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: [email protected]
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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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