Does patient centered care conflict with outcome based care?
The current model of payment (fee for service) certainly has the ability to be manipulated without the focus on the patient. Things are time based and technique based. More time, more techniques… means we did more for the patient. (right?) It is easy to see how this can be skewed.
Now I don’t mean to get on a tangent, but motor learning principles support us doing LESS for a patient and having them LEARN for long term outcomes. Our Assessment notes could read “PT provided environment for pt to develop motor solutions. No tactile or verbal cues were given. Pt did the work.” (an exaggeration because knowledge-of-performance and knowledge-of-results are indeed important, but you get my point). Sometimes doing less is better… but how you gonna get paid wit dat?
Enter Outcome Based Care. Focus on customer satisfaction and the outcomes from care.
Let’s just look at the outcomes, for which it is proposed we will be monetarily judged and rewarded.
As an empathetic biopsychoscoial physical therapist I take patient preference quite seriously. I must ask, however, what happens when outcomes are reduced because of patient preference? That can happen now, of course (patient just wants hotpacks and ESTIM) but we are getting paid for time, so we try to limit it, but no significant harm is done to either party. We can bill, the patient gets what they want and it’s likely a gait-way to patient trust in going forward in effective treatment. As long as the treatment is not dangerous or detrimental to the patient’s health, no problem right?
That equation changes when outcomes are the primary focus. Hotpacks never cured a thing. Yes they may relax a patient or you can choose to use it as a reward, but it’s not progress towards an outcome.
Some current scenarios that may affect outcomes: 1) A patient that doesn’t prefer to complete tasks (shown by research to improve their condition) in a timely manner. 2) Patients that have significant co-morbidities that are not picked up on an intake form and easily computed into a payment algorithm (sorry FOTO). 3) Patients that don’t want to get better, they prefer to be taken care of and the benefits of being disabled outweigh a return to function. And, 4) a smaller portion of patients want to litigate their way into prosperity and thereby need to demonstrate worsening physical health.
None of the above scenarios are unique to an outcome based system. But an outcome based system is unique to those scenarios. Outcomes seem to be going towards a bundled payment system, where payment is made in a “bundle” for a specific problem/deficit. I fear the hospital model of surgical care is to be the future. (total knee in the morning, discharged by 4pm to home health). This may work in the hospital because their “outcome” is “new metal parts placed inside body.” Outcome met. Our outcomes are return to function.
Will we try to get them in and out even quicker? (I’m a big fan of creating independent patients, not just in function, but also in recovery management and self efficacy, so a proper discharge is the ultimate goal… jussayin) If we do get them out quicker, who do we pass them to? A hospital PT can refer to home health, inpatient rehab, skilled nursing, home and then to outpatient care… all to lessen their cost burden and continue to “care” for the patient’s recovery needs. Shall we in Outpatient expect to pass down to personal trainers and the like? This topic may be a digression again… but it seems appropriate to the discussion.
Either way, to get back to the patient’s perspective, how do outcomes play into patient thoughts on what care should be? If they don’t care how it goes and just want the end result, well, that might work just fine. Or it might not, since you may not get the outcomes you and they want, so their expectations will not be met.
Contrast that with a patient who wants things done a certain way (lots of explanation, those glenohumeral mobs you do and some ESTIM at the end of treatment). Well, if you get them back to 85% (15% shy of the outcome) they may be more satisfied with care. We have all had patients thank us and recommend us to others even though their specific outcomes were not attained.
Customer satisfaction is whole other conversation… although uniquely and deeply tied to this post. Let’s assume that it’s tied into patient preference, from their perspective, and not worry about how it’s measured from our perspective, for right now.
Perhaps the real problem lies in trying to tie payment to outcomes… in the real world, conversation solves these issues. I can discuss Plan Of Care and it’s merits, make concessions with a patient on scheduling or other experience aspects, etc. A conversation between two people is how the direction of the ship is charted. Where the marketplace finds value in that… well it’s left to be seen.
A good outcome is only patient centered if the patient prefers a good outcome.