aspect of patient-centeredness, on the other hand, puts the patient in the position of a customer. ... Meanwhile, the clinical partnership domain focuses on communication and collaboration as a means of achieving the goal of better outcomes."

Robert Berenson

The Urban report argues that while it's possible to pursue all these different versions of patient-centeredness, they won't always line up.

"Patients may choose a provider in part based on price, but the successful shopper expects a clinical partnership rather than the caveat emptor relationship of seller-buyer once inside the exam room," the authors write. "On the other side of the stethoscope, physicians worry what happens to their ethical obligations if a 'patient' becomes the 'customer.'"

Other challenges to patient-centeredness have to do with the many government groups working to emphasize the notion. Millenson and Berenson suggest that requirements and associated efforts from the Affordable Care Act, the HITECH Act, and the Medicare Access and CHIP Reauthorization Act and others, while admirable in and of themselves, aren't well coordinated.

"These efforts in HHS and elsewhere in the federal government should be comprehensively catalogued and subjected to the same strategic scrutiny as other care improvement activities," they write. "That hasn’t yet happened, yet is particularly important at a time of rapid innovation in patient-generated health data."

Finally, the authors point out that patient-centeredness is also complicated to measure, which in turn makes it hard to track progress of efforts to promote it. Various tools exist to measure a patient experience, patient activation, health confidence, and patient reported outcomes. But which of those metrics or which combination of those metrics truly reflects patient-centered care is still an open question.

Equally important is making sure that all patients -- regardless of race, gender, age, and other demographic factors -- reap the benefits of a patient-centered system.

"Patients are not homogenous," the report reads. "For example, a collaborative relationship with the physician may have a greater impact on women’s adherence to medication than men’s. The goal of collaboration trumpeted at policy conferences may not resonate with underserved minorities harboring underlying deep mistrust of 'the system.' (And, distressingly, one recent study found that doctors talked less often with patients of 'other' races and ethnicities about the reasons for treatment recommendations.) 'Autonomy' can mean different things to the young and to the old and to different ethnic groups."