Kaiser Permanente redux

In 1933, Dr. Sidney Garfield was finding it difficult to make a living in fee-for-service medical practice. He hit upon the idea of prepaid medical care, which he offered to the 5,000 workers building the Los Angeles Aqueduct for a nickel a day. In 1938, at the invitation of Henry Kaiser, Garfield offered prepaid care to workers on the Grand Coulee Dam.

The rest is history.

If Kaiser Permanente and the idea of prepaid care interests you - and it should - check out this story about Dr. David Ores in today's New York Times.

Dr. Ores is 51, lives in a cheap (by NYC standards) apartment on the lower East Side, owns two Harleys, has a tattoo of a naked woman wearing a pink cowboy hat on his arm, and is shown blowing a cloud of cigar smoke in a photo accompanying the article. Like Dr. Garfield (who is in a suit and tie in all the photos I've seen) Dr. Ores has contracted to provide prepaid care - to restaurant workers whose employers pay a dollar a month per worker for outpatient care. (The article doesn't say how hospital care is paid for.)

The article emphasizes Dr. Ores' counter-cultural persona, but prepayment is not a counter-cultural idea. If the national policy debate goes in a sensible direction we'll be seeing lots more prepaid care in the future.

In the meanwhile, enjoy reading about Dr. Ores and the restaurant workers!

Doctor-Patient Sex

Doctor-patient sex is in the news again.

Here's a report from the Texas Medical Board about an action it took against Dr. Kenneth Baird, a family practitioner in Plano, Texas (see here and here for information about Dr. Baird)

On April 3, 2009, the Board and Dr. Baird entered into an Agreed Order requiring that, within one year, he complete the professional boundaries course offered by Vanderbilt University or the University of California San Diego Physician Assessment and Clinical Education (PACE) program; that for each of the next two years he obtain 10 hours of continuing medical education in ethics; and that within 180 days he pay an administrative penalty of $10,000. The action was based on Dr. Baird’s having had a sexual relationship with a patient.

Two things interested me about Dr. Baird's situation. First, he's not a psychiatrist! It's a relief not to have one more sorry example of misconduct from my own specialty. Second, the case points us to an important question - if sex between doctor and patient is seen as wrong, what makes it wrong?

The common answer is that sexual involvement harms the patient. We know from individual cases that this is often true. But even if doctor-patient sex is harmful in 99% of the cases, it's hard to see why it is always harmful. And if we can identify or imagine situations where it is not harmful, does that make those situations ethically acceptable?

In 2008 the Texas Medical Association rendered an opinion that appears to make use of emotions or insights derived from the doctor-patient relationship the key factor:

SEXUAL MISCONDUCT. Sexual contact that occurs concurrent with the patient-physician relationship constitutes sexual misconduct and is unethical. Sexual or romantic relationships with current or former patients or key third parties are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from the professional relationship. Key third parties include, but are not limited to, spouses or partners, parents, guardians, or proxies.

Harm to the patient and exploiting the clinical relationship for personal gratification are clearly reprehensible. But since these factors are probably not present in every case they do not provide a basis for an absolute prohibition.

The Texas Medical Association would have done better if they had gone back to Hippocrates:

With purity and with holiness I will pass my life and practice my Art...Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.

Hippocrates based his prohibition of doctor-patient sex on the intrinsic responsibilities of the medical profession, not on the consequences of seducing male or female members of the house the physician entered. As a member of the medical profession the physician professes a set of values. Hippocrates' terms "purity," "holiness" and "for the benefit of the sick" hold up very well after almost 2500 years.

Developing a sexual relationship with a present or former patient tarnishes the profession itself, whatever its effect on the individual patient. Harm to the patient is a probable outcome of doctor-patient sex. But harm to the profession is an inevitable outcome. Patients, the public, and physicians themselves, will lose trust in and respect for the medical profession. Hippocrates explains what's wrong with doctor-patient sex better than the Texas Medical Board does. I hope this is part of the 10 hours of ethics education the Board directed Dr. Baird to take!

Medical Students, Murder, and Ethics Education

On Tuesday night April 14 Julia Brisman, who offered erotic massage services on Craigslist, was murdered at the Back Bay Marriott Hotel in Boston. Yesterday the Boston Police arrested Phillip Markoff, a second year Boston University medical student, and charged him with the killing and a an earlier attack carried out in similar circumstances.

The Boston Globe article about Markoff's arrest includes a photograph showing a clean cut, handsome young man smiling as he puts on his white coat for the first time. According to a fellow student who studied anatomy with him "he seemed like a nice guy, and he was a helpful, smart kid." His former stepfather said "He's a great kid...I just can't believe what's going on...He's a very bright, intelligent, articulate guy. I just keep thinking there must be some mistake."

And of course there may be a mistake. Markoff is accused, not convicted. But the story invites speculation as to how someone who comes across as a fine person could commit murder.

My thoughts about this come from another murder. On October 31, 1999, May Greineder, wife of Dr. Dirk Greineder, a colleague I respected and admired, was murdered. I immediately wrote a letter of condolence to Dirk. I didn't know him outside of work, but I had seen a number of his patients (he was a distinguished allergist) over the years. Their description of his skill, commitment and kindness made me proud to have him as a colleague. When one of my children needed to see an allergist I had him see Dirk. Dirk knew of my interest in ethics and had contributed thoughtful observations to a project I had done. If I had been asked to name colleagues who exemplified superb medical ethics, Dirk would have been high on my list.

You can see where this story is going. On June 29, 2001 Dirk was convicted of first degree murder. He has always insisted that he did not commit the crime, and his adult children support him, but he is in prison for life. (If you want to read about this painful story, see here.)

The idea that exemplary ethics and extreme evil can exist in the same person isn't new. Robert Louis Stevenson's "Strange Case of Dr. Jekyll and Mr. Hyde" was a big seller when it was published in 1886. The Jekyll/Hyde phenomenon, and more mundane situations like the fact that Bernard Madoff, whose Ponzi scheme cost investors fifty billion dollars, was a respected philanthropist and an observant Jew, lead to soul searching about the relevance of ethics and religion to human behavior.

I teach medical ethics and consult to organizations about ethics and strategy. These are personal issues for me. Here's what Moses Pava, also a teacher of ethics, had to say about Madoff:

I got to know Bernie Madoff through his service to Yeshiva University’s Sy Syms School of Business. Until news of the scandal broke, he served as chairman of our board. I, and other faculty members, worked closely with him on an academic committee, meeting frequently at his now-infamous Midtown office.

He is charming, soft-spoken and fatherly. Like the old E.F. Hutton commercials, when Bernie spoke, people listened. As he presumably did for many others, he provided us with charismatic leadership and a strong sense of security and optimism. There was little doubt when Bernie Madoff was in the room about who was the decision-maker.

Now, of course, the money is gone, the charisma has evaporated and, instead of security and optimism, there is fear, uncertainty and concern about the future.

Personally, I begin to wonder, does my work teaching business ethics even matter? Can an academic course on business ethics really stop a would-be Bernie Madoff? Not likely.

Bernie Madoff stole gigantic sums of money, but perhaps more importantly he has diminished society’s stock of social capital. In a single stroke, the revelation of his actions has made it more difficult for us to trust one another. He has loosened the taken-for-granted connections that bind us together and robbed us of some of our faith and hope in the future. If yesterday, some of us were naïve idealists, today we are all hard-headed realists. And that is a shame.

But, of course, we all know that Bernie Madoff was not acting alone. He had many enablers. There are those who invested other people’s money with him and did not engage in the due diligence their position of responsibility required. There were likely others who invested with him suspecting that all was not kosher but assuming that he was earning real profits with inside information or by front-running.

Perhaps the biggest enabler though is the prevailing ethos of the business world. We live in a world that has become increasingly oriented toward a bottom-line mentality. Ours is a culture of money first. In every business school I know of, we teach our students to maximize profits. Good enough is never enough...

I will continue to teach business ethics but I have learned through recent events that this is only a tiny part of a much larger job. Unless we all become informal ethics teachers, none of us will get where we want to go.

Teaching ethics won't prevent the Madoff's of the world from carrying out crimes they fully understand to be evil. But I agree with Professor Pava that ethics education has a role in improving individual behavior and organizational conduct. I'll say more about this role in future postings.

Splitting Pills and Promoting Good Ethics

A recent article from Minnesota describes the pill-splitting program at HealthPartners, a 52 year old not-for-profit HMO serving 635,000 members. The point of the story is that only a quarter of the members who could make use of the program are actually doing so.

I was curious to understand why so few HealthPartners members did what I so regularly advised patients in my own practice to do, so I went to the HealthPartners website and found a description of the program. Because the program exemplifies admirable ethics I quote it in full:

Save money with our pill splitting program
Now you can cut your prescription bill in half with select medications when you use HealthPartners' new pill splitting program.

How it works
With this program, you save money when you split higher strength pills into your prescribed dose. Instead of 30 lower strength tablets, you receive 30 tablets with twice the strength to last for 60 doses -- all for one copay. We are able to reduce your drug costs because the cost per pill for higher strength is about the same as they are for lower strength pills.

How to get started
When you're ready for a refill, fill your prescription as you normally do. Just tell the pharmacist that you'd like to use the Half-Tablet Advantage Program.
Pharmacies can adjust the medication strength and directions, dispensing a higher-strength medication for splitting in half for your prescribed dose.
You receive 30 tablets (to last for two months) and pay a single copay.
Your pharmacy can give you a tablet splitter for a small cost.

Which medications are covered with the program?
Medications on the Half-Tablet Advantage Program Drug List have been carefully chosen based on their wide therapeutic margin (slight differences in the daily doses of these medications make very little therapeutic difference), tablet characteristics and ingredient costs. Some of these medications come as scored tablets, and others are not scored (and will need a pill-splitter).

Splitting other medications may also be clinically appropriate, but this program applies only to select medications.

HealthPartners Half-Tablet Advantage Program Drug List:
Cholesterol medications: atorvastatin (Lipitor) and simvastatin (Zocor).
Antidepressants: sertraline (Zoloft), escitalopram (Lexapro), paroxetine (Paxil, generic).

Pill splitting is not recommended for all patients
Splitting tablets may be more difficult and may not be appropriate for patients with poor eyesight, tremors, debilitating arthritis, poor memory or behavioral health issues. Providers, pharmacists and patients can at any time decide that pill splitting isn't appropriate in a particular case. The Half-Tablet Advantage Program is totally voluntary.

I'm perplexed as to why any patient would not make use of this program. It is restricted to medications that are clearly safe to split. (In my view the program could go further than it does!) It cuts a member's copayment in half. And, because HealthPartners is a community-minded, mission-driven, not-for-profit enterprise, the savings that accrue to the health plan go towards socially valuable uses, not, as is so commonly feared in U.S. health care, huge executive bonuses and swollen overhead budgets.

I hope HealthPartners surveys members who could use the pill-splitting program but aren't to learn their reasons. My guess is that the main reasons would be (a) lack of knowledge about the program and (b) erroneous fears about the safety of pill splitting. And for some, (c) physical limitations make pill splitting difficult.

But for some, doubt about whether the drug savings contribute to a socially valuable purpose may be be their reason for not using it. My belief comes in part from a discussion I had some years ago with a patient who had survived the holocaust and who was very grateful to the U.S. for taking him in after the war:

Me: So just to review, we've agreed that using a low dose of Zoloft (25 mgm) would be a good idea.

My patient: That's right.

Me: The drug company charges the same amount to our pharmacy [I practiced at a not-for-profit HMO, much like HealthPartners] for different size pills. When I prescribe 25 mgms of Zoloft I usually recommend splitting a 50 mgm pill in half. That will save some money for you and for the pharmacy. Does that seem fair to you?

My Patient: Yes.

Me: Because I teach and write about these things I want to ask you another question. Do you think it would be fair and reasonable for me to ask you to split a 100 mgm pill into quarters? This is very rarely done and it's fine for you to say "no."

My patient: It doesn't seem reasonable to me.

Me: That's fine. Here is a prescription for the 50 mgm size...

After the appointment, while I was finishing my note, my patient returned to the office:

My Patient: I thought more about your question. This country has done so much for me that I thought the least I could do is to give something back by splitting the larger pill into quarters.

We talked a bit more, and he clarified for me that what changed after he left the office was his reframing the pill splitting as something that served wider society as well as his own pocket book.

Splitting pills in accord with the exemplary program at HealthPartners serves a public good as well as a private one. If I were in charge of the program, in addition to publicizing it more to members and encouraging the doctors to make more use of it, I'd add a sentence about the benefits pill splitting confers on the HealthPartners community to the description I quoted above.

Creating a Culture of Research

I recently came upon a terrific article - "Creating a Culture of Research" - that lays out a strategy aimed at making it easier to do scientifically (and ethically) sound clinical research. I write about it here because while its focus is on research, the article has significant implications for organizational ethics in health care.

The authors, Andy Avins and Harley Goldberg, are both associated with Northern California Kaiser-Permanente. Here's the core of their vision:

Perhaps the most important aspect of change is the need for clinical research to be seen as the enormous social good that it is. By providing the knowledge base that establishes effective prevention and therapy, research participants (often by assuming some amount of risk) provide a gift that transcends the simple scientific aspects of their contributions. Yet, unlike many other members of our society who contribute to the general good, these individuals are rarely recognized for their commitment. Similarly, knowledge of the research process is probably very low among the lay public...Such circumstances contribute strongly to the difficulty in recruiting participants to important research investigations. It is time to take a public-health approach towards confronting these issues directly.

Creating a culture more conducive to clinical research requires actions in several domains:

• As mentioned in the above quotation, the public must see participation in clinical research as a contribution to societal well-being. Charitable gift-giving is strong in the U.S. Participation in clinical research is like making a gift to the heart fund a hospital.


• Clinicians must see supporting clinical research as part of their professional responsibility. We ask clinicians to provide evidence-based care. Without their help evidence won't be created.


• Health plans and large health care organizations benefit from evidence about clinical effectiveness. This creates "a special responsibility to become partners in this process and contribute to this agenda."


• Researchers must make participation in research more feasible for patients and clinicians. And, to an even greater extent than when the article was published two years ago, "research participants are entitled to the expectation that those designing and carrying out research protocols are free from suspicious conflicts of interest."

Preaching about the importance of scientifically and ethically sound clinical research won't enhance the research process - a concerted campaign will be required. Unfortunately, the flood of revelations about suppression of negative results in commercially sponsored research and corruption of medical judgment makes fostering a culture of research much more difficult.

I agree with Avins and Goldberg about the importance of strengthening the clinical research enterprise. And from the perspective of ethics I like the potential impact of their ideas on (a) the doctor-patient relationship and (b) health care organizations.

In my writing, teaching, and in this blog, I've often sounded off about the degree to which we underattend to population interests in our approach to health care ethics. In teaching and in the media we focus on the numerator (the individual) but largely ignore the denominator (the population the individual is part of). This myopic approach to ethics encourages selfishness (as if only the individual matters) and social irresponsibility (as if collateral damage from our overly individual-centered system - like our high uninsurance rate - doesn't matter).

In encouraging clinicians and patients to see themselves as collaborators in supporting the advance of medical knowledge we're encouraging them to add a sense of social responsibility to the guiding ethic of care and to recognize the limits of what we know. These would be salutary changes.

With regard to health plans, hospitals and medical groups, the perspective Avins and Goldberg argue for invites all participants in health care to recognize that we have a shared responsibility to contribute to generating the evidence required for "evidence-based practice." This outlook urges us to make the organizations we are part of true learning communities.

A campaign to create a culture of research as envisioned by Avins and Goldberg would have a constructive effect on the ethics of our health system as well. I'm ready to sign on!

Medicare Open to All (2)

Two weeks ago, in a post about "Medicare Open to All," I argued that a while from some perspectives a public program could be seen as an unfair competitor for private insurers, it could also play the role of "downfield blocker" in making tough choices about encouraging real price competition and bringing back some of the desirable innovations from the "managed care" era.

I wondered if I was being a hopelessly naive academic egghead in taking this position. Perhaps I was, but in "A Public 'Fix' for Health Care Need not Abandon the Market" in today's Washington Post, business columnist Steven Pearlstein makes the same argument.

The public sector role in the U.S. health care system is a very polarized topic. Single payer advocates want a public national health plan. Market advocates attack the idea as "socialized medicine" and call for more, not less, reliance on market forces. For the moment it looks as if policy makers are looking for ways to bridge the gap between the two camps. To understand the policy dynamics better Pearlstein's article is worth a look.

"Skin in the Game"

Here's a story that could be the basis for a class about the U.S. health care "system." My interlaced comments are in bold italics:

When Ben Schreiner, a 62-year-old retired Bank of America executive, found out last year he would need surgery for a double hernia, he started evaluating possible doctors and hospitals.

Ben's condition - a clearly diagnosed, non-urgent, standard surgical procedure - is well-suited to the "consumer" model of health care. The procedure is done at a limited number of facilities and data on experience, complication rates and cost is usually available.

But he didn’t look into the medical center in his hometown, Camden, S.C., or the bigger hospitals in nearby Columbia. Instead, his search led him to consider surgery in such far-flung places as Ireland, Thailand and Turkey.

For the procedure Ben needed, continuity of care was a relatively secondary consideration, so "shopping" far away from home was possible. Hernia surgery can reasonably be "outsourced." This would not be the case, however, for the majority of medical interventions.

Ultimately he decided on San José, Costa Rica, where just a week or so after the outpatient procedure and initial recovery, he and his wife were sightseeing throughout the country, then relaxing at a lush resort. He was home four weeks later, with no complications.

Mr. Schreiner is what’s known in the health care world as a “medical tourist.” No longer covered under his former employer’s insurance and too young to qualify for Medicare, Mr. Schreiner has a private health insurance policy with a steep $10,000 deductible.

Ben's demographic segment - no longer having employment-based insurance and too young for Medicare - will grow as the baby boomer's age. By taking a large deductible he lowered the cost of his insurance premiums, but in all likelihood those premiums were still quite high.

Not wanting to spend all of that on the $14,000 his operation would have cost stateside, he paid only $3,900 in hospital and doctor’s bills in Costa Rica. “I didn’t have to fork over my entire deductible,” Mr. Schreiner said. “What’s more, they bent over backwards there to take care of me — no waiting, a friendly staff, everyone spoke English.”

As a former bank executive Ben is presumably adept at running the numbers. The combination of Ben's skills with a non-urgent medical need for a procedure about which information is relatively available makes this kind of comparative "shopping" possible.

Ben Schreiner is a poster person for the market model of health care. His experience shows how market forces can potentially reshape health care in the U.S. If enough of Ben's neighbors in South Carolina go out of state and out of the country for hernia surgery, local surgeons and a local facility will ultimately figure out how to provide the surgery at a lower cost.

Ben's story appeals to two deeply held American values. First, he took responsibility for himself, by (a) choosing to take on substantial financial risk for his health care choices and (b) venturing to a far away "frontier" to find what he was looking for. And, he respected and used market forces, which our culture reveres much as we revere the six-gun carried by brave cowboys.

But extrapolating Ben's experience to a comprehensive proposal for how to govern the health system as is done by market hawks in the U.S. overlooks the fact that relatively simple elective procedures that require little or no continuity of care are the exception, not the rule. Individual responsibility and market forces will certainly play a major role in the forthcoming U.S. debate about health care reform, but they can't accomplish the task on their own.