You Say 'Patient-Centered Care.' He Says It's Not Enough.

"Collaborative healthcare" describes the necessary shift away from "pseudo patient-centeredness," says an advocate for patients.

"Collaborative healthcare," says writer, consultant, and patient advocate Michael L. Millenson, is "a shifting constellation of collaborations for sickness care that is shaped by people based on their life circumstances."

Writing in the BMJ, he argues that as patients gain more control and seek out non-traditional sources of care, providers will have to be less paternalistic. That means being part of, but not always the center of "a well-being and care relationship."

Millenson spoke with HealthLeaders Media recently about how the concept of collaborative care will help physicians, hospitals, and health systems respond and offer true patient-centered care. The transcript below has been lightly edited.

HLM: Where did the concept of collaborative health come from?

Millenson: I've been going to Health 2.0 meetings for many years. I could see the rise of Internet and participatory medicine, as well as concerns about the social determinants of health.

Yet, they were treated as different phenomena. So, I started to think there was a common theme here that has to do with a loss of control by the profession and the entrance of non-medical actors.

HLM: Why does that lead you to say "patient-centered is no longer enough? "

Millenson: The term patient-centered doesn't fit in these circumstances. This is a description of something that is happing outside the healthcare system's control and will sometimes exclude the traditional healthcare system.

HLM: Why is this change such a challenge for doctors, and how can they respond?

Millenson: This is difficult for medical professionals to put their minds around, that they can be excluded. Talking about shared information, shared engagement, and shared accountability starts to give them a framework to adjust to this.

I want the healthcare systems to adapt and be a good partner… It's better for patient. It's better for the healthcare system. But to do that, they have to understand that they are going to have to give up a measure of control so they can face the future.

This concept [of collaborative care] is dynamic and it recognizes shifting boundaries.

That has not always been the case. It's an ecosystem. Sometimes I'll be engaged with my health plan. I might be engaged with another vendor, and not with my doctors.

Sometimes I want my doctor to engage with those people… It is dynamic. This is what makes it difficult. Boundaries blur.

HLM: You talk about retail stores collecting fitness data and widespread access to interactive web sites. Is that why you mean by a shift of control away from doctors?

Millenson: It's saying that we, the individuals, will control when we interact with the healthcare system and, often, how we interact with the healthcare system.

It may be something that looks like a traditional relationship; it may be a very different relationship. That is going to originate from patients and our collaboration with you (the provider), not your pseudo-patient centeredness.

HLM: Can you describe pseudo-patient centeredness?

Millenson: Most of what is done as patient-centered care is customer service.

Customer service is great, but genuine sharing of power, being out in the community, that's what hospitals need to do.

Also, much of what the healthcare system talks about as engagement and patient centeredness is really compliance in nicer language. 'I want to engage you so you understand why you should do what I told you to do.'

Sometimes there is nothing wrong with that. Your doctor told you take the meds and you ought to take your meds, and now your providers are going to engage you in a different way so you take your meds.

But often, for the provider, it is simply 'I came to a decision. This is what I think you should do and I'm going to engage you until you realize that I'm right and do what I told you.'

HLM: How does the recognition that meeting social needs such as housing and transportation fit into the concept of collaborative health?

Millenson: Theoretically in the best of all possible worlds, our society would be taking care of public health and homelessness…Even if you are middle class and you are going home all alone, because you are elderly there would be help from a social service agency or a church or a synagogue.

None of this would be the responsibility of the healthcare system, but that is not the real world. What's happened is we are making social needs the responsibility of the healthcare system and breaking down the boundaries.

Now all of the sudden if you [the providers] are talking to me about my need for a wheelchair ramp and my home life, you are engaging me in a different way.

If now my health plan is providing foods and someone from the plan calls and asks how I am doing, that changes my relationship with my doctor.

HLM: What do health systems need to know about this new paradigm?

Millenson: If they wait until they are forced out of the old system, if they try to cling to control for too long, they will lose out and patients will lose out.

People who go into healthcare go into it to do good. People who decide to become hospital administrators, their second choice was not headge fund manage. They care about people. They want to do well, but they get caught up in the system.

They should understand that the relationships are changing and they need to change. I think this is a great opportunity for hospital to reset.

When there is change, and you act on the change, you can come out on top.

HLM: Will collaborative care save money?

Millenson: The real answer is we don't know. Everything is always touted as cost saving. We don't know whether or not these electronic interventions are truly going to be cost saving. We do know that addressing the social determinant of health saves money.