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Sunday, 3 October 2010

Medical Homes, Patient Empowerment, or Both

There are two main beliefs in U.S. policy circles about how to improve health care quality and contain costs - strengthening the role of primary care physicians as "coordinators" or "integrators" of care, and empowering patients to "drive the health care market" by becoming value-oriented consumers.

The two approaches keep different company in policy-land. Strengthening primary care, as by establishing medical homes and accountable care organizations, tends to appeal to public health oriented, liberal folks. Empowering patients to take on the consumer role, as by transparency about quality and cost and "skin in the game" through financial risk, tends to appeal to market oriented, conservative folks.

Looked at from 30,000 feet the two approaches appear to reflect very different value orientations. Advocates for physician-led reform largely trust physicians to be motivated by professional ideals. Their aim is to enable physicians to carry out these ideals in their practices. Advocates for market-driven reform see physicians as Homo economicus, motivated in accord with Adam Smith's teachings:
"It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest."
By giving patients who have significant financial responsibility for their care reliable information about quality and cost, they will "shop" for care and shape medical care the same way that consumerism shapes the performance of other markets.

In our increasingly polarized political culture, physician-led reform and market-driven reform tend to be treated as either/or alternatives. Those who favor physician-led reform believe "the other side" just doesn't understand professionalism and our wish, when sick, to be cared for, not to shop. Those who favor market-driven reform believe "the other side" is naive about physician motivation and paternalistic towards patients.

This polarization is destructive. We won't get anywhere in the reform process without primary care leadership and activist patients. If the health system disbelieves in professional altruism, altruism will disappear. But wise physicians understand how much we need our patients to guide and monitor us, just as they need us to guide and monitor them. And prudent consumer-patients want compassionate caretakers, not just responsive Homo economicus.

"Physician-patient partnership" is a current buzz word. But properly understood it's the key to meaningful health reform. In the next few weeks I'll be writing more on what "physician-patient partnership" means.


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