Tragic Choices at Grady Hospital

On October 3, Grady Hospital in Atlanta closed its dialysis clinic. Grady committed itself to cover the cost of dialysis for three months for any of the 96 patients under its care who did not have an alternative source of dialysis. The three month extension is up on January 3. An undetermined number of patients - possibly as many as 50 - do not yet have a settled plan for continued treatment.

Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year, but has been in dire financial straits for many years.

In 2007, in the context of massive financial losses, the board voted to turn Grady over to an independent 501(c)(3) corporation, hoping that a more business-like board could bring managerial discipline to the hospital and make tough decisions the more political board was not willing to make.

This past summer the board showed it could make tough decisions when it voted to close the dialysis clinic, which was losing $2.5 million each year.

The dialysis clinic is a prototypic safety net program. 35% of the patients are undocumented and uninsured. Another 30% are documented but uninsured. 8% are prisoners. The facility itself is old, with outmoded equipment.

In a September ruling as to whether Grady should be allowed to close the clinic, Judge Ural Glanville of the Fulton County Superior Court recognized the severity of the trade off between Grady's stability and the importance of the clinic to the patients it served:

"Indeed, no value can be placed on human life. Nevertheless, when contemplating the use of injunctive authority, the court is required to balance relative equities, even in cases involving issues of life and death. If the court were to require [Grady] to maintain...the services forming the basis of the complaint, it would likely result in an adverse effect on the services offered to other individuals and the public at-large."

A group of plaintiff's brought a class action suit to block the January 3 funding cutoff, but on December 15 the suit was dismissed.

Predictably, Grady is being vilified as an uncaring killer. When confronted by a City Council member the chair of the Grady board responded by accusing the Council of grandstanding - demanding that the clinic be continued without providing funds to do it. I think this was a useful confrontation.

Uninsured patients, most notably immigrants, and especially undocumented immigrants, are caught in the middle of a life-and-death form of the game of "hot potato." Grady Hospital, as a safety net provider, inevitably loses, since its mission is to care for those who have nowhere else to go. When the public, through its government, stints on funding, safety net programs like Grady are left holding human lives in their care. What is a safety net provider to do if the funds allocated to it by the public don't allow it to meet the needs of its patients?

Clearly, a safety net provider is accountable for using the funds it receives in the most efficient manner possible. But we the public can't be allowed to turf our moral accountability to the Gradys of the world. We the public created safety net providers to care for the underserved, not to take on the burden of our sins in the manner of Jesus. I believe Grady is right to provoke a crisis over dialysis services. If some of its patients are still in limbo on January 3, Grady can't simply set them loose. It will have to continue to provide for them. But it should keep pointing the finger at its funding sources, with the message that Winston Churchill gave in World War II - "Give us the tools, and we will [do] the job," along with this corollary message - "If you choose not to give us the tools, acknowledge that you are the killers, and take responsibility for your decisions!"

(For a previous post on Grady Hospital, see here.)

The Ethics of Virtual Medical Visits

OptumHealth, a division of UnitedHealthGroup, will soon be offering a web-based platform for connecting patients and doctors by video. When the largest health insurer enters the E-visit space we know a change is coming. The Optum program will roll out in Texas in 2010.

I think virtual visits are a great step forward. But I'm chastened by this critique in the article about Optum:

"This is a pale imitation of a doctor visit. It’s basically saying, ‘We’re going to give up any pretense of examining the patient and most of the nonverbal clues that doctors use.'"

If the quote were anonymous I might have dismissed it as fuddy-duddyism. But it's from Dr. David Himmelstein, a friend, a superb primary care physician, a brilliant policy researcher, and co-founder of Physicians for a National Health Program (PNHP - the single payer advocacy group) - the opposite of a fuddy-duddy!

Experience with E-care is just beginning to emerge. In January, the Hawaii Medical Service Association (HMSA - Hawaii's Blue Cross Blue Shield) began offering 24/7 access via telephone and the web to physicians in its network who sign up to provide the service. Hawaii is a natural place to start, since for a number of patients, seeing a doctor in person would require flying to another island. If I were a primary care physician in Hawaii, I'd sign up to do it!

The infrastructure is provided by American Well, a Boston-based company that provides secure infrastructure for web visits, automated billing, and care coordination. The technologies involved aren't new, but packaging them to create tools easy for patients and clinicians to use is a valuable step forward.

I write about Optum and American Well on an ethics site becuse the fundamental step of trying to meet "constructive," "health promoting" patient preferences evinces an ethical focus on patient and public values. Even in my dark ages psychiatry practice I had patients who were VERY grateful for the opportunity to use email to monitor and manage the medications we were using, or to use email to discuss issues we had initially opened up in the office. And when email served my patients' needs it was a win/win tool, since I could access it from home at times that were convenient for me as well.

David Himmelstein is absolutely correct in noting the ways in which E-visits fall short of what an expert physician can transact in the office. But there is a segment of the public that places more value on convenience and timeliness than on a high quality in-person relationship. I have less of a sense of the pros and cons of E-visits for this segment, but it's an experiment worth conducting, on the hypothesis that E-access is better than no access!

(More information on the HMSA program is available from a Fortune article here and a Business Week article here.

Medical Culture and Costs at UCLA

An article about the cost of end-of-life care in this morning's New York Times focuses on the Ronald Reagan UCLA Medical Center. UCLA has a national reputation for high quality/high tech care, but also for high costs. According to the Dartmouth studies, Medicare pays UCLA $50,000 during the last 6 months of a patient's life compared to $25,000 at the Mayo Clinic.

The article quoted CEO David Feinberg as saying “If you come into this hospital, we’re not going to let you die”!

I have memories that shed light on the story.

From July 1964 to June 1965 I was a medical intern at UCLA, before returning to Boston to train in psychiatry. I don't remember any limits being set on the tests we ordered until the chief resident came to us in the spring to say "folks, we're running out of money for tests, so cut back where you can." He was apologetic for having to cramp our style. The question of when tests were medically important to do, when they were wasteful, and when the risk of false positive results or otherwise misleading findings was so great that doing the test would be, in medical jargon, "contraindicated," was never discussed. UCLA was probably not unusual in that era, but in retrospect it seems that a cost-unconscious ethos was already part of the culture.

The article in the Times also discussed UCLA's ethic of doing everything possible for patients - sometimes with extraordinarily beneficial results. I experienced this in a very positive way as an intern. During one of my ward rotations a young professor was admitted for a heart attack. He was stable, but the physician in charge had me sleep in the same room with him as an additional element of safety. My skills at cardiology were, to put it politely, "developing" at best. But the message of concern and caution embodied in my assignment made a strong impression on me. (I was also aware of the absence of equity - we didn't have interns sleeping in the rooms of our other heart attack patients.)

Dr. Feinberg, the CEO, is a child psychiatrist. Prior to becoming CEO of the UCLA hospitals he was medical director for the Neuropsychiatric Hospital there. Psychiatry has always been subject to limits in ways the rest of medicine hasn't. In addition to his medical training, Dr. Feinberg has an MBA. I trust that his comment about how UCLA is "not going to let you die" is a wry way of tweaking a culture that has been overly technology-driven and underattentive to the ethics of medical costs.

(See here for a profile of Dr. Feinberg, here for the New York Times story, and here for "Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care," a paper I wrote in 1994.)

Patient Safety, Ethics, and Psychiatry

This fall I was asked to discuss a case for the Agency for Healthcare Research and Quality Mortality and Morbidity Rounds - a web-based patient safety education site.

At first I thought they were writing to the wrong Dr. Sabin. Patient safety isn't an area of my expertise. But the case they asked me to discuss had major issues of ethics and psychiatry that arose in the care of a homeless man with a history of IV drug use, admitted to a hospital with a methicillin-resistant Staphylococcus aureus (MRSA) abscess near the spine. The patient left the hospital against medical advice (AMA) with bad aftereffects.

I won't recapitulate the case and my discussion here. The moral of the story in the case I discussed was that homeless IV drug users are more "foreign" to most hospital staff than patients from "foreign" countries. Caring for people who we may see as "other" calls for distinctive cultural competence skills. When an institution lacks those skills safety is jeopardized. Ethics and psychiatric consultation can often be helpful.

(I read a number of cases on the website and found them uniformly engaging and informative. The AHRQ site is well worth visiting.)

Crunch Time in Health Care Reform

We're in the end game of health care reform.

As I said in my last post, we're seeing real debate in the Senate, but - unfortunately - only among the Democrats, since the Republicans have united around their goal of preventing the Democrats from passing a bill.

Yesterday two of our best commentators - David Brooks and Paul Krugman - discussed whether Senators should support the bill. Brooks (here) agonizes over the choice, but ultimately concludes that he would vote no. Here's why:

"...if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach."

Krugman (here), I believe, would agree with Brook's analysis of the pluses and minuses in the bill. But he ends up encouraging a "yes" vote:

"With all its flaws, the Senate health bill would be the biggest expansion of the social safety net since Medicare, greatly improving the lives of millions. Getting this bill would be much, much better than watching health care reform fail...Bear in mind also the lessons of history: social insurance programs tend to start out highly imperfect and incomplete, but get better and more comprehensive as the years go by. Thus Social Security originally had huge gaps in coverage — and a majority of African-Americans, in particular, fell through those gaps. But it was improved over time, and it’s now the bedrock of retirement stability for the vast majority of Americans."

For three reasons I think Krugman got it right:

1. The perfect is the enemy of the good. No matter where one falls on the spectrum from single payer advocate to market hawk, the Senate bill is hard to love. The legislative sausage moving through the reform process won't satisfy anyone's dreams. But the right comparison is with the status quo, not the ideal. It's been 16 years since the last serious effort at health reform. Senators should ask - "would we rather tinker with the status quo for the next 16 years or work with the framework created by the bill?" Imagining a better bill isn't a reason for voting "no." We're not going to see a better bill. Only those who (a) genuinely believe that tinkering with the status quo is the better course to follow from 2009 to 2025 or (b) expect that when we go further into economic hell in our health system handbasket we'll be readier to pass a better bill should vote against the bill we have.
   


2. Wishful thinking won't control health care costs. The bill is rightly seen as doing little to contain costs. But many of those who make this attack are the same ones who shouted "evil rationing" and "death panel" when costs were dealt with more directly. We've made progress as a body politic in understanding that health care cost containment is a moral and economic necessity, but we haven't grown up enough yet to dig in to the cost problem openly, honestly and vigorously. In 1914 Freud introduced the concept of "working through" a "neurosis" - clarifying the elements of a conflict, identifying the basis of our resistances to change, and moving forward as best we can - as the pathway to change. It's a sloppy and slow process - "an arduous task for the subject of the analysis and a trial of patience for the analyst" - is how he described it. As it was with Freud's patients trying to cure neuroses in 1914, so it is with our population trying to cure the health system through political action in 2009. Alas, knowing that our system is profoundly wasteful and unjust doesn't create the will to to make bold choices any more than knowing the source of our neuroses erases our quirks. We have to take baby steps - working through!
   


3. It's time to retire Reagan's sound bite that "government is the problem." In his inaugural speech in 1980 President Reagan said "Government is not a solution to our problem, government is the problem." It's still the central tenet of Republican theology. (See here for a video clip of Reagan's speech.) Because of our pervasive distrust of government, proposals like single payer insurance or a "public option," which would be mainstream ideas in most other developed economies, are seen as "radical" and "socialist" in the U.S. Our readiness to believe that support for doctor-patient dialogue about appropriate care for the elderly meant "death panels" showed just how powerful the grip of the perspective Reagan articulated so forcefully is in our national psyche. (See here for a discussion of the "paranoid style" in American politics.)
   
   Atul Gawande's characteristically insightful article in the December 14 New Yorker draws an analogy between the federal government's creative role in catalyzing development of U.S. agriculture at the turn of the 20th century to the potential impact of the many pilot programs promoted in the Senate bill. His argument won't convince the right wing mullahs, but I think anyone with even a partly open mind will see the many ways public action could foster positive change.

The Senate bill, and whatever comes out of the Senate-House conference, is the best option for change we're likely to have before 2025. It will be VERY imperfect. There will be LOTS to criticize. But voting it down and endorsing the status quo would be the wrong course for the country to take.

Empty Republican Rhetoric on Health Reform

I've just read "Health Care Reform - A Republican View," by Iowa Senator Chuck Grassley, in today's online edition of the New England Journal of Medicine.

It's disgracefully empty rhetoric!

Senator Grassley is an intelligent person, ready to crusade for values he believes in. I've praised his advocacy for strong conflict of interest protections here and here. In that area he's been a real leader.

But his New England Journal screed is simply a rehash of Regan-era platitudes about the evils of government and threats to our freedom. It's the marching orders for the 40 Senate Republicans, who, unless Senator Snowe defects, are maintaining (a) remarkable unity and (b) stunning absence of positive ideas.

I do agree with Senator Grassley's emphasis on tort reform. Even though economic analysis suggests that malpractice reform will have limited financial impact, anyone who is close to medical practice knows how corrosive the threat of malpractice action has become. The system does not promote improved quality and does not take good care of those who have suffered. The Republicans are right on this issue.

We've actually had some thoughtful debate in the Senate, but it's all within the ranks of the Democrats. Since the Republicans appear to be united behind Senator Jim DeMint's campaign to "break" President Obama and create his "Waterloo" by defeating health reform, their role has simply been to say "no." They've left it to the Democrats to argue about alternatives.

Read the New England Journal piece and see what you think.

Facebook Friends, Judges, and Conflict of Interest

Florida's Judicial Ethics Advisory Committee was recently asked the following question:

Whether a judge may add lawyers who may appear before the judge as "friends" on a social networking site, and permit such lawyers to add the judge as their "friend."

The majority - correctly - said "no," in accord with the expectation that judges will not "convey or permit others to convey the impression that they are in a special position to influence the judge." The principle behind the majority's conclusion is this:

Irresponsible or improper conduct by judges erodes public confidence in the judiciary. A judge must avoid all impropriety and appearance of impropriety. A judge must expect to be the subject of constant public scrutiny. A judge must therefore accept restrictions on the judge's conduct that might be viewed as burdensome by the ordinary citizen and should do so freely and willingly.

What's most interesting about the advice is the minority view on the Committee:

The minority believes that the listing of lawyers who may appear before the judge as "friends" on a judge's social networking page does not reasonably convey to others the impression that these lawyers are in a special position to influence the judge. The minority concludes that social networking sites have become so ubiquitous that the term "friend" on these pages does not convey the same meaning that it did in the pre-internet age; that today, the term "friend" on social networking sites merely conveys the message that a person so identified is a contact or acquaintance; and that such an identification does not convey that a person is a "friend" in the traditional sense, i.e., a person attached to another person by feelings of affection or personal regard...the minority concludes that identification of a lawyer who may appear before a judge as a "friend" on a social networking site does not convey the impression that the person is in a position to influence the judge...

Two things stand out about the minority position:

First, there's a generation gap with regard to social networking, so that for some, a "Facebook friend" isn't necessarily a "real friend." But since some Facebook friends are indeed real friends, it seems to me that the minority is wrong. An observer would have to do a differential diagnosis of the term "friend." That process can't be counted on to protect public trust in the judge.

Second, both majority and minority were solidly focused on appearance. They don't ruminate about whether the judge is really friends with the lawyer and actually subject to influence. To maintain public trust judges don't simply scrutinize their motives - they have to start by scrutinizing how their conduct would appear to a skeptical observer.

We've not made that distinction at all well in medicine. Later this week I'll be writing about how failure to take appearance seriously is again undermining an important American Psychiatric Association initiative.

(The Florida Judicial Ethics Advisory Committee opinion is available here.)

Will Reducing Health Care Costs Kill Patients?

David Leonhardt, economics columnist for the New York Times, continues to do superb reporting and analysis of our health system. Print journalists don't have the reach of the right wing talk show blowhards, but a steady drum of thoughtful, informed voices like Leonhardt can chip away at the flood of disinformation we receive.

I just came upon his column from a couple of days ago and wanted to toot the horn for it. Here's an excerpt:

The House has shown little interest in cost control. President Obama and his administration have pushed aggressively for it, but they have limited leverage. Mr. Obama can’t credibly threaten to veto any of the health reform bills that now seem likely to emerge from Congress.

So after the 11 [Senate] freshmen announced their [cost-cutting] plan on Tuesday, I caught up with Mark Warner, the Virginia Democrat who is the group’s leader, underneath the Capitol building and asked him how he and his colleagues would deal with the inevitable scare stories still to come: How do you respond to a lobbyist who effectively accuses you of killing patients?

“I don’t know any other way than you take incremental steps,” Mr. Warner said, “and you hope you get to the tipping point where fear and misinformation don’t have an effect, because people see these things don’t do what they are accused of doing.”

That, obviously, is the long-term strategy. In coming weeks, we’ll see how well Mr. Warner and his colleagues deal with the immediate pressure. The Grim Reaper is a tough opponent.

I encourage readers - especially those from outside of the U.S. who are struggling to fathom what on earth is going on in our health reform process - to look at Leonhardt's full article. (And for a previous post on Leonhardt's discussion of rationing, see here.)

Problems for Medicine as a Self-Regulating Profession

Professions are occupations that society believes (a) serve vital human needs, (b) require a high level of knowledge, judgment and skill, (c) place societal benefit ahead of personal interests, (d) adhere to a strong ethical code and (e) can be trusted with substantial autonomy because of their commitment self-regulation.

I've recently had several occasions to talk with residents about their experience giving and receiving critical feedback during residency training. Their reports suggest that we are not educating for professional self-regulation as well as we should. If this is true, the professional autonomy we physicians cherish so much is on shaky footing.

The big picture I got is that critical feedback oscillates between extremes. Sometimes it is given with a sledgehammer - as if residents will learn only if cudgeled into submission. Other times it is whispered (or not given at all) - as if residents are too fragile to hear anything negative about their performance.

The eruptive form of critical feedback can lead to the equivalent of putting in earplugs - residents begin to interpret critical feedback as a symptom of ill-will or flawed character and discount it. The unduly timid approach to giving critical feedback can lead to a "no news is good news" outcome - residents interpret the absence of criticism as a message that their performance is fine, even if it isn't.

The residents were concerned that they had not yet developed a repertoire of skills for giving constructive critical feedback to colleagues and were not being coached in how to do it. When I told a group about a resident who, while shadowing me in practice, (a) felt I'd made a significant mistake, (b) brought her concern to a seminar to see what others thought about the situation, then (c) told me her views in what I experienced as a very constructive spirit, they were (d) amazed at her courage.

It's not surprising that we physicians do a poor job of giving constructive critical feedback to each other. Two reasons stand out for me. First, since the 19th century, cannons of medical etiquette have taught that physicians should treat each other with courtesy. Criticism was seen as a symptom of professional rivalry, not a manifestation of collaboration for improvement. Second, medical mistakes can cause harm, even death. Giving critical feedback can feel like an accusation of incompetence, and receiving it can elicit shame and guilt.

When I did an initial literature search about giving and receiving critical feedback among physicians I came up blank. We do write about personal accountability, as in this article about "System Failure versus Personal Accountability - the Case for Clean Hands." And we've made lots of progress in understanding the value of acknowledging mistakes with our patients and more skill in how best to do it. But we've not done at all as well with the topic of how to give and receive constructive critical feedback in our relationships with each other. This is a serious flaw in self-regulation.

(For a previous post about etiquette in medicine see here.)

Massachusetts Association of Health Plans Ethics Forum

Yesterday I attended a goodbye party for Dr. Marylou Buyse, who has been President and CEO of the Massachusetts Association of Health Plans (MAHP) since April 2001. MAHP is a trade association representing 12 Massachusetts health plans that together provide coverage for 2.3 million Massachusetts residents. Marylou is moving to Texas to become chief medical officer at Scott & White Health Plan.

When I first met Marylou in 2001, 6 months after she started working at MAHP, I proposed a cockeyed idea - that MAHP should sponsor a statewide ethics forum to bring together health plans and interested others to discuss ethical issues in managed care. Her immediate reaction was - "that's a great idea - let's do it!"

Anti-trust regulations are designed to prevent enterprises in the same economic sector from conspiring to create an anti-competitive cabal. Without an umbrella to convene public discussion, the kind of collaborative discussion and education I envisioned would run afoul of anti-trust law. MAHP stepped in, and Marylou became the godparent to a process that is still going strong.

The first forum, in March 2002, took off from two controversial cases about coverage for liver transplant for patients who were HIV positive. The twenty fourth forum - "Is Rational Public Conversation about End of Life Care Possible?" - was held three weeks ago. Other topics include: "Ethical Challenges in Managing Pharmacy Benefits: Can Good Management be good Medicine?" (2003); "Bariatric Surgery: Exploring the Ethical Issues" (2004); "The Ethical Dimensions in Public Reporting of Clinical Performance Data" (2005); "Ethical Challenges of Massachusetts Health Care Reform" (2006); "Medical Tourism – an Emerging Ethical Issue" (2007); and, "Virtual Visits: What are the values-related questions for health plans in promoting electronic visits in the information age?" (2008).

I've co-chaired the forum discussions - first with Dan Rome and then with Paul Fulton, both medical directors at Tufts Health Plan. A guest opens the meeting with a 5-10 minute overview of the area. The rest is discussion. In light of anti-trust concerns the forums don't involve action planning of any kind. We typically have 30 - 40 attendees, from health plans, government, NGOs, and industry. The discussions have been rich and thoughtful. The fact that so many busy people come to a 7:30 AM event is a vote of confidence in the value of the event.

In learning to write for publication and in mentoring younger colleagues the most useful question to raise is - "so what?" With regard to the MAHP Ethics Forum attendees have responded to the "so what?" question with reasons like these, which I've reconstructed from conversations I've had:

1. "We're all in our silos with noses to the grindstone. It's helpful to step back and ask - 'what are the ultimate purposes for what we do?' Doing that helps me get back to what's most important in our work."
   
   
2. "I take a lot of things in the insurance world for granted. The forums have led me to raise some useful questions about the work."
   
   
3. "Raising questions isn't always popular. It helps hearing from colleagues who like to turn things upside down the way I do."
   
   

I've tried to stimulate other states to develop their own forums but so far I've struck out on that effort. Hospitals are familiar with ethics committees and ethics consults, but that kind of going back to first principles is new to the insurance world.

In our parting conversation Marylou suggested that we try to do the same thing in Texas. Lone Star State - here we come!

A Promising Proposal for Reducing Health Care Costs

Bruce Bullen, interim CEO at Harvard Pilgrim Health Care, recently made this proposal for the financing of health care reform on his "Let's Talk Health Care" blog:

Financing for the bill should come from system-wide medical cost savings, not from health care taxes and Medicare reimbursement reductions, which will only make matters worse in the commercial market. A collaborative effort with sector-specific annual targets monitored and enforced by government should be undertaken by all health care system stakeholders – health plans, hospitals, doctors, pharmaceutical manufacturers, equipment manufacturers, etc – to lower projected medical trend increases by 1.5 – 2% to fund the bill. This effort could begin immediately without raising insurance costs.

In 1997, Don Berwick, Howard Hiatt, Penny Janeway and Richard Smith, calling themselves the "Tavistock Group" (they met at the British Medical Association office at Tavistock Square), proposed a set of ethical principles for everybody in health care (see here). They recognized that the health system is like a water filled balloon - squeeze it in one spot and it pops out elsewhere. Their idea, and the principles they developed, were excellent. But like so many other good ideas about health care it went nowhere.

Ideas don't change health care. Facts on the ground are required.

That's what I like about Bruce Bullen's proposal. Over the years we've carved our health system into silos. No silo can improve quality or efficiency on its own. Collaboration is required. But our national ideological commitment to competition and disparagement of cooperation has blocked serious efforts to collaborate.

I believe Bullen is also correct in suggesting that health reform should be financed by savings from within the health system, not new taxes or across the board reductions in Medicare reimbursement. A combination of collaboration and courage could yield both savings and improved quality.

I don't know it there's any likelihood for this idea to be built into federal health reform, but it's a natural to implement at the state level. In Massachusetts we already have annual hearings about health system performance. It wouldn't be too much of a stretch to move from hearings, which are a bit like being called to the principal's office to explain our behavior, to a working group, chaired by government, with targets for each sector and the entire system, as Bullen envisions.

A Practical Approach to Organizational Ethics

I've been meeting with a number of organizations to help them develop new ways to deal with the ethical dimensions of their activities. They've asked for practical pointers on how to get started. I've presented this list of six:

1. Understand two meanings of "should." Even the most collegially managed organizations have an underlying heirarchy. "Higher levels" can tell "subordinates" what they should do. Ethics is about values - what we should do. One reason organization are uneasy about formal ethics activities is fear that ethics folks would feel empowered to tell the organization what it should do in the managerial sense of "should," supplanting the CEO and Board. This isn't a question about the organization's commitment to values, but rather a question of who is in charge. We need to understand the distinction between the "managerial 'should'" and the "ethical 'should'."
   
   


2. Ensure managerial authority. If the CEO isn't "Chief Ethics Officer," organizational ethics activities will be a waste of time. Explicit endorsement and support from senior leadership is a requiremnt. An organizational ethics committee wouldn't have influenced Enron!
   
   


3. Ensure moral authority. Managerial authority comes via delegation. Moral authority comes from the respect pertinent others have for those who take the lead in organizational ethics activities. To be effective, organizational ethics activities require both managerial sanction and moral authority.
   
   


4. Ensure appropriate leadership skills. Organizational ethics consultation isn't an academic activity. Analytic and conceptual skills are required, but they have to play out with a wide range of people inside and often outside of the organization. Facilitation, relationship management, and solid understanding of the full range of organizational function are also crucial leadership skills for organizational ethics. To conduct effective organizational ethics activities in hospitals, group practices, and health plans, it's necessary to be comfortable dealing with both clinical and administrative matters and personnel.
   
   


5. Apply stakeholder theory. Here's how the excellent AMA Institute of Ethics publication "Organizational Ethics in Healthcare" defines stakeholder theory:
   
   
   "The core thesis of stakeholder theory is the normative
   claim that the interests of all the parties involved in any
   transaction ought to be considered in determining how
   to act ethically. In order to determine how an organization
   ought to act in a particular situation, it is necessary first to
   identify each of the parties (individual and collective)
   with whom the organization interacts and what each
   party has at stake. Second, one must ask how the
   organization ought to act in relation to each party, and
   then how the organization’s several obligations to these
   parties ought to be ranked, both in general and in the
   situation at hand."
   
   
   
   Faith-based organizations use guidance from their creed in dealing with complex ethical questions, but secular organizations typically find ethical reasoning that draws on the perspectives of its stakeholders more comprehensible and persuasive. Except in the rare situation in which a secular health organization embraces an ethical credo from outside of the organization, the stakeholder approach is most effective.
   
   
   
6. Monitor and adapt as needed. In an ethics class the analytical conclusion is the end point. But organizational ethics consultation isn't a classroom exercise. Well-managed organizations apply a quality improvement approach to all of their activities, including organizational ethics. It's great to make a timely decision, but greater yet if that decision works on the ground. If it doesn't it needs to be tweaked.

I'll probably modify this list of pointers over time, but for the moment these six have been useful in a range of settings.

Obesity, Health Insurance, and Employer Incentives

Federal health reform is the front page news, but states and businesses are the laboratories for change. Next to Governors, who have to deal with hideous budget problems driven by declining revenues and escalating Medicaid costs, employers who offer health insurance to their employees are most directly concerned about health care costs.

Health reform requires three ingredients: (1) facing facts, (2) thinking strategically and (3) embracing individual and population concerns. Given the virulent divisiveness of current U.S. politics, employers who offer health insurance are the most promising venue for applying this triad in a "businesslike" manner!

In previous posts I've written about how IBM promotes primary care and encourages employees to find a medical home (here), how Foundation Coal and Peabody Energy understand and act in accord with comparative effectiveness concepts (here), and how the Hannaford supermarket chain rewards employees who have surgical procedures like joint replacement in Singapore, where high quality services are available at lower cost (here). An article in yesterday's New York Times - "Health Care Savings Could Start in the Cafeteria" - describes a pilot collaboration between employers, a health plan, and The Full Yield, a start up health improvement company.

Starting in January, employees at John Hancock and the City of Boston will be able to enroll in a year-long Full Yield program that will provide access to healthful prepared meals, nutrition coaching, and other self-management tools. At John Hancock participants will get $100 worth of coupons that can be used at the office cafeteria and at local supermarkets that carry the Full Yield products. At the City of Boston, participants will have a series of biometric measurements taken at least three times during the year. The Full Yield is partnering with Harvard Pilgrim Health Care, the not for profit insurance company for which I run the ethics program, to administer and evaluate the program.

The Safeway company has apparently achieved the near-miracle of keeping its employee health insurance costs level since 2005. Steven Burd, the CEO, attributes its success to "creating a culture of health," part of which involves incentives for managing tobacco use, healthy weight, blood pressure and cholesterol levels. For achieving targets in those four areas, employees can reduce their contribution to health insurance premium, by up to $780 per year for individuals and $1,560 per year for families. (see here)

Incentives - especially if they're guided by insights from behavioral economics - work. (See, for example, this article in JAMA by Kevin Volpp and colleagues.) And, since obesity is a highly stigmatized condition that tracks closely with socioeconomic status, the wrong kinds of incentives could reinforce prejudice and discriminate unjustly. But those risks are reasons to use incentives carefully and monitor for negative impacts as well as success - just as good clinicians do for the treatments they administer - not reasons to avoid incentives altogether.

I continue to believe that employer/employee collaboration on behalf of promoting health and constraining health care costs within the workplace "family" is an extremely promising approach to transforming our national health non-system!

Doctor-Patient Sex: Why is it Unethical?

Earlier today I responded to the following anonymous response to a post I wrote in April about doctor-patient sex:

What is the actual harm to the patient? I have found countless articles and sites that claim dr. patient sex is "obviously harmful to the patient." Well, I am not a medical professional and not all the reasons are obvious to me. I am however somewhat of a victim in this sort of case (with a diagnostic consultant) and am trying to understand what happened. All I know is he gave me hope and then killed it through abandonment, etc. He made lots of promises and didn't keep them.

The comment got me thinking. To the best of my knowledge, every medical specialty in all of the countries whose medical ethics I'm familiar with finds doctor-patient sex unethical. But as the questioner noted, it's not clear what the basis of that ethical condemnation is.

I did some on line browsing in the literature and came upon an excellent article - "Arguments for Zero Tolerance of Sexual Contact between Doctors and Patients" - by R.M. Cullen, a GP in New Zealand.

Dr. Cullen examines four common justifications of the zero tolerance view of doctor-patient sex and finds them all inadequate to the task:

1. Sex with patients is always harmful. Cullen points out that the evidence base for this conclusion is skimpy. There are no surveys of large numbers of patients who have had sex with their physicians to see how many have been harmed. What we have is powerful case reports of individual situations that were harmful to specific individuals. These don't prove that doctor-patient sex is inevitably harmful.
   
   
2. Sex with patients always violates the principles that define an ethical sexual relationship: trust, equitable power balance, and consent. Cullen quotes a position paper by the College of Physicians of Ontario that concludes that because of the inevitable power imbalance between physician and patient, valid consent is never possible. But here too it is possible to imagine doctor-patient relationships that do not violate the principles.
   
   
3. Sex with patients is always inconsistent with the virtues that characterize the ethical physician. Here Cullen cites an argument that to be ethical a physician must be self-effacing and self-sacrificing, and that these virtues rule out deriving sexual satisfaction with a patient. Once again Cullen concludes that we can imagine circumstances in which a self-effacing and self-sacrificing doctor falls in love with a patient and is loved in return.
   
   
4. Finally, Cullen considers the argument that the intrinsic nature of medicine may forbid sexual contact with patients on an a priori basis. Edmund Pelligrino makes the strongest argument of this kind, in "Toward a Reconstruction of Medical Morality" and elsewhere. Pellegrino argues that three phenomena – the fact of illness, the act of profession, and the process of care – if understood properly, provide a coherent basis for professional ethics, including the prohibition of doctor-patent sex. But here, too, Cullen finds it possible to postulate examples that could evade this perspective.

Cullen's own argument for the zero tolerance position is simple and practical:

It first attempts establish that, as a matter of policy, sexual contact between doctors and patients ought to be prohibited. Then, [it asserts] that doctors have a moral obligation to comply with such a prohibition. If this is true then it follows, as a matter of definition, that doctors who have sexual contact with patients have behaved immorally.

[This] counterfactual argument may be summarised as:

Proposition. If sexual contact between doctors and patients were allowed then there would be unacceptable consequences.

Conclusion. Sexual contact between doctors and patients should not be allowed.

Cullen argues - in my view correctly - that it is not necessary to prove that every instance of doctor-patient sex will be harmful, contrary to principles and virtues, or inconsistent with the fundamental nature of medicine, to establish that doctor-patient sexual relationships are unethical. The medical profession can, and should, adopt a zero tolerance ethical stance based on (a) the potential for harm to the patient with (b) no offsetting potential benefits for the patient, combined with (c) the inevitable harm to trust in the medical profession itself, and via that loss of trust, loss of healing capacity.

Once the medical profession has committed itself to the zero tolerance standard, every member of the profession is bound by that commitment. A physician who participates in a sexual relationship is by that very act an unethical physician, regardless of his motives or whether the patient is harmed.

Drew Altman on President Obama's Leadership

There's been lots of debate as to whether the President has been a wise leader or a wimpy neophyte in the health reform process. I've felt that as discombobulated as things have been, we couldn't realistically hope for a more linear unfolding, and that the President is doing things right.

In his superb series of "Pulling it Together" columns, Drew Altman, President and CEO of the Kaiser Family Foundation, nailed the leadership issue earlier today. He argues that President Obama has been wise to keep his cards close to his chest so far, and that the time to come on strong about his detailed positions will be "when there is a bill in conference; then again when that bill moves from conference to the floor of the House and the Senate and is the focus of intense lobbying and national debate." It's a (short) column well worth reading.(See here for the column.)

Death Panel Plots and Mammogram Conspiracies

A number of friends are in despair over the possibility of rational political and public reflection about health policy.

I'm not.

Perhaps I'm a cockeyed optimist, but I see the summer's folly about death panels and the eruption about the Preventive Services Task Force recommendations as part of a societal learning process.

In the teaching I do about health care limits I often point out that limits are part of sharing finite resources within a population and that the way we learn about sharing as children teaches important political lessons.

Sharing toys doesn't come naturally. Parents (a) give cognitive messages ("it's fair that Johnny gets a turn with the toy") (b) provide emotional succor for the tantrums that follow, while (c) being firm about the need to share in order (d) not to raise selfish monsters. This process takes lots of time.

Some of the death panel madness was fomented by duplicitous politicians and talk radio hosts, just as we saw during the Bush years at the end of Terri Schiavo's life. But some people truly experienced the idea of end of life counselling as an assault on life and freedom by a death-dealing government. If 2 year olds could speak as adults I expect that they would respond to being asked to share their toys in similar fashion - "This toy means my whole life to me - you're killing me by asking me to share it - this idea of sharing is worse than a death panel!" We don't expect the child to learn all at once, and we can't expect the same from the body politic.

Unfortunately, the duplicitous politicians and audience-hungry talk show hosts are like bystanders who would rush up to the child having a tantrum to say - "you're right - it's outrageous that you've been asked to share your toy - your parent is a socialist!" This will make the learning harder and slower.

The mammogram furor is related, but different. The ever-changing recommendations are genuinely confusing, and people of intelligence and integrity can reasonably disagree. But seeing a government plot in the very idea of the new recommendations has to be understood in light of Kubler Ross's stages of grief theory. Recognizing that mammograms are not a magic bullet that can be counted on to ward off breast cancer confronts us with mortality. Denial of the epidemiological facts about the limitations of the test, combined with our suspicion that the government is a harsh parent insisting that we share all that is important to us with others, underlies some of the backlash we are seeing.

For those who understand the need for limits and for evidence-based health policy, what's needed is the patient persistence that good parents have in teaching us to share. This doesn't mean that fellow citizens who understand end of life counselling to mean death panels or see epidemiology as government conspiracy are childish. Surprising as it is to those of us who obsess about health policy and health system ethics, not everyone has been wonkishly immersed in these issues. Societal learning takes time.

The differential diagnosis between between an honorable person on a learning trajectory and a duplicitous politician can be difficult. But it's hard to believe that people as smart as Newt Gingrich and John Boehner really believe the death panel drivel they indulged in. I leave it to Rahm Emanuel to devise the best responses to duplicitous opportunism. But for all those who are open to learning, President Obama's ability to explain and inspire are what's needed. And as wise parents know, he'll have to do it again and again!

(For an excellent discussion of playground learning, see Steve Almond's op ed here. And for an important analysis of the death panel madness, see a discussion by Representative Earl Blumenauer here.)

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!

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.

Can we Discuss "How Much is Life Worth" without going ballistic?

I've been invited to speak next week at a conference based on the article by Tito Fojo and Christine Grady ("How Much is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question") that I wrote a post about three weeks ago. The opportunity has led me to a clearer perspective on the currently undiscussable topic of health care rationing.

Fojo and Grady's central argument - that we in the U.S. should rein in our expenditures on interventions that produce small benefits at enormous cost is so obviously correct that the question to ask is not "are they right?" but rather "what's preventing us from doing what we so obviously need to do?"

I've thought about that question in light of the decision process that NICE (National Institute for Health and Clinical Excellence) uses for the guidance it provides to the National Health Service. NICE has created an elegant approach to setting limits. The logic of NICE's process is simple. (1) The National Health Service has a budget. (2) Every expenditure has an an opportunity cost and should be compared to alternative uses of the funds. (3) For selected new interventions, NICE reviews the evidence about its clinical effectiveness. (4) If the intervention offers clinical benefit NICE asks how much those benefits cost, defined as cost/QALY (Quality Adjusted Life Year). (5) NICE applies a template of social value judgments to the facts that emerge from its analysis. (6) The template includes a threshold range (20-30 thousand pounds/QALY) to guide decisions and a framework for deciding when and how to make exceptions to the threshold. (7) The entire process is conducted in a public manner, with opportunities to see the reasoning behind the conclusions and to raise challenges.

NICE fine tunes its approach over time, but its fundamental logic is sound. The impediment to us in the U.S. doing what Fojo and Grady urge us to do is not the absence of a method for deciding about the worth of marginal benefit. Any country ready to tackle rationing could take NICE's procedures off the shelf, study them, and adapt the process to its own culture and institutions.

The key word here is "ready." And, as Hamlet told us, "readiness is all!"

Experienced psychotherapists teach that the hardest job in treatment is dealing with the resistances to change. Once these impediments have been worked with well enough change almost takes care of itself. That model applies at the level of social process as well.

In my talk I'll take Fojo and Grady's argument as the starting point. They're obviously right. The folks at the conference are predisposed to agree - that's why they invited me. I'm going to suggest that making decisions about marginal benefit is, at heart, not all that difficult. NICE shows us how to do it. The task for all those who agree with Fojo and Grady is not to persuade others to see the same truth, but to chip away at the impediments to seeing the obvious. I'll write more about chipping away impediments in future postings.

(See here for NICE's Social Values Judgments report and here for reports from the Citizens Council.)

Rebellion Against the Individual Insurance Mandate

This morning's New York Times reports that legislators in a dozen states are launching a rebellion against the possibility of a mandate that individuals must buy health insurance or pay a penalty. The legislators hope to amend their state constitutions to prohibit any federal requirement that individuals (or employers) must "play or pay."

In 2008 Arizona, a hotbed of radical anti-government sentiment, the electorate almost passed Proposition 101, "The Freedom of Choice in Health Care Act," that would have put the following into the Arizona constitution:

Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan.

The vote could hardly have been closer - 920,341 (49.8%) for and 928,452 (50.2%) against. A tweaked version of Proposition 101 will be on the 2010 ballot and may well win this time.

The brain trust behind the rebellion is the American Legislative Exchange Council (ALEC), a 30+ year old organization of conservative state legislators and policy analysts. ALEC's model legislative proposal is only available to members, but the gist of the proposal is can be seen here:

When consumers control the dollars, they make the decisions. On the other hand, a single-payer health system—which forces patients to enroll in a one-size-fits-all plan with rich benefits and weak cost-sharing—will cause spending to skyrocket and policymakers to ration care as a cost-containment measure...Under a socialized medicine scheme, many patients will suffer, and some will die on a waiting list...ALEC's Freedom of Choice in Health Care Act ensures a person's right to pay directly for medical care.

ALEC pushes all of the conservative buttons - "one-size-fits-all," "ration care" and "socialized medicine."

ALEC and the legislators in the twelve mandate-fighting states appear to favor the "consumer-driven" approach to health insurance, in which individuals are asked to do their own rationing by having to spend their own money on health services. I don't know how ALEC proposes to achieve universal coverage without a mandate. The alternative funding mechanism is to tax the better off to pay for the worse off, not a popular conservative approach.

When I first joined the practice at Harvard Community Health Plan, a non profit HMO, in 1975, "community rating" applied, and all employers were charged the same per-worker premium. Over time the payment system shifted to "experience rating," in which employers were charged in accord with the actual cost of providing care for their employees. This meant that employers were penalized for having older workers who were likely to cost more, and for making it possible for workers with chronic illnesses to hold jobs. Now conservative groups like ALEC want to disaggregate the community down to the level of individuals having the "right" to pay for their own care.

Even if a robust federal health law is passed states will continue to be crucial laboratories for reform initiatives. I'm at the opposite end of the political spectrum from ALEC and favor communitarian approaches to managing the health system. But I'd be happy to see an ethically guided state experiment that (a) achieved universal coverage, (b) tracked its results and allowed independent researchers to assess the state's performance, while (c) putting conservative principles into practice. My guess is that the rebellious legislators are better at shouting "fire" (or rather, "socialized medicine") than solving problems on the ground, but rather than trade sound bites it would be better to see if they can make their ideas work in a clinically sound and socially responsible manner.

Conservative critics of health reform emanate sound bites brilliantly. It's time to see if they can walk their talk!

(An op-ed supporting Arizona Proposition 101 by George Will is here. The Resolution that will be on the Arizona ballot in 2010 is here.)