Patient Centered and Paternalistic: Both/and is better than either/or.
When House Speaker Paul Ryan describes what he thinks should replace the Affordable Care Act, he says health care needs to be more patient centered. He is not espousing the long-held view among clinical professionals that patient-centered care ensures that patient preferences and values guide clinical decision-making à la the Institute of Medicine’s (IOM) definition. Instead, Ryan defines patient-centered health care as a set of policy changes that will result in lower costs, more insurance coverage options, and greater control over where someone can receive health care.
Both uses of patient-centered are related to consumers being more proactive about evaluating the costs and benefits of their decisions. Nevertheless, we shouldn’t confuse the fundamental differences between them. Ryan’s version is about market-based consumerism and an individual’s purchasing power, whereas the IOM version is about shared decision-making and the power of partnerships. One definition positions patients and physicians as partners; the other casts care as a commodity.
There are many sectors where the “consumer experience” is considered the ultimate bellwether of business success. For today’s tech, food, auto or hospitality sectors, customer loyalty experts suggest innovative products are routinely at risk of becoming a commodity in today’s super accelerated, supply chain. Fanatical service (and delighted customers) is the ultimate differentiator. Thrive and survive. Don’t be confused here; the customer had better be doing the thriving.
But what of today’s health care sector? Should the customer experience be the differentiator that satisfies either the Ryan or IOM definitions of where this market should go? To be sure, competition in health care has much in common with other sectors with respect to earning customer satisfaction. Still, once wait times are winnowed and billing is error-free, making such market comparisons is not only inadequate, it’s imprudent.
The Health Research Enhancement Organization that I lead recently hosted our Think Tank member’s symposium to deliberate on “the voice of the employee.” Borrowing on the persuasive science behind the shared medical decision-making movement, we asked whether employee health promotion programs are shifting from a business case focused on health care cost containment to an employee well-being case more oriented toward the employee experience. Where wellness programs have arguably been paternalistic, trying to engage employees in better self-care, what would it look like if wellness were much more employee-centered? We had medical directors, health promotion and marketing experts, and researchers debating the merits and drawbacks of employee-centered wellness program design.
High expectations and high support
Too often, we specialists talk only to each other as we sort through issues, so I reached into another sector and invited Pauline Dow, the chief academic officer of an Austin, Texas school district, who has long been ensconced in “school choice” issues. Though Dow doesn’t skirt the ideological divides that make charter schools and standardized testing politically polarizing, she mostly leans on evidence when she argues that “high stakes testing” is paying Peter while robbing Paul. Referencing her service to the “Texas Commission on Next Generation Assessments and Accountability,” Dow describes how standardized testing is creating winners and losers among students given their diverse backgrounds and dissimilar learning styles. Surveys show most parents recognize the flaws in testing metrics and are opposed to them, and worse, teacher’s opinions are barely represented in the debates about testing and school choice.
What do teachers, police officers, counselors, coaches, tax accountants, and manufacturing supervisors share in common? Popularity, or the satisfaction of their “customers,” isn’t the ultimate differentiator. Outcomes are. And so it should be with physicians and the health care sector. Writing in The Atlantic about “The Problem with Satisfied Patients,” Alexandra Robbins cites research showing how physicians reimbursed according to patient satisfaction scores are talking less to their patients about substance abuse, smoking, or mental health problems. Related to this, the most satisfied patients are more likely to die than those less satisfied, likely due to being accommodated with more hospitalizations and prescriptions. Or, as emergency room physician Sandra Scott Simons wrote: “Basing medical care on patient satisfaction is as smart as basing school on child satisfaction… What’s wrong with medicine these days is what’s wrong with America. Personality and ‘customer service’ are valued more than competency, honesty, and outcome… Unfortunately, with Press Ganey hanging over our heads, we’re too eager to please everyone and too afraid of offending anyone.”
As much as I will continue to advocate for more employee-centered approaches to the design of employee wellness programs, I consider efforts to improve the employee experience a means to an end. Satisfaction is not the end I’m most interested in. Like school choice or patient-centered care, offering greater support that is sensitive to employee needs has to be accompanied by boundaries relating to the goals of an organization, or, in the case of wellness programs, the vision of employers, employees, and health promotion experts alike. Cutting through the vitriolic debates for and against charter schools, David Leonhardt argues that “schools that work” are those with high expectations and high support. For Pauline Dow, this has always meant a plethora of assessment methods like science projects, reading response logs, digital portfolios, journals or project-based demonstrations. She is as committed to Peter’s success as to Paul’s. And so I hope it can be as Paul Ryan and reform advocates advance their versions of patient-centered health care. A successful market must uphold health outcomes as a differentiator that matters as much as—or more than—consumer satisfaction with costs and choices.
Dr. Paul Terry is president and CEO of the Health Enhancement Research Organization (HERO), a national membership driven think tank based in Waconia, Minn., and editor in chief of the American Journal of Health Promotion. HERO is dedicated to positively influencing the health and well-being of employees, families, and communities.