In Defense of "Bean Counters"

I've been speaking about health reform and managed care in different venues around the country. With regard to cost containment I often hear the phrase "bean counters" - as in "Do you want bean counters controlling your life by reducing your medical care to a set of numbers?"

This post is in praise of the much abused act of "bean counting."

When I first began to practice at the not-for-profit Harvard Community Health Plan HMO in 1975 I had a young patient with severe alcoholism. While drunk he got into a fight and was admitted to a psychiatric hospital. I'd been in charge of a psychiatric hospital unit before coming to the HMO and I knew that my patient would be better served by an alcohol treatment program, which would also, it happens, be cheaper. That's the basic definition of win/win.

But when I called the attending psychiatrist about my patient, to urge discharge to my care, I heard him say to the chief of the unit, who had been a teacher of mine during residency - "I have Sabin on the phone...he used to care about patients, but now he cares about money!"

I was really p - - - - d off by the comment, but it led to many years of thinking about how our health system can do a better job of caring about patients and caring about money. (See here for an article I wrote with that title 15 years ago.) I've come to use a framework that encourages all participants in health care to embrace two core values – compassionate fidelity to the needs of individual patients and responsible stewardship of the resources we place in public and private insurance pools.

Fidelity is about individuals. Stewardship is about populations. These two values are the pillars of an ethical health system.

Fidelity - the commitment to seek benefit for the patient and to avoid doing harm - has been at the heart of medical ethics since the time of Hippocrates. As long as health care was a transaction between a single patient and a single physician paid for by the patient’s own funds (or by barter), there was no need for insurance. Population concerns and stewardship were not important considerations.

But as health care became more complex and vastly more expensive societies created insurance mechanisms through which people pool funds to help them pay for care when they need it. In countries like Canada and England, where coverage is universal and paid for by taxes, the ethical importance of stewardship is easy to understand. As important as health care is the public has many uses for its funds. These societies see responsible stewardship as a moral requirement

In the complex U.S. health system it is much harder for the population and its leaders to understand how insurance funds are created. As a result, our society has not recognized stewardship as an ethically justifiable process. That's how we've come to demean attention to the cost of care as “bean counting.”

In the mind of the public (and some political leaders) “stewardship” is often confused with “rationing.” In health care, rationing refers to withholding beneficial services, such as very expensive cancer therapies, because of their cost. In reality, stewardship is the best way to avoid a need to ration! Responsible stewardship by insurers involves (a) seeking elimination of interventions that are not needed but can cause harm (as by side effects), (b) substituting equally effective but less costly interventions, such as generics for branded drugs, or prudent watchful waiting for doing a costly but unnecessary test today, and (c) careful contracting. The more insurers do (a) - (c) the less need society will have to (d) ration - in the sense of deliberately choosing not to provide interventions likely to be beneficial.

Stewardship isn't just a job for public and private insurers. It's best seen as a responsibility for all who are concerned with health and health care. As individuals we are stewards of our own well-being, even if most of us do a poor job. The provider community - physicians, nurses and other clinicians - is in the best position to differentiate between efficient and inefficient health care and to provide what patients need in the right way, at the right place, at the right time. And the employers who pay for insurance would rather invest more in employee wages and research and development than in ever-increasing health care costs.

Ideally, the health reform process would move our society along a learning curve towards better understanding and appreciation of the moral importance of stewardship. But so far the voices changing "bean counters - up against the wall!" have been the loudest.

Abortion and Health Reform

The current clash about abortion and health reform is a tragedy. It reflects the breakdown of civil national discourse.

Although I'm a strong supporter of accessible abortion services, I see abortion as a a sad human event, to be avoided as much as possible.

And I respect the views of the majority of the "pro-life" community who oppose abortion in a thoughtful, conscience-driven manner and who respect those who hold the "pro-choice" position in an equally thoughtful, conscience-driven manner. Unfortunately the hate-laden screamers and the madness of committing murder on behalf of purported "reverence for life" has tainted the anti-abortion position, just as suicide bomber-murderers have tainted the noble traditions of Islam.

If Representatives Stupak and Pitt, their supporters, and the Conference of Bishops, were simply trying to ensure that health reform would continue the 33 year history of the Hyde amendment in prohibiting direct federal funding of abortion, I would be with them. (See here for the wording of the Stupak-Pitt amendment.) Abortion is currently an unresolvable moral conflict in the U.S. about which people of conscience cannot agree. Protecting access to abortion when states wish to fund the services or private insurance contracts include them while not allowing federal tax money to pay for abortion is a fair resolution. It won't leave anyone fully happy. That's something a mature democracy must be able to accept.

But Stupak-Pitt appears to have a much wider scope than the Hyde amendment, including prohibiting abortion in private insurance sold through any "exchange" created by the legislation. If the amendment is trying to extend constraints on abortion by hijacking health reform to achieve that aim the supporters ought to put their cards on the table and acknowledge that blackmail is their aim: "We think further restraint of abortion is more important than reforming our health system, so unless we get our way we'll block any legislation." If that's not their intent they should work with leadership to achieve a fair resolution.

Threatening to kill health reform unless abortion constraints are extended would be a misguided way of witnessing one's conscience. If abortion opponents take this path "pro-choicers" will take an equally hard line. The U.S. would miss a rare opportunity to tip toe towards greater social justice in health care.

A Psychiatrist's Reflections on Dr. Hasan

I'm not going to speculate publicly about Dr. Hasan's psychological state, about which, of course, I know nothing. The American Psychiatric Association Principles of Medical Ethics very clearly - and in my view correctly - prohibit armchair psychoanalysis:

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

Today's New York Times reported that Dr. Hasan was in contact with a jihad-supporting cleric in Yemen many months ago (see here) and that he bought the gun that was allegedly used in the crime at Fort Hood shortly after arriving in Texas. Those public reports lead me to these thoughts about psychiatric education and the ethical responsibility for self scrutiny.

A central component of clinical education in psychiatry is that we clinicians need to observe ourselves as carefully as we observe our patients. Our thoughts and feelings are important sources of "data" - they can give information about our patients. In my residency the training director told us that "no human being is truly boring. If you feel bored while you're with a patient it's either because the patient is talking to hide what's important, which makes what he's saying an empty shell, or what he's saying threatens you, and your boredom is a defense."

In more than 40 years of practice since hearing that precept it has served me (and fellow residents) well. Whenever I felt bored I went into action - which of the two alternatives was going on?

The news reports suggest that the idea of criminal action entered Dr. Hassan's mind long before he carried it out. Honest human beings acknowledge that all manner of things come into their minds. The most notorious failing on the part of psychiatrists is sex with patients. The proper professional response to sexual thoughts about a patient is "differential diagnosis." Why is this reaction occurring? Is it telling me the patient is lonely, or making an erotic appeal? If so, that's the proper focus of therapeutic attention. But if the reaction is more about me, then the professional should ask - what is it telling me about myself? What do I need to do? The proper professional response is to ask for consultation when the answers aren't clear.

Psychiatric ethics are unambiguous about sexual involvement with patients - whether it is a current or former patient, sexual involvement is always unethical. If a psychiatrist found himself beginning to rationalize why the ethical principles do not apply to him it is as much of a danger signal as hearing about suicidal plans from a patient. Immediate consultation is required.

Similarly, it wouldn't be a sign of "pathology" if a thought of harming others were to enter a clinician's mind. The same training director told a story to make the point that aggressive thoughts were not in themselves unhealthy, and might even be constructive: "It was the minister's 50th anniversary of what looked like a very happy marriage. A mischievous parishioner asked 'Minsiter - tell the truth - in 50 years of marriage did you ever think of divorce?' After a moment of thought the minister responded - 'divorce, never....murder, often...'"

But if a fantasy about harming patients, colleagues or others took on a life of its own it would call for immediate consultation with a colleague and some form of corrective action. It's when aggressive and erotic fantasies are kept secret that they fester and turn dangerous.

Nicholas Kristof on "Unhealthy America" - One Grand Slam and One Stikeout

I greatly admire New York Times columnist Nicholas Kristof's reportorial thoroughness and passion for social justice. So I wasn't surprised that I agreed with the opening passage in his November 5 column on "Unhealthy America":

The moment of truth for health care is at hand, and the distortion that perhaps gets the most traction is this:

We have the greatest health care system in the world. Sure, it has flaws, but it saves lives in ways that other countries can only dream of. Abroad, people sit on waiting lists for months, so why should we squander billions of dollars to mess with a system that is the envy of the world? As Senator Richard Shelby of Alabama puts it, President Obama’s plans amount to “the first step in destroying the best health care system the world has ever known.”

That self-aggrandizing delusion may be the single greatest myth in the health care debate...

Kristof goes on to cite multiple studies that show just how mediocre our overall "system" is. This is educative journalism at its best.

Then he stumbled:

I regularly receive heartbreaking e-mails from readers simultaneously combating the predations of disease and insurers. One correspondent, Linda, told me how she had been diagnosed earlier this year with abdominal and bladder cancer — leading to battles with her insurance company.

“I will never forget standing outside the chemo treatment room knowing that the medication needed to save my life was only a few feet away, but that because I had private insurance it wasn’t available to me,” Linda wrote. “I read a comment from someone saying that they didn’t want a faceless government bureaucrat deciding if they would or would not get treatment. Well, a faceless bureaucrat from my private insurance made the decision that I wouldn’t get treatment and that I wasn’t worth saving.”

The flow of Kristof's article makes it clear that he is presenting Linda's painful story as an indictment of the inurer. But there are three basic possibilities for understanding Linda's tragic situation, only one of which is malfeasance. Kristof invites readers to see the insurer as guilty as charged, just one more example of insurer "villainy."

This is bad journalism, especially coming from a brilliant and ordinarily trustworthy reporter like Kristof. He missed an opportunity to educate his readers by making these important distinctions:

1. The medication Linda wants is a validated, "evidence-based" form of chemotherapy and the insurer knows this, but chooses not to cover it, duplicitously claiming that it is not "medically necessary." A court that found an insurer guilty of doing this would, and should, levy hefty punitive damages.
2. There are new findings about the medication or about Linda's particular condition that the insurer has not given proper weight to. In this situation, an appeal that documents the rationale for why the medication should be seen as effective should succeed. I have been part of an insurance appeals process and have seen numerous situations over the years in which decisions were seen in a new light when new information was introduced.
3. The medication Linda wants is ineffective, but an uninformed or overzealous physician has told her it's what she needs. In the 1990s, bone marrow transplant for advanced breast cancer was covered on the basis of faith and hope. Insurers who refused to cover it were sued. In a famous case (Fox v Healthnet) the plaintiff's family was awarded huge punitive damages. The treatment was ultimately found to be ineffective, but only after 30,00 women had received it, often with the result of increased suffering and shortened survival. (False Hope, by Richard Rettig and others describes the the painful saga in detail.) If this is the situation Linda should receive clear explanation and compassionate care, but not agreement that the insurer has committed a moral crime. And the physicians who are misleading her should receive a combination of reeducation and chastisement for giving such bad advice.

The fact that one of our best journalists is contributing to our national failure to understand the need for clinically informed, ethically justifiable limits says a lot about how difficult the learning curve will be. As I've often said in this blog, even if Mother Theresa was in charge of an insurance plan, she would not cover every cancer chemotherapy that we petition for.

(Norman Daniels and I discuss these issues in detail in Setting Limits Fairly.)

Should Health Insurance Pay for Prayers for Healing?

If the Los Angeles Times is to be believed, the Senate health reform bill requires insurers to consider covering prayer "treatments" as medical expenses. The provision was inserted by Senator Hatch from Utah, with support from my own two Senators - Kennedy and Kerry! The Christian Science Church, which has substantial wealth, is based in Massachusetts. This probably explains why two ordinarily thoughtful liberal Senators supported such an absurdity.

In my clinical practice I often encouraged patients to use prayer as part of their "management strategy" for handling their conditions. And when patients with serious ailments asked me to remember them in my prayers I said I would, even though I do not do petitionary prayer. (I generally interpreted the request to be about concern for their well being and commitment to them, which is why I felt comfortable saying "yes" to the request.) But when prayer for patients by others has been subjected to experimental study it has not been effective. Mandating ineffective treatments is exactly what legislatures should not do.

The article quotes Erwin Chemerinsky, dean of the UC Irvine School of Law, as saying the provision raises serious questions about government support of religion: "I think when Congress mandates that health companies provide coverage for prayer, it has the effect of the government advancing religion." I disagree.

If prayer were shown to be effective in curing disease (and it hasn't been) it would seem just as reasonable for insurance to cover it as to cover acupuncture or hypnosis. For insurers to say "we will cover Christian prayer, but not Muslim prayer" or vice versa, would appear to be government endorsement of a particular religion. But endorsing a practice (prayer) doesn't require endorsing a belief (in a supreme being).

The reason for opposing the provision for covering prayer under insurance is that interventions that have been tested and found to be ineffective should not be paid for by communal funds. That should be a no-brainer in a rationally governed health system. But rational governance is not a covered benefit in the U.S. health "system"!

A Moral Conundrum in Massachusetts Health Reform

The Massachusetts legislature is beginning to deliberate about the Special Commission on the Health Care Payment System's recommendation that the state phase out fee-for-service payment and replace it with global payments to "Accountable Care Organizations" (ACOs). At a conference this past Friday, Representative Harriet Stanley, Chair of the Massachusetts House Committee on Health Care Financing, told the audience that “cost containment is absolutely essential,” that she and other legislators want to see short term (1-2 years) cost savings, and that legislative action is likely before next summer.

Most reports sit on the shelf until they die of old age. That's not likely to happen with the report from the Special Commission. It, and the state, deserve, and will probably get, a lot of attention, as Massachusetts locks horns with the problem of costs! Massachusetts health reform will continue to be an important laboratory for federal policy developments.

Here's the moral conundrum the state will have to grapple with:

1. ACOs (combinations of hospital(s), groups of physicians, and other providers) will be responsible for caring for a population within a budget. To do this, and to promote integrated care, they will want to provide maximum care from within the ACO's own network.
   
   


2. But the Special Commission wasn't naive - it understood that in the era of capitation, consumers demanded free choice and rebelled against staying within networks. Here's what the report says - "While payments to ACOs will follow the enrollee’s choice of a primary care physician, patients will not be restricted (unless as a condition of their insurance contract) to providers in their primary care physician’s ACO" (p 57).
   
   


3. #1 and #2 point in opposite directions - #1 implies physician-guided treatment within the ACO while #2 implies patient-guided treatment within the entire community of clinicians (not necessarily restricted to Massachusetts).
   
   


4. I've had an opportunity to pose this conundrum to a member of the state legislature. The legislator gave a two part answer. Here's Part I of the answer - "If a patient wants a 'branded' service and equally good alternatives are available within the ACO, it's OK to be kept within the ACO. But if patients can't get the services they need within the ACO, that's a different story."
   
   


5. If our measurement of quality was precise enough and showed that surgeon A/hospital B (within the ACO) got results that were just as good as surgeon C/hospital D (outside the ACO), this principle would work well. It would be clear that the patient's wish reflected "preference," not "need." Saying "no" could readily be justified as a fair, evidence-based decision.
   
   


6. Unfortunately, we almost never have this information! I asked the legislator what happens then. Part II of the answer was - "we're thinking about this all the time - my staff would be interested in talking about it with you..."
   
   
7. I was glad to hear that the legislature is fretting over the question of how to adjudicate among the values of choice ("liberty"), efficiency, and integration of care (quality). Better information will make the tension among these values easier to address, but I don't see any way of avoiding some tough choices.

If Massachusetts is going to get a grip on its very high medical cost structure the state - probably starting with the Governor - will have to address the conundrum of "choice versus efficiency." We'll try to wiggle out of confronting the conflict between core values, but I don't think we'll be able to. This will be a real test of leadership!

Are Health Insurers Villains?

Since I direct the ethics program at a health insurer (Harvard Pilgrim Health Care - a regional non profit company serving 1.1 million members in Massachusetts, New Hampshire and Maine), I've thought a lot about our national assault on insurers as "villains."

I've come to see the dissing of insurers as arising from five sources: (1) incidents of real "villainy"; (2) a critical view of the U.S. "system" of competing insurers; (3) lack of public acceptance of the need for stewardship; (4) societal PTSD from the managed care era; and, (5) politicians' need for a scapegoat.

1. The biblical story about Lucifer indicates that even angels commit evil deeds. If angels can't avoid sin, it's not surprising that virtually every human enterprise includes "villainy." Large organizations, such as insurers, are especially vulnerable to flying at 30,000 feet and not seeing the impact of what they do on the individuals they deal with. And, having many employees increases the risk that an individual employee will be inept in ways that cause harm or deliberately roguish. This risk is just as true for churches, hospitals, schools and other organizations. There's no reason to think that health insurers are cut from a different cloth than the rest of us. But because health care is a sacred calling, examples of bad behavior outrage us.
   
   
2. A substantial number of Americans regard the current structure of the U.S. health "system" itself as unethical. I agree. For many, that view leads to blaming health insurers for the rules of the game they are playing in. It's as if a pacifist blamed football teams for tackling each other when their real critique is of the game itself. The system we're currently in requires insurers who want to remain solvent to screen people who enroll as individuals for preexisting conditions. If Mother Theresa were made CEO of an insurer in the U.S. she could not discontinue the practice. (Because the "system" requires practices of that kind she would turn down the job and stay in Calcutta!)
   
   
3. I've written many times about our national failure to understand that containing health care costs is a ethical requirement, not a moral abomination. For the public, caring about patients ("fidelity") is "good," while managing costs ("stewardship") is "evil." We confuse the aphorism "life is priceless" with economic truth. Much political rhetoric asserts that what the physician prescribes is ipso facto "medically necessary" and therefore should not be questioned. Since provider behavior drives the cost of insurance this puts insurers an the unenviable position - the only positive role for them is to pay for what the physician or hospital recommends.
   
   
4. In the 1980s/1990s U.S. social policy asked insurers to manage care. Except for organizations like Kaiser Permanente and Group Health Cooperative this split caring for patients ("fidelity") and responsibility for health care funds ("stewardship") into opposing camps. The public, and physicians in fee for service practice, believed that physicians cared about patients and were "good," while insurers cared about money and were "bad." This was especially true with for profit insurers, but all health insurers are still tarred by the managed care brush.
   
   
5. Politics proceeds via sound bites designed to arouse emotion. Politicians need enemies. For the conservatives it's "socialized medicine" and "takeover by government." For the administration it's "greedy health insurance villains." These simplified, reflexive positions fire up the political base but create a major obstacle to thoughtful political discourse. We saw this process in clearest form in the mindless conservative rants about "death panels," but the global vilification of health insurers as "villains" is equally mindless.

Much of the journalism I've read in venues like the Boston Globe, Los Angeles Times, New York Times and Washington Post has been thoughtful and sophisticated. What's not yet clear is how much we - the public - have learned thus far from the health reform process. My pessimistic self says we're stuck in sound bite mud. But my optimistic self says we're inching forward in our understanding of the ethics of our health system.

The answer isn't yet in!