Wednesday, January 14, 2009

Fixing American Healthcare - by Dr. Rich Fogoros

In October, when I belatedly came upon Dr. Rich Fogoros's "Covert Rationing" blog, I knew I'd found a kindred spirit. Even though DrRich (his blogging name) identifies himself as a Milton Friedmanite, and I'm New England liberal, we agree that (a) our society has an ethical responsibility to ration health care, (b) that we ration all the time but do it covertly, and (c) our current political culture pretends that rationing is an avoidable evil, not an ethical requirement.

DrRich recently wrote about "Setting Limits Fairly" - the book Norman Daniels and I wrote. Not surprisingly, because we agree on so much, he praised it. Now I'm writing about his book - "Fixing American Healthcare." Not surprisingly, I think it's terrific, and encourage readers to go to DrRich's blog and to read the book.

DrRich presents a "grand unification theory of healthcare" in the form of a 2 by 2 table. The vertical axis goes from low quality decisions at the bottom to high quality decisions at the top. The horizontal axis goes from individual decisions on the right to centralized decisions on the left. This simple framework is very powerful for explaining the mess our system is in. DrRich shows how we've moved from quadrant III (low quality decisions made by individual doctors and patients), which led to chaos, highly variable quality, and escalating costs, to quadrant IV, in which centralized decisions lead inevitably to covert rationing.

What makes covert rationing inevitable is the collision between two incompatible pieces of belief - that access to health care is an entitlement and that limits are unacceptable. DrRich argues that because all members of society contribute to financing the health system the social contract requires that health care must be available to all. It's the delusion that limits can be avoided that has to go. He envisions a system in which a generous but limited package of benefits are available to all, with opportunity for purchasing a wider range of coverage with individual funds.

I especially like DrRich's emphasis on the role "empowered patients" play in the system he envisions. DrRich has practiced medicine (cardiology), written text books and done research. He conceptualizes medical care as a partnership between clinicians out from under the bureaucratic fetters the current system places on them and activist patients. It's a vision of the kind of health care the residents I teach want to practice. Unlike so many of the free marketeers who write about medicine he doesn't reduce caretaking to an arms length commercial transaction between wary "consumers" and chastened "providers."

While each of the ten chapters is replete with pearls of insight, I was especially impressed with chapter 9 - "How to Ration Healthcare." DrRich presents the best thought out practical framework for rationing that I've seen. He uses comprehensible mathematical formulae to show how clinical evidence and core values can be factored into decision-making in a systematic manner.

The most useful part of "Setting Limits Fairly" is its conceptualization of "accountability for reasonableness" - a societal process for fair, open and potentially socially acceptable rationing. If we combine that framework for process with Rich Fogoros's lucid analysis of how specific rationing decisions can best be made, we have the underpinnings of how a society and an actual health system could set clinically informed, ethically justifiable limits.

Now we need political leadership with the courage to tell us what we need to hear!


Annie said...

I read Covert Rationing, but haven't yet read the Grand Unification Theory book.

I posit that reform must really be rebuilding - and of course, one doesn't build top down or sideways, but from the ground up.

The best I've been able to conceptualize would be to use a rough Maslow's hierarchy scale and to place four pillars on the ground level: primary/public/preventive/patient participative health.

That seems to be congruent with both your and Rich's models and theories.

If we can get everyone covered with accessible, affordable and appropriate essential services within that framework, then the increasingly scarce resources for high tech/high complexity/high resource intensity/high cost healthcare can be more openly debated and perhaps rationed based on evidence-based criteria for effectiveness, essential for resuscitation and life support, and other measures which can be measured on risk/benefit scales.

RAND just released an interactive tool called COMPARE for health policy model analysis and prediction. Interesting to me in that physicians and nurses are not presented in any other venue other than "capacity" and the demographic numbers are old.

Single payer as a reimbursement mechanism isn't addressed, nor is universal healthcare.

Finally, as more physicians are practicing as employees, I foresee the same problems with the loss of practice control, autonomy and decision-making. Nursing is at the brink of catastrophic and in my view, unrecoverable failure as a profession over these same issues. Nurses have been very effectively divided against themselves and their profession's interests by virtue of using employed nursing administrators to express fealty to employers over nurse colleagues and nursing where the interests conflict. Patient advocacy is severely compromised when nurses fear retaliation and career ruination (as a whistle-blower who has experienced the viciousness and violence of doing that, albeit reluctantly, I admit I'm biased). Nursing looks to external legislation to regulate what is legitimately nursing's to control. There is no powerful national professional voice, as nursing administrators affiliate as a subsidiary of the American Hospital Association instead of the American Nurses Association (which is the body charged with representing nursing's interests and with establishing and maintaining nursing's code of ethics).

Isn't this erosion of professional control and power also occurring in medicine?

Perhaps concomitantly with national healthcare reform, new models of self-governed professional practice groups comprised of both physicians and nurses can be developed in which the members s/elect their own clinical, administrative, research and academic leaders, establish their own career and salary advancement tracks, and then contract directly with groups of patients, businesses and patient care organizations to provide select professional services.

In this, nursing and medical leaders are accountable to their colleagues instead of to organizations, and patient advocacy can be practiced more robustly. these groups can contract with academic institutions and provide for joint appointments, for application of research so that bench to bedside times are reduced, and they (especially in nursing's case) can bring expert nurses to the clinical arenas, where direct care nurses have been for far too long deprived of close and frequent contact with nurses in academia and research.

Annie said...

At the risk of way too much opining, I was made aware this morning of a public comment call for the revised Nursing Social Policy Statement. I wondered if you are familiar with it, and the link at my name will take you to the American Nurses Association links and a draft of the document, which formalizes the social contract of nursing with the American public.

Jim Sabin said...

Hi Annie -

I'm still in India (I wrote the post about Rich Fogoros's book before I left) and I won't try to respond to all of your very rich, thoughtful and important comments while I'm here. (I'll aim to do that when I'm back in the U.S.) The issues you raise about the ethical status of the professions are here in India in very strong form. India is seeing VERY powerful entry of commercial values into health care, and very limited funding of the public sector.

The issues you raise are at the heart of why I started this blog about health organization/health system ethics. I'll look forward to responding at greater length in the future.



Anonymous said...

Our Health Care System

The following are facts that are believed to exist regarding the present U.S. Health Care System. This may be why about 80 percent of U.S. citizens understandably want our health care system overhauled desperately due to the inadequate health care they receive and access:
The U.S. is ranked number 42 related to life expectancy and infant mortality, which is rather low.
However, the U.S. is ranked number one in the world for spending the most for health care- as well as being number one for those with chronic diseases. About 125 million people have such diseases. This is about 70 percent of the Medicare budget that is spent treating these terrible illnesses. Health Care costs are now well over 2 trillion dollars of our gross domestic product. This is three times the amount nearly 20 years ago- and 8 times the amount it was about 30 years ago. Most is spent with medical institutions, as far as health expenditures are concerned. One third of that amount is nothing more than administrative toxic waste that does not involve the restoration of the health of others. This illustrates how absurd the U.S. Health Care System is presently. Nearly 7000 dollars is spent on every citizen for health care every year, and that, too, is more than anyone else in the world.
We have around 50 million citizens without any health insurance, which may cause about 20 thousand deaths per year. This includes millions of children without health care, which is added to the planned or implemented cuts in the government SCHIP program for children, which alone covers about 7 million kids.
Our children.
Nearly half of the states in the U.S. are planning on or have made cuts to Medicaid, which covers about 60 million people, and those on Medicaid are in need of this coverage is largely due to unemployment. With these Medicaid cuts, over a million people will lose their health care coverage and benefits to a damaging degree.
About 70 percent of citizens have some form of health insurance, and the premiums for their insurance have increased nearly 90 percent in the past 8 years. About 45 percent of health care is provided by our government- which is predicted to experience a severe financial crisis in the near future with some government health care programs, it has been reported. Most doctors want a single payer health care system, which would save about 400 billion dollars a year- about 20 percent less than what we are paying now. The American College of Physicians, second in size only to the American Medical Association, supports a single payer health care system. The AMA, historically opposed to a single payer health care system, has close to half of its members in favor of this system. Less than a third of all physicians are members of the AMA, according to others.
Our health care we offer citizens is the present system is sort of a hybrid of a national and private health care system that has obviously mutated to a degree that is incapable of being fully functional due to perhaps copious amounts and levels of individual and legal entities.
Health Care must be the priority immediately by the new administration and congress. Challenges include the 700 billion dollars that have been pledged with the financial bailout that will occur, since the proposed health care plan of the next administration is projected to cost over a trillion dollars within the first year or so of the proposed plan to recalibrate health care for all of us in the U.S. Yet considering the hundreds of billions of dollars that are speculated to be saved with a reform of the country’s health care system, health policy analysts should not be greatly concerned on the steakholders who may be affected by this reform of our health care system that is desperately needed. Tom Daschle leads this Transition’s Health Policy Team. And we also have Ed Kennedy, the committee chair and a prolific legislator. So if the right people have been selected for this reforming team, the urgency and priority regarding our nation’s health care needs should be rather overt to the country’s citizens.
Half of all patients do not receive proper treatment to restore their health, it has been stated. Medical errors desperately need to be reduced as well, it has been reported, which should be addressed as well.
It is estimated that the U.S. needs presently tens of thousands more primary care physicians to fully satisfy the necessities of those members of the public health. This specialty makes nearly 100 thousand less in income compared with other physician specialties, yet they are and have been the backbone of the U.S. health care system. PCPs manage the chronically ill patients, who would benefit the most from the much needed coordination and continuity of care that PCPs historically have strived to provide for them. Nearly have of the population has at least one chronic illness- with many of those having more than one of these types of illnesses. A good portion of these very ill patients have numerous illnesses that are chronic, and this is responsible for well over 50 percent of the entire Medicare budget.
The shortage of primary care physicians is due to numerous variables, such as administrative hassles that are quite vexing for these doctors, along with ever increasing patient loads complicated by the progressively increasing cost to provide care for their patients. Many PCPs are retiring early, and most medical school graduates do not strive to become this specialty for obvious reasons. In fact, the number entering family practice residencies has decreased by half over the past decade or so. PCPs also have extensive student loans from their training to complicate their rather excessive workloads as caregivers.
Yet if primary care physicians were increased in number with the populations they serve and are dedicated to their welfare. Studies have shown that mortality rates would decrease due to increased patient outcomes if this increase were to occur. This specialty would also optimize preventative care more for their patients. Studies have also shown that, if enough PCPs are practicing in a given geographical area, hospital admissions are decreased, as well as visits to emergency rooms. This is due to the ideal continuity in health care these PCPs provide if they are numbered correctly to treat and restore others. Also, the quality improves, as well as the outcomes for their patients. Most importantly, the quality of life for their patients is much improved if there are enough PCPs to handle the overwhelming load of responsibility they presently have due to this shortage of their specialty that is suppose to increase in the years to come. The American College of Physicians believes that a patient centered national health care workforce policy is needed to address these issues that would ideally restructure the payment policies that exist presently with primary care physicians.
Further vexing is that it is quite apparent that we have some greedy health care corporations that take advantage of our health care system. Over a billion dollars was recovered for Medicare and Medicaid fraud last year through settlements paid to the department of Justice because some organizations who deliberately ripped off taxpayers. These are the taxpayers in the U.S. who have a fragmented health care system with substantial components and different levels of government- composed of several legal entities and individuals, which has resulted in medical anarchy, so it seems.
Thanks to various corporations infecting our Health Care System in the United States, the following variables sum up this system as it exists today. Perhaps the United States National Health Insurance Act (H.R. 676) is the best solution to meet our health care needs as citizens, it appears. We would finally have, as with most other countries, a Universal Health Care system that will allow free choice of doctors and hospitals, potentially, and health care for all completely. It should and likely will be funded by a combination of payroll taxes and general tax revenue which is realistically possible. Because the following needs to be corrected regarding the U.S. Health Care System:
Access- citizens do not have the right or ability to make use of this system as we should.
Efficiency- this system strives on creating much waste and expense as it possibly can.
Quality- the standard of excellence we deserve as citizens with our health care is missing in action.
Sustainability- We as citizens cannot continue to keep our health care system in as it is designed at this time- as it exists today.
Dan Abshear