ORI GIN AL ARTICLE

What is Patient-Centered Care? A Typology of Modelsand Missions

Sandra J. Tanenbaum

� Springer Science+Business Media New York 2013

Abstract Recently adopted health care practices and policies describe themselves

as ‘‘patient-centered care.’’ The meaning of the term, however, remains contested

and obscure. This paper offers a typology of ‘‘patient-centered care’’ models that

aims to contribute to greater clarity about, continuing discussion of, and further

advances in patient-centered care. The paper imposes an original analytic frame-

work on extensive material covering mostly US health care and health policy topics

over several decades. It finds that four models of patient-centered care emphasize:

patients versus their parts; patients versus providers; patients/providers/states versus

‘‘the system’’; and patients and providers as persons. Each type is distinguishable

along three dimensions: epistemological orientations, practical accommodations,

and policy tools. Based on this analysis, the paper recommends that four questions

be asked of any proposal that claims to provide patient-centered care: Is this care a

means to an end or an end in itself? Are patients here subjects or objects? Are

patients here individuals or aggregates? How do we know what patients want and

need? The typology reveals that models are neither entirely compatible nor entirely

incompatible and may be usefully combined in certain practices and policies. In

other instances, internal contradictions may jeopardize the realization of coherent

patient-centered care.

Keywords Health policy � Medical practice � Patient-centered care �Philosophy of health care � United States

S. J. Tanenbaum (&)

Division of Health Services Management and Policy, College of Public Health, The Ohio State

University, 200B Cunz Hall, 1841 Neil Ave., Columbus, OH 43201, USA

e-mail: tanenbaum.1@osu.edu

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Health Care Anal

DOI 10.1007/s10728-013-0257-0

Introduction

The meaning of the term ‘‘patient-centered care’’ is at once obvious and obscure.

Most of us think of patients as being at the center of care; if not the patient, then

who? Students of health care, however, understand that the politics and economics

of medicine often position professionals and institutions at the center of care, with

patients left to accommodate themselves to a system designed, primarily, for

someone else. Contemporary health reformers, including the President of the United

States, are now engaged in efforts to make health care more ‘‘patient-centered,’’ but

patient-centered care is not a new concept. It first appeared in the work of British

psychoanalyst Enid Balint, who in the late 1960s proposed it as a form of

psychotherapy to be practiced by primary care physicians with patients whose

illnesses were partly or entirely psychosomatic [2]. Many versions of patient-

centered care have followed, some employing the term explicitly but all proposing a

renewed focus on the patient as opposed to other health care actors and institutions.

This paper attempts to typologize these models and their diverse epistemological,

practical, and policy aspects. This first categorization of types of patient-centered

care will hopefully elicit further discussion and refinement (Table 1).

In this typology, the various models of patient-centered care are conceptualized

as having missions, i.e., as solving problems in the US health care system.

Proponents of each type argue that centering on the patient will redress a distinct

failing in health care as it is currently delivered. All four models have

epistemological orientations, call for practical accommodations, and are represented

in specific policy tools. The table’s ordering of types is roughly chronological but

does not necessarily signify a progression. Neither are the models always mutually

exclusive, although as detailed below, some were formulated to refute or improve

upon previous models. In the interest of space, a needed fifth column specifying

obstacles to realizing these types has been left for a future paper. This paper

attempts only to orient future discussion to critical distinctions among the models

because although they are conceived as solutions to problems, they also present the

problem of knowing what we mean by patient-centered care.

Type I responds to the narrow scope and reductionism of biomedicine and offers

positivist social science for use in primary care as a corrective. Type II responds to

the disempowerment of patients vis-a-vis providers and takes political and

procedural forms: Health care consumer movements elevate patients’ experiential

knowledge and individual preferences; formalized shared decision-making and

patient survey analysis downplay these elements but inform and represent patients

with new forms of ‘‘objectivity.’’ Type III responds to the perverse economic, legal

and professional incentives that produce a patient-unfriendly health care system,

including under- and over-treatment and pervasive fragmentation, and creates

economic incentives and engineering innovations to encourage system reorganiza-

tion. Type IV represents a relatively new and as yet developing model of patient-

centered care with roots in humanist, phenomenological and narrative medicine. Its

most unified expression has been in response to the rise of evidence-based medicine

(EBM), and it juxtaposes medicine as an interpretive practice by whole persons to

EBM’s insistence on medicine as the application of statistical science.

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This paper will delineate and discuss each of the types. It will acknowledge their

compatibilities and incompatibilities and establish that at least in the US context,

patient-centered care is, among other things, an attempt by reformers to enlist ‘‘the

patient’’ in their efforts to cure the system’s ills. Finally, the distinctions among the

models will suggest that four clarifying questions be asked of any proposal to

provide ‘‘patient-centered care’’: Is this care a means to an end or an end in itself?

Are patients here subjects or objects? Are patients here individuals or aggregates?

How do we know what patients want and need?

Type I: Whole Patients Versus Their Parts

The biopsychosocial model of medical care was popularized by US physician

George Engel and his colleagues at the University of Rochester Medical School.

The term was originally coined in 1954 by Roy Grinker, who had been analyzed by

Freud, in order to promote biological psychiatry in a psychoanalytic world [24].

Engel, also a psychiatrist, introduced the biopsychosocial model in a 1977 article in

Science. In his 1980 article in the American Journal of Psychiatry, ‘‘The Clinical

Application of the Biopsychosocial Model,’’ he asserted that it was a ‘‘scientific

model constructed to take into account the missing dimensions of the biomedical

model’’ [18: 535]. It was, in other words, an improvement on biomedicine as

practiced because it enlarged the reach of scientific method to new aspects of

Table 1 Patient-centered care: a typology of models and missions

Models/missions Epistemological

orientations

Practical

accommodations

Policy tools

Type I Whole patient

versus part of

patient, e.g.,

disease, organ

system

Biopsychosocial

model, i.e., addition

of positivist social

science to medical

science

Family medicine;

primary care by non-

MDs; Integrated

physical and mental

health care

Increased reimbursement;

loan repayment;

residency slots for

primary care

practitioners

Type II Patients

versus providers:

1. Political

2. Procedural

1. Individual

experiential

knowledge and

preference

2. Aggregate

preference; decision

analysis

Shared decision-making;

Patient surveys;

Decision aids

Patient-Centered

Outcomes Research

Institute; value-based

purchasing using patient

surveys

Type III Patients/

providers/states

versus the

‘‘system,’’ i.e.,

perverse incentives

Economics and

engineering; clinical

epidemiology

Care coordination, incl.

case management,

patient navigators;

Integrated delivery

systems

Health homes;

Accountable Care

Organizations; bundled

payments; money

follows the person

Type IV Patients/

providers as persons

Narrative and

interpretation;

Epistemological

pluralism

Medical education;

reorganization of care

processes

Macro-level cost controls;

hospital accreditation

requirements

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routine patient care. Specifically, contemporary medicine, reflecting the enormous

postwar investment in biomedical research, was seen as neglecting the whole person

of the patient, who was a psychological and social being as well as a biological one.

Engel made two basic points. First, a reductionist view of the patient is an

inadequate view; care after a myocardial infarction, for example, should consider

‘‘systems derangements at the cardiovascular level as well as the symbolic level…’’

[18: 538]. Second, this kind of consideration need not lure physicians away from

science; unlike ‘‘holistic’’ or ‘‘humanistic’’ medicine, the biopsychosocial model

would adhere entirely to scientific method [18: 543]. It extends medicine’s reach

into what might be called positivist social science, including positivist approaches in

psychology and sociology.

Over the last 30 years, the biopsychosocial model has been widely studied,

elaborated upon and taught to medical students; it has served as ‘‘a cornerstone for

the training of family physicians’’ [4]. In 2004, the Future of Family Medicine

Project Leadership Committee committed that field to providing, among other

things, patient-centered care as defined by the Institute of Medicine. The extent to

which the biopsychosocial model suits that definition—‘‘care that is respectful of

and responsive to individual patient preferences, needs and values, and ensuring that

patient values guide all clinical decisions’’ (IOM 2001, cited [22: S6])—is disputed.

Epstein [21], for example, warns against conflating patient-centered and biopsy-

chosocial medicine because patient-centered care can be entirely medical,

depending on the condition and the patient. Bartz [4] analyzes one physician’s

interactions with her patients and concludes that a biopsychosocial approach may

still be instrumental and utilitarian and in that sense not patient-centered at all. In a

response to Bartz, Brody [8] explains that the biopsychosocial model and patient-

centered care are complementary: The former was proposed as an ethically neutral

model of medical science while the latter puts science in an ethical context.

Family physicians may disagree about the nuances of the biopsychosocial model,

but its legacy as a foundation for family medicine and primary care generally is

clear. Among physicians who do not specialize, the whole patient—the biopsycho-

social one–is the appropriate focus of care; furthermore, patients may be treated as

wholes rather than parts only in the context of primary care. In fact, one of the four

defining characteristics of primary care as currently understood is ‘‘long-term

person- (not disease) focused care’’ [54]. Engel has been cited in efforts to define

and strengthen primary care in the US (e.g., [31]), and although his own research

focused on psychosomatic illness, the biopsychosocial model served more generally

to indict the reductionism of biomedicine and by extension its inclination toward

specialization. The work of primary care advocates, such as Starfield et al. [54],

built on the biopsychosocial model with empirical demonstrations of the value of

primary care to patients and health care systems.

To the extent that primary care physicians practice biopsychosocial care, this

model of patient-centered care is advanced by policies enacted to support them.

None, however, has been successful in increasing the proportion of generalist

physicians, in part because they do significantly narrow the differential between

generalists’ and specialists’ pay. Adjustments to Medicare physician payment under

the Resource-Based Relative Value Scale (RBRVS), medical school loan repayment

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programs, and a number of provisions under the Accountable Care Act (ACA)

(‘‘Obamacare’’) are typical of the effort. The ACA provides some financial

incentives to primary care physicians in the form of 2 years of higher Medicare-

level reimbursement under fee-for-service Medicaid (public assistance medicine for

some poor Americans) and a 5-year, 10 % reimbursement bonus under Medicare.

Among the workforce-related provisions of the Affordable Care Act is a

redistribution of residency training slots with priority given to primary care

physicians, among others, and the funding of primary care residency training in

community-based, ambulatory health settings, including federally qualified health

centers [33].

Not all primary care is delivered by physicians of course. McKinlay and Marceau

[38] go so far as to explain that primary care physicians are approaching

obsolescence. For one thing, nurse practitioners do much the same work as these

physicians and may be better suited to caring for whole patients. A practical

accommodation of biopsychosocial nursing was reported in the Washington Post in

2013 [36]. Health Quality Partners, a health plan in Pennsylvania serving

chronically ill patients, deploys nurses to make home visits weekly or monthly

even if a patient’s condition is stable. These nurses observe patients in their home

environments and speak to them about their health and health behaviors; patients

report that this communication is more honest and informative than what they

experience in the physician’s office. The Health Quality Partners program was

evaluated by an independent consulting firm using a randomized controlled trial

design. It was found to reduce hospitalizations by 33 % and costs by 22 %. Still, the

federal Medicare program (social insurance medicine for elderly and some disabled

Americans), which authorized the program as a demonstration project, refuses to

institute it on a larger scale. At least one knowledgeable observer believes this

decision results from the biases toward specialized and technical medicine the

biopsychosocial model was meant to correct [36].

The biopsychosocial model may also be at work in policy initiatives to integrate

physical and mental health care for people with mental illness. Findings of

significant premature mortality among mentally ill people [14] have resulted in a set

of policy proposals to integrate primary and mental health care. Although there is no

single integrated care model, the federal Substance Abuse and Mental Health

Services Administration (SAMHSA) is using ACA funds to support integrated care

demonstration projects across the country. The grantees are community mental

health providers who must create access to basic primary care either in-house or

through cooperative agreements [56]. This policy may not be what Engel

envisioned. As a researcher in psychosomatic illness, he focused on psychological

origins of physical illnesses. Integrated care reforms, in contrast, posit the origin of

ill health not in mental processes, but in the treatment of people with mental illness.

That is, a combination of poverty, psychotropic medication, and limited access to

physical health care contributes to high rates of chronic illness and premature death

among mentally ill people [45]; integrated care is charged with providing primary

care and tertiary prevention in a number of extant care settings. Still, integrated care

does ask that medicine acknowledge the whole person (with mental illness) and the

relationships among physical, mental and social aspects of health. It may be viewed,

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then, as are policies to support primary care more generally, as partaking in the

biopsychosocial model.

Type II: Patients Versus Providers

Another version of patient-centered care arose from the US health care consumer

movement that began in the 1970s. The consumer movement sought to increase

patients’ control over the medical services they received, both in the consulting

room and in the health care market. Probably the strongest rebuke to medical

paternalism came from the women’s health movement, which was fuelled by

women’s individual and collective dissatisfaction with reproductive care [42, 49].

This movement’s stunningly successful manifesto, Our Bodies, Ourselves, legiti-

mated women’s experiential knowledge and personal preferences and demystified

medical care, particularly reproductive care. This was a direct challenge to the

dominance of the (mostly male) medical profession and was grounded in

emancipatory politics [ 42].

The mental health recovery movement, like the women’s health movement,

sought to empower mental patients vis-a-vis providers and institutions, in part by

legitimating experiential knowledge and peer support [40]. Beginning in the 1980s,

‘‘patients’’ came to called ‘‘consumers’’ among themselves and in the public mental

health system [59], and this shift in terminology characterized the emancipatory

agenda. The term ‘‘consumer’’ for this population was unintentionally ironic or

perhaps aspirational; these particular consumers had very few resources and

opportunities for choice. Still, it did signal that mentally ill people, whose choices

had been denigrated or disregarded by providers and institutions, were now

permitted—if not always encouraged—to determine some things for themselves.

Other voices of health care consumerism adopted the language of the market

(e.g., [30]. They proposed that health care professionals be subject to the same

market discipline as commercial vendors. This was an exercise of economic rather

than political power (although the regulatory state might be invoked to protect

consumers from indifferent or predatory providers). In this formulation, patients had

the right not only to be heard by their physicians but to choose their providers and

among their options for care. Furthermore, under the economic theory of moral

hazard, consumers bearing more of the cost of their care would create a more

efficient market and thereby lower overall costs. Currently, Republican Congress-

man and staunch opponent of the ACA, Paul Ryan (R-WI) proposes that patients

bear additional risk in the marketplace and refers to this explicitly as ‘‘patient-

centered care’’ [48].

Model II was also advanced in less political/economic and more procedural

ways. Most notably, the concept of ‘‘shared decision-making’’ began to appear in

the literature in the 1970s and 1980s [12]. By 2012, a NEJM article called it the

‘‘pinnacle of patient-centered care’’ [3: 780]. Charles et al. [12] proposed a concept

of shared decision-making, noting that it seemed to be linked to positive patient

outcomes and identifying its roots in a ‘‘consumer rights movement’’ (682) that

included a ‘‘patient challenge to physician authority’’ (682). For these authors, the

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key characteristics of shared decision-making were that: it involves at least two

participants, the physician and patient; both take steps to participate in the process

of treatment decision-making; it has information-sharing as a prerequisite; and a

treatment decision is made to which both parties agree. It is distinguished from other

models of medical practice–the informed decision-making model, whose physicians

merely purvey information, and the professional-as-agent model whose physicians

decide what the patient would have wanted he or she been equally as informed [12].

Shared decision-making empowers patients in part by reducing the asymmetry of

medical information between patient and physician. Various modes of information-

sharing have been devised, including computerized decision aids for many medical

conditions (IDMF 2012). The aids have been evaluated as contributory to shared

decision-making [44, 61], but they may provide more than information to the

patients using them. They may also elicit preferences in particular terms–those set

by researchers and designers–and encourage patients to think categorically about

benefits and harms [12]. Thus patients may be socialized to decision-making of a

given kind, presumably so they can join the physician’s decision-making process

more efficiently. Furthermore, Elwyn et al. [17] draw on the work of John

Wennberg to distinguish decision support interventions from behavioral support

interventions; they recommend use of the former only under conditions of dual

equipoise. In other words, patients are to share decision-making only about

‘‘preference-sensitive care,’’ i.e., care whose desirability is open to question.

‘‘Effective care,’’ on the other hand, by definition offers greater benefit than harm,

and according to Elwyn et al. [17], there is no role for shared decision-making here.

Rather, behavioral support interventions are appropriate as these consist of the

description, justification and recommendation of actions by the physician to the

patient.

This view of shared decision-making is consonant with the precepts of evidence-

based medicine (EBM). In its classic form, EBM adheres to an evidence hierarchy

where randomized controlled trials or meta-analyses of these trials reside at the top,

and these statistical studies are considered definitive of medical practice. The

physician’s experiential knowledge, in contrast, resides with pathophysiology at the

bottom of the hierarchy, and the patient’s experiential knowledge is not included at

all. In the world of EBM, neither the physician nor the patient is powerful in the face

of ‘‘evidence.’’ In fact, early evidence-based medicine proponents portrayed the

movement as democratizing for just this reason. In the context of patient-centered

care, however, EBM and the myriad guidelines it spawns may act as a constraint on

truly shared decision-making. If evidence is authoritative, why should the patient

have any choice at all? The opposite view is expressed by patient advocate Gruman

[29], for whom ‘‘all care is preference-sensitive care.’’

Model II is reflected in two recent policy initiatives to increase patient

involvement in medical decision-making. One is the establishment, under the

Affordable Care Act, of the public–private Patient-Centered Outcomes Research

Institute (PCORI). PCORI is devoted to funding comparative effectiveness research,

but it emerged from the health reform debate with an additional mission: to make

research processes and products ‘‘patient-centered.’’ The Institute’s working

definition of patient-centered research is that it produces findings useful to

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individual patients and their families for decision-making that respects individual

patient values [46]. PCORI’s approach to patient-centeredness is to engage patients

in the research process from the start. For example, the Institute requires that

proposals for funding specify the investigators’ plans for ensuring patient input at

every stage of the project (PCORI [47].

The second policy representing Model II is also provided for by the ACA and is

the use of patient satisfaction data in scoring hospitals for Medicare’s pay-for-

performance reimbursement system, known as Value-Based Purchasing (VBP).

Beginning is 2013, hospitals’ annual reimbursements will be adjusted for the

‘‘value’’ of the care delivered, i.e., how often the hospital satisfies or improves upon

a set of performance standards, which will grow in number over time. Measures

drawn from the Consumer Assessment of Healthcare Providers and Systems

(CAHPS) survey will account for thirty percent of a hospital’s score, so hospitals—

and eventually physicians and other Medicare providers—will be paid in part based

on the satisfaction of their patients.

It remains to be seen whether either of these policies will actually empower

individual patients vis-a-vis their providers. In the case of the Patient-Centered

Outcomes Research Institute, the funded research may reflect patient concerns, but

it also employs statistical methods to produce aggregate findings—findings that may

not reflect an individual patient’s concerns. PCORI does encourage investigators to

study the heterogeneity of treatment effects (PCORI [47], which have been

neglected in the majority of clinical trials thus far [23]. This may be helpful to

individual patients in their decision-making, but only if these new findings are

treated as informative rather than prescriptive. In the case of Value-Based

Purchasing, the survey will sample a provider’s patients and report their responses.

Individuals’ experiences will not only be registered after the fact but may be washed

out by the experiences of other patients. Perhaps the goal of both PCORI and VBP is

better termed patients-centered care; they introduce the power of patients as a group

into larger processes such as effectiveness research and health care reimbursement.

Type III: Patients/Providers/The State Versus ‘‘The System’’

Health policy discourse frequently references the perverse incentives operating in

the US health care system. These are incentives—economic, legal, and profes-

sional—that motivate providers to act in their own interests and not those of

patients. Fee-for-service reimbursement and malpractice liability represent two such

incentives, both of which are seen to contribute to unnecessary and potentially

harmful care. Critics are also vocal about the fragmented, difficult-to-navigate

nature of the health care system. According to the Commonwealth Fund,

fragmentation is ‘‘a fundamental contributor’’ to the system’s generally poor

performance [50]. Among other things, it affects patient’ experiences by requiring

them to find their care across different providers and care settings,’’ and this renders

them frustrated and at-risk. Enthoven [19] further asserts that fragmentation ‘‘costs

lives’’ through its connection to preventable medical errors. From the family

medicine perspective described in Model I, Stange [53] describes fragmentation as

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‘‘focusing and acting on the parts without adequately appreciating their relationship

to the evolving whole.’’ He endorses treatment of the patient as a whole individual

in a healing relationship, decrying the commoditization, deprofessionalization,

depersonalization, and despair and discord that result from the many forms of health

care fragmentation.

In a recent recent university press volume devoted entirely to the fragmentation

of US health care [16], Cebul et al. [10] identify fragmentation in both insurance

coverage and organizational structures and specify institutional obstacles, such as

the shift to Medicare at age 65, to an assumption of over-arching responsibility for

the care of individual patients. Elsewhere, Enthoven [19] cites practice arrange-

ments that eschew teamwork and information-sharing. Bodenheimer and Grumbach

[6] trace fragmentation to the ascendancy of the biomedical model; the economic

incentives for hospital expansion, including the Hill-Burton Act of 1946 which

funded construction of but not care in hospitals; the assumption of medical

residency training costs by Medicare; the weakness of US health planning efforts

over time; and the American resistance to government control, if not government

funds, in the health care system as a whole. Fragmentation in the US health care

system is unsurprising; it may even be said to be over-determined. It is also the

enemy of patient-centered care.

In response, Model III does not attempt to redefine the patient (Model I) or the

patient’s role (Model II). Rather the third type takes note of perverse incentives and

relies primarily on economics and engineering [57] to make the system more

patient-centered, i.e., to shape providers’ behavior toward the best possible patient

care. Space does not permit a comprehensive review of the decades-long effort to

replace perverse incentives with appropriate ones, ones that are properly ‘‘aligned’’

with desired ends. Any such effort would have to include capitation to prevent over-

treatment; physician bonuses to prevent under-treatment; the use of clinical

guidelines, often with financial ramifications, to reward appropriate treatment;

vertical and virtual integration of health systems to reduce fragmentation; and

patient navigators to help patients get through it all.

As regards fragmentation specifically, there are a number of recent policy

developments aimed at reducing this threat to patient-centered care. ‘‘Medical

home’’ is an old term, first introduced by the American Academy of Pediatrics 1967

to describe coordinated care for children with special needs [55]. In the decades

following, the pediatric medical home was further elaborated, and internists came to

propose an adult primary care medical home (e.g., [25]. By 2007, the largest

primary care physician organizations in the US issued ‘‘Joint Principles’’ for patient-

centered medical homes, including a personal physician team leader for caregivers

who take responsibility for the whole patient [1]. The National Committee for

Quality Assurance (NCQA) has issued a set of voluntary standards for medical

homes [41], and at the level of public policy, the Affordable Care Act created a

Medicaid State Plan option (the option for states to receive federal funds for a given

service) for health homes for recipients with multiple chronic conditions. In order to

qualify as a health home, primary care practices must provide same-day access,

electronic medical records, and patient care teams [32].

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The ACA allows providers to form Accountable Care Organizations (ACOs) for

Medicare beneficiaries. These organizations also coordinate care but join hospitals

and a broad range of clinicians in a single legal entity. The ACO was designed by

Elliott Fisher at the Dartmouth Institute for Health Policy and Clinical Practice,

which is also home to Wennberg and to the Dartmouth Atlas project; under ACOs,

variation in cost and utilization will be reduced through reimbursement policy, i.e.,

the proper economic incentives for providers. An Accountable Care Organization

must have a minimum Medicare population of 5,000 beneficiaries, retrospectively

assigned, and it must coordinate a patient’s health services across levels and sites of

care. To avoid the restrictions of managed care, Medicare beneficiaries are not

limited to providers affiliated with their ACOs, so these organizations must redress

fragmentation even for patients who are free to go elsewhere for care. ACOs will be

at financial risk for meeting standards of quality and cost. Those that assume greater

financial risk will have a greater opportunity to profit from their performance [37,

52].

Medical homes, Accountable Care Organizations and even bundled payment

arrangements [11] attempt to reduce fragmentation in the US health care system.

Another policy aims for patient-centered care in a slightly different way. The

Money Follows the Person (MFP) demonstration project was enacted in 2005 and

expanded under the Affordable Care Act. MFP, like other policies before it,

responded to the institutional bias of the Medicaid program, which for historical and

political reasons, makes it easier for recipients to receive long-term care in an

institution than in the community settings most recipients prefer. As the name

suggests, MFP holds that people, not settings, should qualify for program dollars

based on their needs and preferences. In practice, the program provides 12 months

of additional federal money to states for each recipient who leaves an institution and

takes up residency in the community. Covered services are more expansive than

those ordinarily included in a state’s Medicaid program, and presumably more

customized to a given recipient, and they are funded at least during an individual’s

twelve-month transition period. Furthermore, in most states’ Money Follows the

Person programs, patients may direct their own care to a greater or lesser extent

[34]. Although the total cost of institutionalization does not follow the person and

community-based care risks its own fragmentation, MFP is a Model III policy tool

in that it directs care dollars to individuals service needs rather than to a routine but

less desirable locus of care.

Type IV: Person-Centered Medicine

The fourth type of patient-centered care is perhaps hardest to identify in the

workings of the current health care system. It has intellectual precedents in humanist

[9], phenomenological [60] and narrative [13] medicine, all of which share

epistemological and ethical concerns about how persons are treated when they

become patients. Model IV has emerged in part to respond to the rise of EBM, and it

juxtaposes an interpretive medicine involving whole persons to EBM’s reliance on a

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positivist evidence hierarchy. Person-centered medicine (PCM), which exemplifies

Type IV, is defined by Miles and Mezzich [39] as:

a medicine of the person (of the totality of the person’s health, including its ill

and positive aspects), for the person (promoting the fulfillment of the person’s

life project), by the person (with clinicians extending themselves as full human

beings, well grounded in science and with high ethical aspirations) and with

the person (working respectfully in collaboration and in an empowering

manner through a partnership of patient, family and clinician).

Although scholars and practitioners are engaged in refining this definition of

PCM (see, especially, IJPCM, proponents share a broad critique of medicine as it

is practiced, including its reductionism, epistemological restrictiveness, material-

ism, and neglect not only of the whole patient/person but of the whole clinician/

person.

Person-centered medicine joins the other models’ criticisms of health care.

Although PCM does not hold, as does the biopsychosocial model, that positivist

social science will round out what physicians need to know, it concurs that

biomedicine is too narrow a knowledge base for medical practice. Type IV also

rejects the paternalism and loss of control identified in Type II. It especially shares

with the political version of the consumers’ movement a respect for patients’

experiential knowledge and individual values in the medical encounter and

elsewhere. PCM adds to this a rehabilitation of the physician’s experiential

knowledge and clinical judgment, corrected for the cognitive biases that have been

revealed by psychological research [27]. The procedural side of Model II is less

compatible. Person-centered medicine seeks the expression of patient preference,

but for Model II this can mean preference represented in the aggregate or elicited by

predetermining what patients should know and how they should reason. Model III

helpfully identifies incentives that obstruct Model IV as well as the others: The

interests of whole patients are also lost in the maze of types, levels and loci of care.

For PCM, though, facilitating patients’ access to properly incentivized physicians is

only a first step toward ensuring they get what they need.

Model IV rejects two staples of current patient-centered care discourse. The first

is the assumption that patient-centered care is a means to an end—that it ought to be

pursued because it is more effective and/or less costly medical care [26]. Person-

centered medicine supporters do expect it to lead to better outcomes, especially

those related to individual patient ‘‘satisfaction,’’ but they do not justify the move to

patient-centeredness on these grounds. Patient-centered care does not need

justification. It is, for Model IV, an end in itself. Second, PCM rejects aggregated

measures of effectiveness or satisfaction, such as outcomes research or satisfaction

surveys, when they are determinative of individual patient care. It draws on findings

of genomic variability in the biological sciences and of important cultural,

psychological and spiritual differences among patients by social science and

humanities investigators (e.g., [28, 35]). Indeed evidence-based practice guidelines

have been found to be harmful even when patients are distinguishable by

comorbidities alone [7].

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Practically speaking, person-centered medicine seeks changes to medical

education [15, 20] and care practices [43, 51, 58]. Public policies to support

PCM are still mostly speculative. Type I’s emphasis on primary care and Type III’s

on medical homes seem promising, although current policies regarding the latter

require organizational adaptation to, say, electronic medical records, rather than

professional adaptation to whole patients and physicians. Model II’s ‘‘shared

decision-making’’ could describe PCM, but efforts to standardize decision-making

processes based on criteria determined by professionals is viewed with suspicion.

Person-centered medicine is not likely to result from more and more stringent

‘‘productivity’’ standards or the naıve pursuit of ‘‘evidence’’-based medicine. Over

all, Model IV is most likely to be accommodated in a health care system that relies

on ‘‘fences’’ rather than ‘‘reins’’ [6], one that addresses resource constraints at the

macro level rather than micro-managing physician (or patient) behavior. The

Patient-Centered Outcomes Research Institute has so far emphasized patient

involvement in the research process and research methods that reveal the

heterogeneity of treatment effects. These changes are salutary but still upstream

from centering on the individual patient in care.

In his cri de coeur, ‘‘What ‘Patient-Centered’ Should Mean: Confessions of an

Extremist,’’ Berwick [5] argues for specific changes to hospital care, including

patient self-determination in matters of food, clothing and self-care, and patient

ownership of the medical record. Some of these could become health policy as

accreditation requirements for Medicare reimbursement. He also notes that new

methods of reimbursement, public and private, could free physicians to be more

patient-centered, offering the example of e-mail communication in place of office

visits. Berwick’s particular call for patient-centered care is consonant with person-

centered medicine’s assertion that individuals are at the heart of properly rendered

medical care. For him, patient-centered care is: ‘‘that property of care that welcomes

me to assert my humanity and my individuality. If we be healers, then I suggest that

this is not a route to the point; it is the point’’ (w564).

Which Model(s) of Patient-Centered Care? Four Questions

The typology presented here attempts to delineate existing models of patient-

centered care and their missions. All four types respond to a US health care

system that fails patients in significant ways. Based on the range of disciplines,

eras, and remedies represented, a great variety of people have attempted to fix

these failings, in writing and in practice, and across the epistemological and

political spectra. In some sense, different types of patient-centered care are

looking at patients through different lenses—just the patient, the patient vis-a-vis

the physician, the patient in the health care system, and the patient and physician

as persons—so the models might be seen as accretive rather than incompatible,

especially when it comes to some policy tools, for example, those that make

primary care more attractive to physicians and other practitioners. From a political

perspective, moreover, proponents of any of the models might be willing to share

the name ‘‘patient-centered care’’ so as to enlarge their constituencies through

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ambiguity. Who, indeed, will mobilize in opposition to ‘‘patient-centered care?’’ It

may even be a rhetorical tonic for health policy-makers to call all kinds of care

reforms not ‘‘managed’’ or ‘‘evidence-based’’ but ‘‘patient-centered.’’

On the other hand, there are important differences among the models that

should be acknowledged to avoid undermining the very efforts made to achieve

patient-centered care. These have been noted in the discussion above and can be

summarized in four questions we ought to ask of any proposal for ‘‘patient-

centered care.’’ First, is this care a means to an end or an end in itself? Do we

practice patient-centered care so as to reach some other goal, such as reduced

cost, or is it a goal in itself? Second, are patients here subjects or objects? Do

we regard patients as entities to be acted upon—fixed or managed–or partners in

care based on mutual recognition? Third, are patients here individuals or

aggregates? Do we first regard the patient being treated or some group of

patients who may resemble but are a proxy for that patient? Fourth, how do we

know what a patient wants and needs? Is the patient’s experiential knowledge

considered legitimate? Is the physician’s? These questions need not be

evaluative. That is, they are meant less to elicit approval or disapproval of a

specific kind of patient-centered care than to highlight possible incompatibilities

and contradictions among kinds.

For example, at the encounter level, individual patient empowerment (end/

subject/individual/scientific and experiential) is likely to be incompatible with a

prescriptive decision aid geared to cutting costs (means/object/aggregate/scientific).

On the other hand, it is surely contributory to patient empowerment to possess

(aggregate) findings from research whose outcome measures were chosen by other

patients. Such results are likely to be more relevant to the individual’s decision-

making process than outcome measures chosen by researchers even if they should

never be determinative of his or her care. In other words, the four questions, based

on the models of patient-centered care discussed above, are meant to identify

important properties of any proposal for patient-centered care and therefore to aid in

the formulation and implementation of health policies to achieve the patient-

centered care we want.

At present, political enemies President Obama and Congressman Ryan are

both calling for ‘‘patient-centered care.’’ These two men’s meanings of patient-

centered care are very different and largely incompatible. Still, they, like others

whose work has been cited here, return to the patient in their prescriptions for

change. This may be purely rhetorical and a matter of policy fashion. It may,

however, reflect something about the salutary check on health care ambitions that

a focus on patients provides. Each of the meanings delineated in this paper

attaches to a mission of remediation in health care. Type I challenges a

successful biomedical science; Type II checks a powerful medical profession;

Type III reshapes a wealthy health care market; Type IV shares all of these

targets as well as opposing the new dominance of EBM. In every case, a

renewed focus on patients provides a counterweight to the excesses of other

actors and institutions. Perhaps this is the transcendent meaning and enduring

mission of patient-centered care.

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References

1. American Academy of Family Physicians (AAFP), American Academy of Pediatrics, American

College of Physicians, & American Osteopathic Association. (2007). Joint principles of the patient-

centered medical home. Available at http://www.acponline.org/hpp/approve_jp.pdf. Accessed Mar

10, 2013.

2. Balint, E., Ball, D., & Hare, M. (1969). Training medical students in patient-centered medicine.

Comprehensive Psychiatry, 10(4), 9.

3. Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making: The pinnacle of patient-

centered care. New England Journal of Medicine, 366, 780–781.

4. Bartz, R. (1999). Beyond the psychosocial model: New approaches to doctor–patient interactions.

Journal of Family Practice, 48(8), 601–607.

5. Berwick, D. M. (2009). What ‘‘patient-centered’’ should mean: Confessions of an extremist. Health

Affairs, 28(4), w555–w565.

6. Bodenheimer, T., & Grumbach, K. (2012). Understanding health policy: A clinical approach (6th

ed.). New York: Lange.

7. Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice

guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay

for performance. JAMA, 294(6), 716–724.

8. Brody, H. (1999). The biopsychosocial model, patient-centered care, and culturally sensitive practice.

Journal of Family Practice, 48(8). Available at http://www.jfponline.com/Pages.asp?AID=2680.

Accessed Sept 12, 2012.

9. Cassell, E. J. (1991). The nature of suffering and the goals of medicine. New York: Oxford University

Press.

10. Cebul, R., Rebitzer, J., Taylor, L. J., & Votruba, M. (2013). Organizational fragmentation and care

quality in the US health care system. In E. Elhauge (Ed.), The Fragmentation of US Health Care:

Causes and Solutions. New York: Oxford University Press.

11. Center for Medicare and Medicaid Services (CMS). (n.d.). Bundled payments for care improvement

(BPCI) initiative: General information. Available at www.innovation.cms.gov/initiatives/bundled-

payments/. Accessed Mar 11, 2013.

12. Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: What

does it mean (or it takes at least two to tango). Social Science and Medicine, 44(5), 681–692.

13. Charon, R. (2006). Narrative medicine: Honoring the stories of illness. New York: Oxford University

Press.

14. Colton, C. W., & Manderscheid, R. W. (2006). Conguencies in increased mortality rates, years of

potential life lost, and causes of death among public mental health clients in eight states. Preventing

Chronic Disease, 3(2), 1–14.

15. Dean, A. L., Lambrese, J., Dollase, R., Feller, E., & Taylor, J. S. (2011). Successful implementation

of an LGBTQI health elective into a medical school curriculum: A tool to increase culturally

sensitive care in person-centered medicine. International Journal of Person-Centered Medicine, 1(4),

830–838.

16. Elhauge, E. (Ed.). (2010). The fragmentation of US health care: Causes and solutions. New York:

Oxford University Press.

17. Elwyn, G., Frosch, D., & Rollnick, S. (2009). Dual equipoise shared decision-making: Definitions for

decision and behaviour support interventions. Implementation Science, 4. Available at http://www.

implementationscience.com/content/4/1/75. Accessed Jan 12, 2013.

18. Engel, G. L. (1980). The clinical application of the biopsychosocial model. American Journal of

Psychiatry, 137(5), 535–544.

19. Enthoven, A. C. (2009). Integrated delivery systems: The cure for fragmentation. American Journal

of Managed Care, 15(10), S284–S290.

20. Epperly, T. (2012). Person-centered medical education: North American approaches. International

Journal of Patient-Centered Medicine, 2(1), 38–42.

21. Epstein, R. M. (2000). The science of patient-centered care. Journal of Family Practice, 49(9).

Available at http://www.jponline.com/Pages.asp?AID=2593. Accessed Sept 15, 2012.

22. Future of Family Medicine Project Leadership Committee (FFMPLC). (2004). The future of family

medicine: A collaborative project of the family medicine community. Annals of Family Medicine,

2(suppl. 1), s3–s32.

Health Care Anal

123

23. Gabler, N. B., Duan, N., Liao, D., Elmore, J. G., Ganiats, T. G., & Kravitz, R. L. (2009). Dealing with

the heterogeneity of treatment effects: Is the literature up to the challenge? Trials, 10, 43.

24. Ghaemi, S. N. (2009). The rise and fall of the biopsychosocial model. British Journal of Psychiatry,

195, 3–4.

25. Goroll, A. H., Berenson, R. A., Shoenbaum, S. C., & Gardner, L. B. (2007). Fundamental reform of

payment for adult primary care: Comprehensive payment for comprehensive care. Journal of General

Internal Medicine, 22(3), 410–415.

26. Grob, R. (2012). The heart of patient-centered care. Journal of Health Politics, Policy and Law

1966406 (published ahead of print December 21).

27. Groopman, J. (2007). How doctors think. New York: Houghton Mifflin.

28. Groopman, J., & Hartzband, P. (2011). Your medical mind: How to decide what is right for you. New

York: Penguin.

29. Gruman, J. (2011). Remarks at the third annual comparative effectiveness summit, Washington, D.C.,

October.

30. Herzlinger, R. (1999). Market-driven health care: Who wins, who loses in the transformation of

America’s largest service industry. New York: Perseus Books.

31. Isaacs, S. L., & Knickman, J. R. (Eds.). (2004). Generalist medicine and the US health system. San

Francisco: Jossey-Bass.

32. Kaiser Family Foundation (KFF). (2011a). Medicaid’s new ‘‘health home’’ option. Available at http://

www.kff.org/medicaid/upload/8169.pdf. Accessed Feb 20, 2013.

33. Kaiser Family Foundation (KFF). (2011b). Summary of the new health reform law. Available at

http://www.kff.org/healthreform/upload/8061.pdf. Accessed Jan 15, 2013.

34. Kaiser Family Foundation (KFF). (2013). Money Follows the Person: A 2012 survey of transitions,

services and costs. Available at http://www.kff.org/medicaid/upload/8142-03.pdf. Accessed Mar 11,

2013.

35. Kleinman, A., Das, V., & Lock, M. (Eds.). (1997). Social suffering. Berkeley: University of Cali-

fornia Press.

36. Klein, E. (2013). If this was a pill, you’d do anything to get it. Available at www.washingtonpost.com/

blogs/wonkblog/wp/2013/04/28/if-this-was-a-pill-you’d-do-anything-to-get-it/. Accessed June 17,

2013.

37. Longworth, D. L. (2011). Accountable care organizations, the patient-centered medical home, and

health care reform: What does it all mean? Cleveland Clinic Journal of Medicine, 78(9), 571–582.

38. McKinlay, J., & Marceau, L. (2008). When there is no doctor: Reasons for the disappearance of

primary care physicians in the US during the early 21st century. Social Science and Medicine.

doi:10.10.16/socscimed.2008.06.034.

39. Miles, A., & Mezzich, J. E. (2011). The care of the patient and the soul of the clinic: Person-centered

medicine as an emergent model of modern clinical practice. International Journal of Person-Cen-

tered Medicine, 1(2), 207–222.

40. National Coalition for Mental Health Recovery (NCMHR). (n.d.). Available at http://ncmhr.org/

recovery.htm. Accessed Mar 2, 2013.

41. National Committee for Quality Assurance (NCQA). (n.d.). Patient-centered medical home. Available

at http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx. Accessed

Mar 12, 2013.

42. Norsigian, J., Diskin, V., Doress-Worters, P., Pincus, J., Sanford, W., & Swenson, N. (1999). The

Boston Women’s health book collective and our bodies, ourselves: A brief history and reflection.

Journal of the American Medical Women’s Association, Winter. Available at http://www.ourbodie

sourselves.org/about/jamwa.asp. Accessed Jan 27, 2013.

43. Oana Groene, R., Bolibar, I., & Brotons, C. (2012). Impact, barriers and facilitators of the ‘‘Ask Me

3’’ Patient Communications Intervention in a primary care center in Spain: A mixed-methods

analysis. International Journal of Patient-Centered Medicine, 2(4), 853–861.

44. O’Connor, A. M., Wennberg, J. E., Legare, F., Llewellyn-Thomas, H. A., Moulton, B. W., Sepucha,

K. R., et al. (2007). Toward the ‘‘tipping point’’: Decision aids and informed patient choice. Health

Affairs, 26(3), 716–725.

45. Parks, J., Svensen, D., Singer, P., & Foti, M. E. (Eds) (2006). Morbidity and mortality in people with

serious mental illness. National Association of State Mental Health Program Directors. Available at

http://www.dsamh.utah.gov/docs/mortality-morbidity_nasmhpd.pdf. Accessed Mar 1, 2013.

46. Patient-Centered Outcomes Research Institute (PCORI). (n.d.). Research we support. Available at

http://www.pcori.org/research-we-support/pcor/. Accessed Mar 12, 2013.

Health Care Anal

123

47. Patient Centered Outcomes Research Institute (PCO RI). (2013). Funding announcement: Improving

healthcare systems. Available at http://www.pcori.org/assets/PFA-Improving-Healthcare-Systems.

pdf. Accessed Feb 20, 2013.

48. Rubin, J. (2012). Right turn: Paul Ryan interview, Part 2. Washington Post, May 10. Available at

http://www.washingtonpost.com/blogs/right-turn/post/paul-ryan-interview. Accessed Mar 10, 2013.

49. Ruzek, S. (2007). Transforming doctor–patient relationships. Journal of Health Services Research

and Policy, 12(3), 181–182.

50. Shih, A., Davis, K., Schoenbaum, S., Gauthier, A., Nuzum, R., & McCarthy, D. (2008). Organizing

the U.S. health care delivery system for high performance. The Commonwealth Fund. Available at

www.commonwealthfund.org/Publications/Fund-Reports/2008/Aug/Organizing-the-U-S–Health-Care-

Delivery-System-for-High-Performance.aspx. Accessed Feb 4, 2013.

51. Shrestha, S., Armento, M. E. A., Bush, A. L., Huddleston, C., Zeno, D., Jameson, J. P., et al. (2012).

Pilot findings from a community-based treatment program for late-life anxiety: Implications for

person-centered medicine. International Journal of Person-Centered Medicine, 2(3), 400–409.

52. Skinner, J. (2011). Understanding prices and quantities in the US health care system. Journal of

Health Politics, Policy and Law, 36(4), 791–801.

53. Stange, K. C. (2009). The problem of fragmentation and the need for integrative solutions. Annals of

Family Medicine, 7(2), 100–103.

54. Starfield, B., Shi, L., & Macinko, J. (2005). Contribution of primary care to health systems and

health. Milbank Quarterly, 83(3), 457–502.

55. Stevens, D. (2011). The evolution of the primary care medical home. Community Health Forum

(Winter/Spring), 22–33.

56. Substance Abuse and Mental Health Services Administration (SAMHSA). (n.d.). Primary and

behavioral health care integration. Available at http://www.integration.samhsa.gov/PBHCI_

Program_Profile_2012.pdf. Accessed Mar 1, 2013.

57. Tanenbaum, S. J. (2013). Reducing variation in health care: The rhetorical politics of a policy idea.

Journal of Health Politics, Policy and Law, 38(1), 5–26.

58. Tarter, R. E., Kirisci, L., Ridenour, T., & Bogen, D. (2012). Application of person-centered medicine

in addiction. International Journal of Person-Centered Medicine, 2(2), 240–249.

59. Tomes, N. (2006). The patient as a policy factor: A historical case study of the consumer/survivor

movement in mental health. Health Affairs, 25(3), 720–729.

60. Toombs, S. K. (1993). The meaning of illness: A phenomenological account of the different per-

spectives of physician and patient. Dordrecht: Kluwer Academic Publishers.

61. Wennberg, J. E. (2010). Tracking medicine: A researcher’s quest to understand health care. Oxford:

Oxford University Press.

Health Care Anal

123