Giving Ethics Education a Bad Name

Three months ago I described "A Ridiculous Use of Medical Ethics Teaching" - a case where a recurrent offender was "sentenced" to ethics education in response to continued bad practice.

Today's Washington Post gives another example of the same phenomenon. A Rockville pediatric dentist, Dr. Ophir Alalouf, had his license suspended for performing "extensive dental treatment without clinical justification," at times without authorization from parents.

Dr. Alalouf agreed to a one year suspension of his license. What stuck me is this detail - if he completes a series of courses and exams, the suspension will be shortened.

Everyone in my entire immediate family is involved with education. Education matters. But not as an enforcement policy to correct a pattern of unethical action. This is a 19th century view - that contemplating scripture, whether in penitentiaries or insane asylums - would tame the savage beast of errant action. (David Rothman's "The Discovery of the Asylum" tells this story well.)

If we continue the fantasy that sitting in ethics class will "cure" recurrent violations by mature clinicians we will give ethics education a bad name and fail in our responsibility to protect the public.

Controlling Health Care Costs in Massachusetts

An interesting an important drama about health care costs is coming soon to Massachusetts.

A bill proposed by Senate President Therese Murray that will require annual hearings about the drivers of the health care cost trend is making its way through the Massachusetts legislature. The Senate version would locate provider and insurer hearings in different venues – the Division of Health Care Finance and Policy for providers and the Division of Insurance for insurers.

On Friday, Bruce Bullen, COO of Harvard Pilgrim Health Care and formerly Massachusetts Medicaid Commissioner proposed that the Massachusetts Health Care Quality and Cost Council should conduct the hearings. The Council is part of the Massachusetts Health Care Reform process, charged with promoting transparency about quality and cost and containing the cost trend.

Bullen's proposal is sensible. Any serious effort to get a grip on costs must bring providers and insurers together. Providers structure care. Insurers structure payment. They need to work together. Otherwise we'll be stuck with the kind of finger-pointing that became so familiar in the 1990s.

A recent article by leaders of Partners HealthCare System, the largest provider organization in New England, on "Options for Slowing the Growth of Health Care Costs," correctly states that "the value obtained for health care expenditures must be enhanced." We know from the collapse of insurer-driven managed care, however, that value-enhancement must come from the provider community.

The first approach to cost containment the Partners leaders propose is payment reform - such as capitation and case rates. They recognize that all of these approaches "are potentially disruptive to providers whose businesses are based on fee-for-service payments." Effective payment reform will require providers and insurers at the same table - neither can make it work on their own.

Getting providers and insurers to work together is a necessary but not sufficient condition for cost containment. They will need to articulate and embrace a more communitarian ethic than has governed our thinking about health care to date. Insurers must be sensitive to the provider community's historical commitment to the well-being of individual patients. Providers must be sensitive to insurer responsibility for the care of insured populations, and for being stewards of the funds entrusted to them by employers and individuals.

In my posting on May 2 I described how, when I asked physicians “if you were the czar of your field and your orders were cheerfully followed, how much money could you save with no loss of quality?,” no one ever said less than 25%. Payment arrangements like capitation and case rates can facilitate this process, but only providers can make it happen.

There will be tremendous pushback against any interventions that cause economic pain. This is what drives our capitalistic economy and isn't peculiar to health care. Dealing with the pushback will require skillful political leadership. But unless we endorse an ethic of population health alongside of individual benefit we wont even be able to open the dialogue.

Drug Advertising - What the Public Thinks

If you want a balanced analysis of the pros and cons of how the U.S. public thinks about direct-to-consumer (DTC) drug advertising, yesterday’s testimony to the House Committee on Energy and Commerce by Mollyann Brodie, Vice President and Director of Public Opinion and Media Research at the Kaiser Family Foundation, is the place to start.

DTC drug advertising is a prototypical good-versus-good conflict. Kaiser Foundation surveys show that the public is torn about DTC. Everyone has an opinion, since 91% of adults have seen or heard prescription drug ads!

53% see DTC as mostly a good thing. 40% see it as mostly bad. 67% agree with Pharma’s claim that “prescription drug ads educate people about available treatments and encourage them to get help for medical conditions they might not been aware of.” But 66% think DTC encourages people to take drugs they don’t need, and 77% say that DTC makes drugs too expensive.
Surveys tell us what the public thinks about right and wrong, not what is right and wrong. But the Kaiser Family Foundation findings have important practical implications.

I believe that if we could study the actual impact of drug advertising we would find it to be largely bad, with relatively little accurate education of consumers about health conditions and treatments, and much unnecessary medication use and cost without benefit. But we won't be able to do those studies - it's too hard and too expensive.

Free speech is as deeply held as any American value. That's why the first amendment prohibits "abridging the freedom of speech." Pharma's claim that freedom of speech protects DTC will prevail, and even though I don't like DTC, I think it should prevail.

But the first amendment doesn't prevent regulation of how DTC is conducted, and the public is moving towards readiness to endorse tighter controls. 43% believe the government should do more to “make sure statements about benefits and side effects made in Rx drug ads are not misleading.” Whereas in 1997 33% trusted DTC most of time time, in 2005 only 18% did so, and 34% hardly ever or never trusted ads.

In good-versus-good conflicts like this one we could continue arguing until the cows come home without reaching a consensus. Some will make free speech the top value. Others will give preference to the public's health. But the polls point towards a potential compromise that would respect both key values. With good leadership we could tighten regulation so that truly educative DTC was allowed but duplicitous DTC was not.

This isn't the direction the Bush era FDA has been going in. (See previous posts here and here.) But along with free speech, the right to chuck out an administration is another deeply held American value!

Medical Ethics, Etiquette, and Checklists

Here's what Dr. Michael Kahn learned from his recent hospitalization - "patients may care less about about whether their doctors are reflective and empathic than whether they are respectful and attentive." (His engaging article is in this week's New England Journal of Medicine.)

Dr. Kahn makes a good point. Manners matter! Many of his comments ring true:

When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that "he just stared at his computer screen," "she never smiles," or "I had no idea who I was talking to."

Dr. Kahn goes on to apply the Pronovost checklist concept to first meetings with a hospitalized patient:

1. Ask permission to enter the room; wait for an answer.
2. Introduce yourself, showing ID badge.
3. Shake hands (wear glove if needed).
4. Sit down. Smile if appropriate.
5. Briefly explain your role on the team.
6. Ask the patient how he or she is feeling about being in the hospital.

I think Dr. Kahn is half-way correct.

In the 1980s, in what was then the Harvard Community Health Plan HMO, the leadership introduced what was ultimately called the "smile memo" for support staff: when the patient is within 6 feet of the desk, make eye contact and smile.

But when the directive, taken from service industries like retail stores, arrived at the front desks, the support staff said - "this is an OK idea - but why doesn't it apply to how the doctors and supervisors treat us?" (They didn't mention the nurses, most of whom apparently had good manners!)

They were right. Of course they should be expected to show good manners in dealing with patients. But asking them to do this focused their attention on the fact that they were not consistently treated with comparable respect. That led to a shift in the project - from putting the spotlight on the support staff as the starting point to focusing on how well the higher status folks supported the support staff in their difficult work.

I guarantee that the same thing will happen with Dr. Kahn's proposal. Of course he is right that a physician's behavior counts. As an teen-ager I fought against my mother's constant reminders about manners, but over the years I have been grateful that she knocked many good habits into my resistant adolescent self. Considerate behavior and good manners should be on automatic pilot for everyone who deals with patients.

Pronovost's checklists were about washing hands and draping patients. No one asked why the hospital didn't wash its hands or cover itself. But a checklist of mannerly interactions with patients will - and should - focus on whether the hospital or clinic walks the walk in dealing with its own staff.

A checklist of etiquette alone won't improve the experience of patients. But trying to implement one could trigger useful scrutiny of the ethics and manners of the organization itself.

Massachusetts Health Care Reform - Access and Cost

Measured by access, Massachusetts Health Care Reform is doing very well. But unless the state can get a grip on costs the reform effort will go down the tubes.

As of its second birthday in April, 340,000 - 52% of the formerly uninsured - now have insurance. One third are enrolled in private insurance - 17,000 in the non-subsidized "Commonwealth Choice" program, and the rest through their employers. 174,000 are in subsidized "Commonwealth Care," with half being fully subsidized and half paying between $35 - $105 (for individuals - correspondingly more for families). The rest are newly enrolled in Medicaid.

This year was budgeted at $472 million, but because of higher than expected enrollment in the subsidized program, a supplemental allocation of $153 million was required. For next fiscal year the Governor has requested $869 million instead of the $725 million originally projected. (Details are available in the April report from the Massachusetts Health Connector.)

Unfortunately, progress in dealing with cost has not matched progress on access. The Annual Report of Quality and Cost Council, a key part of the reform program, details an ambitious plan, but shows few accomplishments. A cost/quality website for consumers central to the strategy. Assessing quality is obviously crucial for a health system, but if the website turns Massachusetts citizens into discerning consumers who drive cost down and quality up I'll eat the report.

The most promising idea in the Quality and Cost Council plan is to aggregate claims data from all Massachusetts insurers. If this is accomplished, and if Massachusetts leadership chooses to use the comparisons such a data base would allow (two big "ifs"), Massachusetts would be able to get serious about managing costs.

We can't realistically expect political candidates to talk seriously about cost containment and making tough choices. If we had a nickel for every invocation of the market's invisible hand, acting through individual consumers who shop prudently for care, armed with new information, we could pay for the uninsured.

As I said in the May 4 post, the most promising sources of educative leadership are large businesses and the states. Massachusetts is proud of what it is accomplishing for access. Knowing that all that it has gained will be for naught without serious grappling with cost could trigger some real leadership. Let's hope so!

Why We're So Ineffective in Controlling Health Care Costs

Two recent publications show with painful clarity why we are so unable to moderate the cost increase trend.

The New England Healthcare Institute's (NEHI) aptly-titled report on waste ("How Many More Studies Will it Take?")defines waste as "health care spending that can be eliminated without reducing the quality of care." The report summarizes studies suggesting that up to 30% of the $2.3 trillion we spent on medical care in 2007 is waste, and identifies five root causes of waste in clinical care: (1) variation in the intensity of care; (2) lack of compliance with evidence-based guidelines; (3) limited adoption of clinical information technologies; (4) failure of primary care systems to provide timely access; and, (5) underuse of cost-effective diagnostic tests.

"1994 All Over Again? Public Opinion and Health Care" in this week's New England Journal tell us why the 462 articles (1998 - 2006) about waste in NEHI's Compendium have had so little effect. Although 61% believe that individual Americans spend too much on health care (I'm surprised this number isn't higher), 70% believe that the government spends too little! Only 11% think the government spends too much!

In other words, even though it's totally clear to experts that waste is a significant component of high and rapidly rising health care costs, a large majority of the population endorses increased spending!

So what do we do?

Research, like the 462 studies that are in the NEHI Compendium, is crucial.

But as the NEHI report makes so clear - our problem dealing with waste is not from too little information.

The missing ingredient is educative leadership. There are innumerable constituencies for increasing expenditure - manufacturers of drugs and devices, advocacy groups for particular diseases, all those whose earnings come from providing health care services, and more.

The only natural constituency for tackling waste is the payer community. That community, however, is fragmented into public and private insurers, employers who insure their employees, and individuals who pay out of pocket. Those who profit most from the $2.3 trillion expenditure have thus far controlled public understanding. They have succeeded in portraying insurance companies as greedy "bean counters" and the federal government as incompetent and only likely to make things worse.

The two most promising sources of educative leadership are employers who continue to insure their employees and state governments that are required to balance their budgets.

The business community has come nowhere near using its potential to be businesslike about health care waste. As health care costs continue to drive insurance costs upward, there is potential for employers and employees to collaborate in understanding the cost trend better and working to influence it.

States are caught between increasing costs for Medicaid and state employees and declining revenues. As I said in a recent posting on specialty drugs, states are the most promising source for more rationality in health policy.

The NEHI report is a valuable contribution. But unless business leaders and state governments take the ball and run with it, the next 462 research reports on waste won't make any more difference than the 462 NEHI has summarized!

Learning how to Ration

Over the years I have posed this question to physicians I respect in a wide range of medical specialties – “if you were the czar of your field and your orders were cheerfully followed, how much money could you save with no loss of quality?” No one ever said less than 25%. Lots said more. Many commented that quality could be improved at the same time.

Last month an article in the New England Journal of Medicine on “Options for Slowing the Growth of Health Care Costs” listed 12 approaches, 10 of which are familiar and widely discussed.

Given that we know how to contain costs, why have we been so powerless to do anything?

The last two options in the NEJM article – rationing - give a clue about our stunning inability to get a grip on costs. The authors write - “Should other options fail to provide sufficient cost reductions, policymakers may be forced to consider various forms of rationing.”

I think they have it backwards.

Cost containment hurts. We won’t make serious efforts until not doing it hurts more. That means being ready to start rationing in an explicit fashion. When we understand that the alternative to serious cost containment is more and more explicit rationing we’ll be readier to bite the bullet. As long as explicit rationing is off the table, cost containment will just get lip service and hand wringing.

A Wall Street Journal article – “Weighing Which Babies Get a Costly Drug” – shows how we can start learning how to ration despite the pablum our political leaders (always excepting Oregon) feed us about achieving painless cost containment through electronic medical records and magical market forces.

Synagis (Palivizumab), an antibody to protect against RSV (Respiratory Syncytial Virus) in children under two, is given as a series of monthly injections, usually five. A full course can cost up to $6,000. Synagis reduces the frequency of hospitalization, but not mortality, in vulnerable infants.

In 2003 the Committee on Infectious Diseases & the Committee on Fetus and Newborn of the American Academy of Pediatrics published a policy for use of Synagis, signed by 38 distinguished pediatricians. In a remarkably straightforward way, the first paragraph states:

…immunoprophylaxis should be reserved for use in infants and children at greatest risk of severe RSV infection because of the high cost of this intervention.

Three years later, RAND studied the cost-effectiveness of Synagis in premature infants without lung disease, one of the groups of concern with regard to increased vulnerability to RSV. The study concluded:

...the current recommendations for the use of palivizumab as RSV prophylaxis in premature infants without chronic lung disease are not cost-effective by today's standards. Our analyses support the implementation of more restrictive guidelines for RSV prophylaxis for these infants...

I can't offer expert assessment of the American Academy of Pediatrics guidelines or the RAND study. But I can say that that they are just the kind of studies and deliberations we would need to conduct explicit rationing in an ethical manner.

Major insurance coverage policies largely follow the AAP guidelines and associated studies. Aetna, for example, posts its coverage criteria on the web. As an ethics wonk I was impressed with the wording of the Aetna policy, especially the recurrent use of "Aetna considers Synagis medically necessary for..." rather than "Synagis is medically necessary for..." (emphasis added) By using "considers" Aetna acknowledges that it is making a policy judgment based on its assessment of when the value provided by Synagis warrants its use. That's rationing.

The bottom line is that without using the dreaded "r" word, our society is beginning to learn how to ration. When we become bold enough to say it out loud and practice it more widely we will be energized to work at cost containment in a serious manner.