- Email: [email protected]
Patient-centered health care: Desideratum for medical care reform
Patient Education and Counseling, 19 (1992) 231-239 Elsevier Scientific Publishers Ireland Ltd.
237
Editorial
Patient-Centered Reform
Health Care: Desideratum
As campaigning for the upcoming US Presidential election intensities, the issue of medical care reform now commands center stage. Business goals of profit enhancement and competition have, to an unsettling degree, replaced traditional values of ‘putting the patient first’ [l]. As a result, the American electorate has expressed its dissatisfaction with a medical care system that costs more and more to service a shrinking segment of the population. About 20 cents of every health care dollar is channeled into administrative overhead, a figure which is 60% higher than in Canada and 97% higher than in Britain [2]. A 1990 Gallup poll revealed that 72% of Americans favor some form of a national health care program [3]. Since then, a raft of proposals for reform has been issued, even by those groups benefiting most under the existing state of affairs. Patient education advocates have a major stake in the outcome of this debate. Why? Because experience proves that absent strict regulatory protection, patient education and health promotion are among the first services to be pared in times of economic stringency. Patient education has flourished the most in countries like the Netherlands has enjoyed consistent governmental funding and support from the national hospital association [4]. In an era in which the basic assumptions of the biological model of health care are being called into question [5-81, it appears that much of the political debate on national health insurance takes the existing model for granted. By not examining our assumptions, 0738-3991/92/$05.00 0 1992 Elsevier Printed and Published in Ireland
Scientific
Publishers
Ireland
for Medical Care
however, we run the risk of committing same errors in the future.
the
These are the perspectives which patient educators should be advocating in an era of imminent health care reform: ?? Financing. Historically, financing of medical care services in the US has rewarded the performance of procedures and tests, not counseling or advice. Although the newlyintroduced Relative Value Scale will help redress this imbalance, by law, Medicare still will not reimburse for activities that are purely preventive in nature. It seems paradoxical that a plan purporting to offer ‘health’ insurance would not pay for health promotion. ?? Co-payments and Deductibles. The imposition of co-payments and deductibles deters utilization of low-cost services. Because patient education is inherently less expensive, education is adversely affected by this type of cost-saving strategy. Thus, co-payments should be avoided. ?? Managed
Care. Many of the health reform
proposals advocate the growth of managed care and health maintenance organizations. Experience to date suggests that health maintenance organizations support the provision of patient education and health promotion. ?? Quality Improvement. Although quality improvement now receives far more priority in health care organizations, the consumer still plays a secondary role. If health care is going Ltd.
238
to be responsive to patient’s needs, as patients perceive them, then consumers will have to play a major role in assessments of health care quality. ?? Role of Nurses. Advanced practice nurses are underused in the provision of primary health care. Nurse-midwifery serves as an object lesson. The research indicates that the quality of care rendered by nurse-midwives to low-risk women equals or exceeds that given by physicians [9, lo]. Nurse-midwives are believed to emphasize the provision of patient education. This may be part of the reason behind the low malpractice claim rates for nurse-midwives [ 111.
0 Self-Cure. Self-care represents a major underground resource in health care. About 70% of illness episodes are diagnosed and managed by persons without professional attention [12-141, suggesting that the true health care ‘provider’ is the layperson. How do we recognize the fundamental contribution of self-care within a national health plan? Providing governmental funding to self-care groups may not be the answer, since requirements for accountability and professionalism would accompany such funding, thereby undermining the spirit of self-care. Yet legislation simply acknowledging the fundamental contribution of self-care would do much to shape the spirit of a new order in healthcare.
An Informed Patient. Several plans advocate making information about hospital and physician quality and costs widely available. A centerpiece of President Bush’s plan, this would putatively force the health care system to respond better to market forces. In my view, the public should receive far more information about provider qualifications, complications rates, assessments of patient satisfaction and cost. Yet this cannot be viewed as a panacea. Even under the best of circumstances, an informed consumer cannot substitute for structural reform of a fragmented and inefficient medical care system. ??
Among the existing major proposals for health care reform, all advocate paying greater attention to quality improvement, particularly the plan of the National Leadership Commission on Health Care. Several plans espouse an increased role for managed care, especially Enthoven’s Consumer-Choice Health Plan [ 151. Some would retain copayments and deductibles, others would abolish them. None of the proposals contradict the notion that cognitive and counseling services should be paid for equitably. An enhanced role for advanced practice nurses, however, is ignored by most plans. Patient education advocates need to follow the policy currents and eddies and enter into the debate on health care reform, so that patients themselves stand to gain most from the ultimate outcome. Edward E. Bartlett, DrPH References 1 2
3 4
5 6
Relman AS: The health care industry: Where is it taking us? N Engl J Med 1991; 325: 854-859. Woolhandler S, Himmelstein DU: The deteriorating administrative efliciency of the US health care system. N Engl J Med 1991; 324: 1253-1258. Gallup Poll. February 19, 1990. Storrs, CT: Roper Center for Public Opinion Research. Fahrenfort M: Patient education in Dutch hospitals: The fruits of a decade of endeavors., Patient Educ Couns 1990; 15: 139-150. Bartlett EE: The Educational and Medical Models of Health Care. Patient Educ Couns 1984; 6: 57-61. White KL: The tasks of medicine: Dialogue at Wickenburg. Menlo Park, CA: Kaiser Family Foundation, 1988. Engel GL: The need for a new medical model: A challenge for biomedicine. Science 1976; 196: 129-136. Levin LS et al: Self-care: Lay initiatives in health. New York: Prodist, 1976. Rooks JP et al: Outcomes of care in birth centers: The National Birth Center Study. N Engl J Med 1989; 321: 1804-1811. Thompson JE: Nurse-midwifery research: 1925- 1984. In Werley H and Fitzpatrick J eds. Annual Review of Nursing Research 1986; Vol. 4. Ernst EK: Statement on Malpractice Issues in Childbirth. In Young D ed. Malpractice Issues in Childbirth: Proceedings. Minneapolis, MN: International Childbirth Association, 1985. National Leadership Commission on Health: For the health of a nation. Washington, DC, 1989.
239
12 13 14
Pratt L: The significance of the family in medication. J Comp Family Stud 1973; 1: 13-35. Binns-Elliott EP: An analysis of lay medicine. J R Coil Gen Pratt 1973; 23: 255-264. Verbrugge LM, Ascione FJ: Exploring the iceberg: Common symptoms and how people care for them. Med Care 1987; 25: 539-569.
15
Enthoven
A, Kronick
R: A consumer-choice
health
plan
for the 1990s: Universal health insurance in a system designed to promote quality and economy. N Engl J Med 1989; 320: 29-37; 94-101.
237
Editorial
Patient-Centered Reform
Health Care: Desideratum
As campaigning for the upcoming US Presidential election intensities, the issue of medical care reform now commands center stage. Business goals of profit enhancement and competition have, to an unsettling degree, replaced traditional values of ‘putting the patient first’ [l]. As a result, the American electorate has expressed its dissatisfaction with a medical care system that costs more and more to service a shrinking segment of the population. About 20 cents of every health care dollar is channeled into administrative overhead, a figure which is 60% higher than in Canada and 97% higher than in Britain [2]. A 1990 Gallup poll revealed that 72% of Americans favor some form of a national health care program [3]. Since then, a raft of proposals for reform has been issued, even by those groups benefiting most under the existing state of affairs. Patient education advocates have a major stake in the outcome of this debate. Why? Because experience proves that absent strict regulatory protection, patient education and health promotion are among the first services to be pared in times of economic stringency. Patient education has flourished the most in countries like the Netherlands has enjoyed consistent governmental funding and support from the national hospital association [4]. In an era in which the basic assumptions of the biological model of health care are being called into question [5-81, it appears that much of the political debate on national health insurance takes the existing model for granted. By not examining our assumptions, 0738-3991/92/$05.00 0 1992 Elsevier Printed and Published in Ireland
Scientific
Publishers
Ireland
for Medical Care
however, we run the risk of committing same errors in the future.
the
These are the perspectives which patient educators should be advocating in an era of imminent health care reform: ?? Financing. Historically, financing of medical care services in the US has rewarded the performance of procedures and tests, not counseling or advice. Although the newlyintroduced Relative Value Scale will help redress this imbalance, by law, Medicare still will not reimburse for activities that are purely preventive in nature. It seems paradoxical that a plan purporting to offer ‘health’ insurance would not pay for health promotion. ?? Co-payments and Deductibles. The imposition of co-payments and deductibles deters utilization of low-cost services. Because patient education is inherently less expensive, education is adversely affected by this type of cost-saving strategy. Thus, co-payments should be avoided. ?? Managed
Care. Many of the health reform
proposals advocate the growth of managed care and health maintenance organizations. Experience to date suggests that health maintenance organizations support the provision of patient education and health promotion. ?? Quality Improvement. Although quality improvement now receives far more priority in health care organizations, the consumer still plays a secondary role. If health care is going Ltd.
238
to be responsive to patient’s needs, as patients perceive them, then consumers will have to play a major role in assessments of health care quality. ?? Role of Nurses. Advanced practice nurses are underused in the provision of primary health care. Nurse-midwifery serves as an object lesson. The research indicates that the quality of care rendered by nurse-midwives to low-risk women equals or exceeds that given by physicians [9, lo]. Nurse-midwives are believed to emphasize the provision of patient education. This may be part of the reason behind the low malpractice claim rates for nurse-midwives [ 111.
0 Self-Cure. Self-care represents a major underground resource in health care. About 70% of illness episodes are diagnosed and managed by persons without professional attention [12-141, suggesting that the true health care ‘provider’ is the layperson. How do we recognize the fundamental contribution of self-care within a national health plan? Providing governmental funding to self-care groups may not be the answer, since requirements for accountability and professionalism would accompany such funding, thereby undermining the spirit of self-care. Yet legislation simply acknowledging the fundamental contribution of self-care would do much to shape the spirit of a new order in healthcare.
An Informed Patient. Several plans advocate making information about hospital and physician quality and costs widely available. A centerpiece of President Bush’s plan, this would putatively force the health care system to respond better to market forces. In my view, the public should receive far more information about provider qualifications, complications rates, assessments of patient satisfaction and cost. Yet this cannot be viewed as a panacea. Even under the best of circumstances, an informed consumer cannot substitute for structural reform of a fragmented and inefficient medical care system. ??
Among the existing major proposals for health care reform, all advocate paying greater attention to quality improvement, particularly the plan of the National Leadership Commission on Health Care. Several plans espouse an increased role for managed care, especially Enthoven’s Consumer-Choice Health Plan [ 151. Some would retain copayments and deductibles, others would abolish them. None of the proposals contradict the notion that cognitive and counseling services should be paid for equitably. An enhanced role for advanced practice nurses, however, is ignored by most plans. Patient education advocates need to follow the policy currents and eddies and enter into the debate on health care reform, so that patients themselves stand to gain most from the ultimate outcome. Edward E. Bartlett, DrPH References 1 2
3 4
5 6
Relman AS: The health care industry: Where is it taking us? N Engl J Med 1991; 325: 854-859. Woolhandler S, Himmelstein DU: The deteriorating administrative efliciency of the US health care system. N Engl J Med 1991; 324: 1253-1258. Gallup Poll. February 19, 1990. Storrs, CT: Roper Center for Public Opinion Research. Fahrenfort M: Patient education in Dutch hospitals: The fruits of a decade of endeavors., Patient Educ Couns 1990; 15: 139-150. Bartlett EE: The Educational and Medical Models of Health Care. Patient Educ Couns 1984; 6: 57-61. White KL: The tasks of medicine: Dialogue at Wickenburg. Menlo Park, CA: Kaiser Family Foundation, 1988. Engel GL: The need for a new medical model: A challenge for biomedicine. Science 1976; 196: 129-136. Levin LS et al: Self-care: Lay initiatives in health. New York: Prodist, 1976. Rooks JP et al: Outcomes of care in birth centers: The National Birth Center Study. N Engl J Med 1989; 321: 1804-1811. Thompson JE: Nurse-midwifery research: 1925- 1984. In Werley H and Fitzpatrick J eds. Annual Review of Nursing Research 1986; Vol. 4. Ernst EK: Statement on Malpractice Issues in Childbirth. In Young D ed. Malpractice Issues in Childbirth: Proceedings. Minneapolis, MN: International Childbirth Association, 1985. National Leadership Commission on Health: For the health of a nation. Washington, DC, 1989.
239
12 13 14
Pratt L: The significance of the family in medication. J Comp Family Stud 1973; 1: 13-35. Binns-Elliott EP: An analysis of lay medicine. J R Coil Gen Pratt 1973; 23: 255-264. Verbrugge LM, Ascione FJ: Exploring the iceberg: Common symptoms and how people care for them. Med Care 1987; 25: 539-569.
15
Enthoven
A, Kronick
R: A consumer-choice
health
plan
for the 1990s: Universal health insurance in a system designed to promote quality and economy. N Engl J Med 1989; 320: 29-37; 94-101.