A Patient-Centered Conundrum

Nowadays you hear a lot of about the “patient-centered care model” in medicine.  The Institute of Medicine defines it as “Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”  This model emphases educated decision-making guided by the physician, and is a shift away from the patriarchal “doctor knows best” model of traditional medicine.   It is the direction medicine is going.  Interestingly, it is the model that has been taught to psychologists for decades.  We have known for a long time that this basic model helps most patients (not all) feel empowered and often strengthens the doctor-patient relationship.  It is based on mutual respect and joint decision-making.  But you’ll notice that the definition assumes this relationship is between two people, when usually it is a “menage a trois,” where the third party is the insurance company (and it’s just as sexy as it sounds.)

The insurance company is the other decision-maker and often the most powerful voice in the room.  The insurance company often makes decisions about what care you should receive and whether your provider should be paid.  This relationship is not consistent with the patient-centered model.  Insurance companies don’t base their decision on your values or your wishes, there is often no discussion or dialogue between the insurance company and you or the professional.  They seem to make their decisions capriciously, motivated by a desire to delay payment as long as possible to increase profits, or judgments are based on biblical, opaque rulebooks that constantly change and that health professionals can’t possibly memorize.  You and your professional, be it a physician or psychologist, may have a great plan on which you both agree, but the insurance company may choose to nix it.  Bizarrely, this sometimes happens after the service was provided so the professional doesn’t get paid.

As if this wasn’t frustrating enough, this unwanted three-way also can put the professional in the awkward position of trying to be both patriarchal and patient-centered.  The enlightened health professional may have a patient-centered approach, and may ask you to help make decisions about your care (for example, how often you would like to meet for psychotherapy), yet the professional may then need to act like a patriarch to satisfy the insurance company.  And the insurer is the alpha-wolf, the final arbiter of what treatment should or shouldn’t be paid for.  The insurer doesn’t want to hear about the patient’s decision, or that the professional deferred to the values or wishes of the patient, the insurer wants to hear that it was the professional’s decision, based on clear medical (always medical, not psychological by the way) necessity.  In other words, the insurer expects the professional to be the sole expert and decision maker, and has no real interest in what the patient thinks he/she needs.  The reason for this is that the insurer’s job (aside from making massive profits) is ostensibly to cut costs.  Relationships with their customers based on mutual respect and dialogue make it harder for them to say “no, you don’t need that MRI.  There’s a perfectly good radiation-soaking CT machine right there.  No, not there, not where you are–across town–we won’t pay for that one.  And don’t even ask about arranging transportation from us, that’s not our problem.”

The patient-centered model is a great idea, and the Affordable Care Act certainly embraces it.  But there is still this glaring inconsistency where insurers are concerned.  If we’re really going to adopt this model, we have to go all the way.  Insurers need to be regulated such that they are required to strongly consider the wishes of their customers and respect the plans that patients have with their health professionals.  But, alas, we’re not going to see that change, because it might increase costs.  So what we’re left with is this contradictory situation where the practice of medicine and psychology follows one value system, but the payment for those services follows another.  The professional is given the added job of trying to negotiate these opposing value systems, and the patient suffers the disappointment that comes from being led to believe healthcare is patient-centered, when in fact it is not.