- Email: [email protected]
Interview with Harvey V. Fineberg, MD, PhD
Healthcare 1 (2013) 147–148
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Interview
Interview with Harvey V. Fineberg, MD, PhD Brian W. Powers 250 Longwood Ave., Boston, United States
Harvey V. Fineberg is President of the Institute of Medicine. He served as Provost of Harvard University from 1997 to 2001, following 13 years as Dean of the Harvard School of Public Health. He has devoted most of his academic career to the fields of health policy and medical decision-making. His past research has focused on the process of policy development and implementation, assessment of medical technology, evaluation and use of vaccines, and dissemination of medical innovations. He earned his bachelor's and doctoral degrees from Harvard University. Brian Powers: The Institute of Medicine (IOM) Crossing the Quality Chasm report elevated the focus on patient-centered care. What have been the most notable advances since it was published in 2001? Harvey V. Fineberg: Patient-centeredness was one of the six aims for improvement identified in that report, but all of the other aims feed into patient-centered care. Care cannot be patient centered if it is not safe, effective, timely, and efficient. Over the past decade, one of the biggest changes in the state of practice and performance has been continuous institutional attention to safety and quality, and this has helped move us towards a more patientcentered system. There have also been movements to help patients make better health care choices, such as the Choosing Wisely campaign. Medical education is also putting an increasing emphasis on partnership and participation. There is a focus on teaching physicians not only how to deliver care but also how to listen astutely and understand patient needs and perspectives. BP: Many stakeholders still feel that not enough progress has been made in the past decade. What have been the challenges? HVF: The biggest challenges have to do with culture and incentives. Patient-centered care requires a change in values, expectations, and priority setting for the medical profession. This covers everything from where physicians and patients park, how hours for care are set, what services are available to patients in their home, and how respectfully families are treated. If you go through all of these elements there are still some remnants of the old authoritarian physician model. That sort of approach, grounded in values such as physician individuality and freedom, can work against putting the patient first. Current financial incentives also make it difficult to deliver patient-centered care. Generating more revenue for a hospital or clinician is not always
E-mail address: [email protected] 2213-0764/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hjdsi.2013.07.010
geared around the real needs of patients. For example, when hospitals are reimbursed for inpatient care they are going to be less likely to find ways to take care of patients in their homes. BP: What is the biggest near-term priority for accelerating progress toward a truly patient-centered health care system? HVF: This comes back to culture and incentives. We need to continue to change reimbursement models, moving away from fee for service. Reimbursement for care over a period of time, rather than service by service, will help give providers the flexibility to provide more patient-centered care. A patient-centered health care system also requires a new understanding of professionalism, and a new compact between physicians and patients. Patients need to be given respect and agency, and authority must be shared between physicians and patients. BP: You have dedicated much of your career to clinical decision-making and decision science. How does embracing patient-centered care change the decision-making paradigm? HVF: Technical knowledge is the province of the physician. Physicians have the expertise and knowledge base to understand disease, diagnosis, prognosis, treatment effects, and side effects. But making choices requires weighing values. And values are the province of the patient. The challenge in an emotional and demanding decision setting like medicine is for clinicians to figure out how to properly elicit and take account of preferences while simultaneously bringing their specific knowledge to each decision. Gifted clinicians bring both together in a useful way, guiding patients to the best decision possible based on his or her needs and values. BP: There has been an increasing focus on patient responsibility as a necessary component of a patient-centered health care system. But some patients do not want to take an active role in their care. Should we push for their involvement or meet them where they are? HVF: Some people argue that patient-centered care means that whatever a patient wants is what they get. I do not hold to that. I also do not hold to the view that the right attitude for every patient is the partnership model. Even some very sophisticated and knowledgeable patients just want the physician to tell them what to do. There are three basic models of care: the authoritarian physician model, the physician as information provider model, and the broad partnership model. Patient-centered care is not about a physician adopting one of these styles of practice. Rather, it is about the physician adopting a style of care for each patient under each circumstance. Even for the same patient, the appropriate style may be very different when they are receiving everyday care
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versus that for a life-threatening illness. Physicians need to be able to tune into each patient and understand his or her needs. BP: Many key provisions of the Affordable Care Act (ACA) are being implemented this year. Compared to when the bill was passed, are you more or less optimistic about the ability of the ACA to achieve its goals of improved coverage and a more sustainable system? HVF: I am more optimistic. The Supreme Court upheld the law and, to date, there has been no counter legislation to undermine the law. Many of the early provisions of the ACA have been promising. The Patient-Centered Outcomes Research Institute (PCORI) is poised to have a tremendous and meaningful impact when it comes fully online. Furthermore, provisions that help individuals in their twenties obtain insurance under their parents, and those that cover preventive services free of charge, are all great steps forward. But it is still early. How well the law is implemented will make all of the difference in terms of whether the ACA is a success or failure. This hinges on the hard work of hundreds of people at the state and federal level to ensure that it is implemented fairly and efficiently. BP: What do you see as the single biggest challenge facing implementation of the ACA?
HVF: The challenge with implementation is that everything has to be done well. You can execute well on almost every dimension, but if you miss one step all of the others are for nothing. When implementing the law, it will be important to learn from the experiences of others, such as Massachusetts with exchanges. Adaptability and flexibility will be key to ensure that every essential component is executed well. BP: What will be the biggest locus of reform in the coming years? HVF: Now that we have made progress on coverage, the real challenge ahead is enhancing value—getting more health benefit for every dollar we spend. We cannot continue to spend so many billions without any health benefit. Our country cannot afford it, it's horrible waste, and it makes no sense. BP: What should we keep an eye out for in this space? HVF: Changes in the reimbursement structure, better patient engagement, and sustained efforts by hospitals to eliminate waste are all necessary contributions to this field. Somewhere in America, someone has solved most of these challenges. Discerning what works and how to scale-up and spread successful initiatives will be the challenge.
Contents lists available at ScienceDirect
Healthcare journal homepage: www.elsevier.com/locate/hjdsi
Interview
Interview with Harvey V. Fineberg, MD, PhD Brian W. Powers 250 Longwood Ave., Boston, United States
Harvey V. Fineberg is President of the Institute of Medicine. He served as Provost of Harvard University from 1997 to 2001, following 13 years as Dean of the Harvard School of Public Health. He has devoted most of his academic career to the fields of health policy and medical decision-making. His past research has focused on the process of policy development and implementation, assessment of medical technology, evaluation and use of vaccines, and dissemination of medical innovations. He earned his bachelor's and doctoral degrees from Harvard University. Brian Powers: The Institute of Medicine (IOM) Crossing the Quality Chasm report elevated the focus on patient-centered care. What have been the most notable advances since it was published in 2001? Harvey V. Fineberg: Patient-centeredness was one of the six aims for improvement identified in that report, but all of the other aims feed into patient-centered care. Care cannot be patient centered if it is not safe, effective, timely, and efficient. Over the past decade, one of the biggest changes in the state of practice and performance has been continuous institutional attention to safety and quality, and this has helped move us towards a more patientcentered system. There have also been movements to help patients make better health care choices, such as the Choosing Wisely campaign. Medical education is also putting an increasing emphasis on partnership and participation. There is a focus on teaching physicians not only how to deliver care but also how to listen astutely and understand patient needs and perspectives. BP: Many stakeholders still feel that not enough progress has been made in the past decade. What have been the challenges? HVF: The biggest challenges have to do with culture and incentives. Patient-centered care requires a change in values, expectations, and priority setting for the medical profession. This covers everything from where physicians and patients park, how hours for care are set, what services are available to patients in their home, and how respectfully families are treated. If you go through all of these elements there are still some remnants of the old authoritarian physician model. That sort of approach, grounded in values such as physician individuality and freedom, can work against putting the patient first. Current financial incentives also make it difficult to deliver patient-centered care. Generating more revenue for a hospital or clinician is not always
E-mail address: [email protected] 2213-0764/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hjdsi.2013.07.010
geared around the real needs of patients. For example, when hospitals are reimbursed for inpatient care they are going to be less likely to find ways to take care of patients in their homes. BP: What is the biggest near-term priority for accelerating progress toward a truly patient-centered health care system? HVF: This comes back to culture and incentives. We need to continue to change reimbursement models, moving away from fee for service. Reimbursement for care over a period of time, rather than service by service, will help give providers the flexibility to provide more patient-centered care. A patient-centered health care system also requires a new understanding of professionalism, and a new compact between physicians and patients. Patients need to be given respect and agency, and authority must be shared between physicians and patients. BP: You have dedicated much of your career to clinical decision-making and decision science. How does embracing patient-centered care change the decision-making paradigm? HVF: Technical knowledge is the province of the physician. Physicians have the expertise and knowledge base to understand disease, diagnosis, prognosis, treatment effects, and side effects. But making choices requires weighing values. And values are the province of the patient. The challenge in an emotional and demanding decision setting like medicine is for clinicians to figure out how to properly elicit and take account of preferences while simultaneously bringing their specific knowledge to each decision. Gifted clinicians bring both together in a useful way, guiding patients to the best decision possible based on his or her needs and values. BP: There has been an increasing focus on patient responsibility as a necessary component of a patient-centered health care system. But some patients do not want to take an active role in their care. Should we push for their involvement or meet them where they are? HVF: Some people argue that patient-centered care means that whatever a patient wants is what they get. I do not hold to that. I also do not hold to the view that the right attitude for every patient is the partnership model. Even some very sophisticated and knowledgeable patients just want the physician to tell them what to do. There are three basic models of care: the authoritarian physician model, the physician as information provider model, and the broad partnership model. Patient-centered care is not about a physician adopting one of these styles of practice. Rather, it is about the physician adopting a style of care for each patient under each circumstance. Even for the same patient, the appropriate style may be very different when they are receiving everyday care
148
B.W. Powers / Healthcare 1 (2013) 147–148
versus that for a life-threatening illness. Physicians need to be able to tune into each patient and understand his or her needs. BP: Many key provisions of the Affordable Care Act (ACA) are being implemented this year. Compared to when the bill was passed, are you more or less optimistic about the ability of the ACA to achieve its goals of improved coverage and a more sustainable system? HVF: I am more optimistic. The Supreme Court upheld the law and, to date, there has been no counter legislation to undermine the law. Many of the early provisions of the ACA have been promising. The Patient-Centered Outcomes Research Institute (PCORI) is poised to have a tremendous and meaningful impact when it comes fully online. Furthermore, provisions that help individuals in their twenties obtain insurance under their parents, and those that cover preventive services free of charge, are all great steps forward. But it is still early. How well the law is implemented will make all of the difference in terms of whether the ACA is a success or failure. This hinges on the hard work of hundreds of people at the state and federal level to ensure that it is implemented fairly and efficiently. BP: What do you see as the single biggest challenge facing implementation of the ACA?
HVF: The challenge with implementation is that everything has to be done well. You can execute well on almost every dimension, but if you miss one step all of the others are for nothing. When implementing the law, it will be important to learn from the experiences of others, such as Massachusetts with exchanges. Adaptability and flexibility will be key to ensure that every essential component is executed well. BP: What will be the biggest locus of reform in the coming years? HVF: Now that we have made progress on coverage, the real challenge ahead is enhancing value—getting more health benefit for every dollar we spend. We cannot continue to spend so many billions without any health benefit. Our country cannot afford it, it's horrible waste, and it makes no sense. BP: What should we keep an eye out for in this space? HVF: Changes in the reimbursement structure, better patient engagement, and sustained efforts by hospitals to eliminate waste are all necessary contributions to this field. Somewhere in America, someone has solved most of these challenges. Discerning what works and how to scale-up and spread successful initiatives will be the challenge.