Place the doctor-patient relationship first [OP/note]

I recently attended a half-day medical event: Primary Care in the 21^st Century. Expecting to hear the latest and greatest on new treatments, best care for chronic conditions, and integrating behavioral health into my practice, I was sorely disappointed that nearly the entire 4 hours was spent on payment reform, maximizing coding, using the new ICD10, direct payments for primary care, and fixing the Medicare SGR for good.

Don’t get me wrong, I understand the financial pressures faced by primary care providers and the need to pay primary care providers well for the high quality care they deliver—but is this what health care in the 21^st century has become? Right now, health care seems to be all about transactions: paperwork, billing and coding, deductibles, health risk assessment forms, 1-800 numbers, call centers, credentialing, HIPAA, data entry, and . I could go on, but my hand cramped typing all the transactions that occur in our current health care system.

Of course there have always been transactional components to health care. My Great Uncle’s senior quote from Kirksville Osteopathic College was, “collect before treatment.” Given the time frame of his graduation in the early 1900s I’m hoping he was only being ironic. (My father’s description of him makes me think otherwise.) As my patients often remind me, the transactional part of health care should support the relational part, not the other way around.

What are the relational parts of health care? A personal physician, consultations in the office, house calls, touch, being called by name, chatting about the football game or the weather or your children. The transaction should not come before the relationship with the patient.

. Its claim as “patient-centered” leads me to believe its aspiration is towards this relationship. However, its use on the primary care bully pulpit of payment reform makes me worry.

A recent yearlong conversation with a group of rural community members detailed the centrality of the relationship of the primary care provider and the patient to the success of health care. The patients’ staked a claim on the PCMH as well, finally narrowing their charge to: Medical Home is Relationship. That’s it. PCMH is all about relationship. All the other stuff, the myriad components required to reach NCQA PCMH certification, all those transactions ever-present throughout the health care experience, should be in service to the relationship.

The dyad; the patient and their primary care provider is the place where all that good patient education—the team training, the evidence based guidelines—mix with the patient’s aspirations for a healthy life to create a unique and individual patient-centered encounter. Transaction should serve relationship.

Health care reform must include changing the transactional components of health care, but even that is not enough. Health care reform should also remind us of our roots and our higher calling for relationship between patient and provider.

by

Jack Westfall, MD, MPH

Chief Medical Officer

Colorado Healthop