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!

Insurers and Health Care Costs

In a recent interview, Senator Olympia Snowe commented - "We need a lever to force the [insurance] industry to drive down prices." This is a common view. Unfortunately, it's a view that contributes to public misunderstanding of the drivers of health care costs.

Single payer advocates point to insurance-driven administrative overhead - within insurance companies themselves and at provider sites to cope with the complexities of billing - as the source of runaway costs and the key potential source of savings. Single payer advocates anticipate savings from eliminating insurance companies. But these aren't the savings Senator Snowe is talking about. She, along with many other legislators, are counting on market mechanisms and competition between insurers to drive expenditures down more than on administrative savings.

Here's where the problem comes in. Insurers can only achieve non-administrative savings in two ways. Decrease the volume of services or decrease provider prices. But by putting insurers in the doghouse we've made it next to impossible for them to get a grip on either volume or prices.

We clinicians know that the U.S. buys much more medical care than than we need. As individual clinicians we may believe our own care patterns are fine, and the problem is with our colleagues. But I've never met a clinician who didn't see lots of opportunity to reduce the volume of interventions we provide, without any loss of health. But the time between any proposal to reduce the scope of what we offer and an eruption of death panel nonsense would be nanoseconds! And since insurers have been so vigorously portrayed as "villains," they can't expect much support if they try to reduce Dr. Kildare's charges.

Portraying "health reform" as "health insurance reform" may be effective politics, but we can't expect "villainous" insurers to deal effectively with our bloated care system. For the moment we've created a no-win situation with regard to cost containment. We reject reject the single payer alternative, vilify insurance companies, and then expect those "villainous" companies to carry out the delicate function of reforming the U.S. delivery system. Locking horns with providers and convincing the public that we currently purchase vast quantities of unnecessary, and often harmful, care, requires trust. And we've systematically portrayed insurers as untrustworthy.

I don't expect this impasse to be solved in the current legislative process. We've barely mentioned delivery system reform in a way the public understands. Policy wonks understand the importance of the Dartmouth Atlas and recognize that high quality systems like Geisinger, Kaiser Permanente, Mayo Clinic and Harvard Vanguard can provide better care at a lower cost. But the public doesn't get it yet, and won't until there has been a substantial educative process.

The real work of health reform will happen after whatever legislation emerges from the Congressional struggles we're still in the midst of.

Is Ethics Relevant for Health Reform?

As I sat down to prepare a talk on health reform and ethics I'll be giving soon, a Tina Turner song started to play in my head - but with "ethics" substituted for "love":

"What's ethics got to do, got to do with it?
What's ethics but a second hand emotion?"

Given the mind-numbing daily stories about twists and turns in Washington and the daft Republican rhetoric about "socialized medicine" and "death panels," an observer might conclude - "health reform is only about politics and special interests - ethics is an irrelevant second hand emotion!"

I've had that thought myself. But I think it's wrong.

There's no doubt that partisan politics and special interests are leading players in the reform process. (As an example, see here 'for an audio of Senator Jim DeMint's excitement about "breaking" President Obama and creating his "Waterloo" by defeating health reform.) But in addition to the impact of PAC money bribes and armies of lobbyists, politicians and special interests try to get their way by playing on the public's strongly held but unexamined values. From the political perspective this is "stealth ethics." From the philosophical perspective we might call it "pseudo ethics."

President Obama reported receiving a letter saying (see here for a videoclip of the President telling the story):

"I don't want government-run health care. I don't want socialized medicine. And don't touch my Medicare."

This story got a big laugh from the President's AARP audience. But it makes a deeper point about ethics and health reform. Ethical reflection isn't just a matter of asserting values. It requires bringing our values to bear on the world of facts, and, reciprocally, modifying our values as the facts may require. The joke here is that the anti-government, libertarian letter writer made the facts fit the values. Since she (it was a woman) liked Medicare, Medicare couldn't possibly be a government program!

Muddled "pseudo ethics" are stirring the reform pot in several ways. Here are two examples:

• Health insurers are "villains." There's lots to criticize in the conduct of insurance companies and in the way we've structured our health "system" around competing insurers. But even if Mother Theresa were in charge of U.S. health care we'd need an insurance function to oversee the way we spend our funds and to seek value for money. The global condemnation of insurers abets the public fantasy that if we get rid of the villains we'll be in a paradise that requires no difficult choices.
  
  
• From a moral perspective the aphorism "life is priceless" conveys what Albert Schweizer called "reverence for life." But as a piece of economic guidance the aphorism is psychotic. It implies that any limit that threatens life is evil. In actuality we constantly make choices that involve weighing life against other values - how much to spend on auto safety, whether to put defibrillators on every street corner, or whether the convenience of texting while driving is worth the risk to mortality (ours and others) it poses. By not distinguishing between the metaphoric meaning of "priceless" as applied to whether life should be revered and the need to use funds wisely, we again invite the body politic to remain ignorant about our ethical obligation to set limits in health care.

So ethics does have something "to do with it" - it's not just "a second hand emotion." But what's required is not shouting about values - that's easy, and accomplishes nothing. What's really needed is the much more difficult task of shuttling between values and facts - looking at the facts in light of our values, modifying those values as needed, as when the anti-government libertarian contemplates the fact that Medicare is a 44 year old government program, and developing options that serve important values to the greatest extent possible.

If the democratic process works as the founding fathers hoped it would, this is what the legislative process should strive to do with the bills that have been developed in the House and the Senate.

Why Comparative Effectiveness Research is so Important

I'm on the road now, and yesterday gave the talk I wrote about (here) last week. (I'm not writing about the venue of the talk since it was an internal meeting, not a public session.)

I came away from the event convinced more than ever that a robust program of comparative effectiveness research (CER) is the crucial next baby step for improving the value of what we in the U.S. health "system" do in health care and making the topic of health care costs less toxic. Sadly, the challenge for us in the U.S. is to begin to deal with runaway costs in a serious fashion rather than waiting for the tooth fairy or the Wizard of Oz to make the problem go away. (See "Cost Control: How Incapacitated are We?" by Paul Menzel on the Hastings Center Health Care Cost Monitor for an analysis of the almost total collapse of meaningful cost containment in the health reform process.)

CER studies compare alternative approaches to treating the same condition. It's most straightforward when the comparison is between drug A and drug B, but in principle we can compare a drug to, say, meditation or exercise, as well. The legislation that is moving through Congress is careful to insist that CER cannot be used to manage care or drive insurance coverage. Drug companies are terrified at the prospect that CER will deflate their claims about "me too" drugs. Medical specialists fear that a sham treatment may equal or outperfom their favorite procedures, as has happened in prior research on surgery. It's a fairly safe prediction that the first thing that will happen from CER is....very little.

CER dramatizes the fact that much of what we do in health care is based on faith, not evidence. It treats our beliefs as hypotheses which may be correct but could be off the mark. For healing to occur we must have faith in our doctors. The more evidence our doctors have about what works best the more that faith is warranted and will be rewarded.

Because it's so obvious that when two approaches are equivalent there has to be a VERY good reason for not choosing the less costly alternative, CER will gradually shake us out of the reflexive U.S. attitude that costs should not be considered in delivering care. It's best to see the health reform process as a first step, not a "solution." If Congress can fashion a bill that the President can sign we'll have demonstrated that our fractious and wildly irrational political process can engage with health care. It seems certain that whatever emerges will be profoundly imperfect. But if the body politic and the legislature comes away from the reform process with more confidence about tackling health care, we'll be in a better position to learn from the flaws in what emerges and to take some wiser next steps.

That's where CER comes in. It enacts a scientific approach to a realm that is increasingly dominated by advertising and economic interests. The first useful impact will be when insured folks say "let's bring premiums down by doing what works best at the lowest cost" and taxpayers say "let's put some teeth into Medicare by using the results of CER." Vested interests have blocked these steps in the legislative process so far. But if the public, and our political leaders, see more facts emerging from CER, it will be harder for PAC contributions and advertising flim flam to drive health care.