Wednesday, July 28, 2010

Disgraceful Republican Attacks on Don Berwick

The Republican attack machine is at it again. Here's what they're saying about Don Berwick, President Obama's inspired choice to lead Medicare and Medicaid:
Utah Senator Orin Hatch: "Dr. Berwick has a great reputation as a pediatrician, but he's made some of the most outlandish statements I've heard in years."

Wyoming Senator John Barrasso, who is an orthopedic surgeon: "health care rationing czar."

Texas Representative John Carter: "Dr. Berwick is a proponent of the British health care system and believes in rationing your health care and redistributing wealth."
I assume that as with the preposterous "death panel" demagoguery, these intelligent men know better. Unfortunately, the Republican campaign of disinformation is likely to be effective.

Anyone with even a modicum of understanding of health care knows that the U.S. rations by income and access to insurance. Those with a bit more knowledge understand that rationing is an ethical requirement, not a moral abomination, if we're ever going to slow the cancerous growth of health care costs.

Berwick's consistent message is that by steady concentration on quality we will improve health and save money at the same time. And, if it is still necessary to contain costs, which it will be, we should ration in a thoughtful manner, concentrating on high cost/low yield areas, rather than on the purely economic grounds we apply at present.

Claiming that rationing (a) does not happen now and (b) is part of a Democratic plot is (c) in line with the Republican claim that reducing taxes on the wealthy will help to lower the deficit. But telling lies in a tone of certainty, and repeating the lies often enough, has proved, alas, to be a effective partisan tactic.

Attacking Berwick for his recognition of the admirable accomplishments of the National Health Service plays well with American exceptionalism and jingoism. But encouraging the body politic to believe that we have nothing to learn from others is like parents telling children they already know enough so why bother with reading or arithmetic.

Health care ethics requires open mindedness and thoughtful deliberation. The Republican tactics are like shouting "fire" in a theater. Insofar as their campaign of fear and disinformation is listened to it will block meaningful health reform and quality improvement.

I hope the administration can orchestrate bold public statements by all of the hospitals and clinics Berwick and his Institute for Healthcare Improvement have helped. The public trusts doctors and nurses more than politicians. The stories these organizations can tell would show the Republican attacks to be disgracefully ill-informed, disgracefully partisan, or both.

Sunday, July 25, 2010

Consumer Directed Health Care Can Work!

On Thursday during a break in the cloudy/rainy weather in Vermont, I took the 3/4 mile hike up to Lake Pleiad, a mountain lake that's a favorite swimming spot. The weather was dicey and there was only one other person there, a large man with two large tattoos, who, I learned, had been a bouncer in a bar, but now now worked for a small manufacturing company.

I asked about the health insurance the company provided. Here's my reconstruction of what he said:
It's a health savings account type of thing. I have a $5,000 deductible. It's a good deal because the employer puts some money into the savings account. The deductible is a lot of money, but I'd only have to spend it all if I went into the hospital. I'd rather take that risk and have a lower monthly premium, even though a 'lower premium' is still a lot! Doctor visits and tests don't come to all that much. I don't just take a doctor's word about things - I ask a lot of questions. 'What could this test show? Would the results make us do anything different? How important is it?' Sometimes they give me a good answer, and I'm satisfied, but sometime it seems like they didn't really have a good reason, and I don't do it. You've got to ask questions!"
I asked him if the deductible got him to ask more questions. It did. "When you're laying out the money, you think about things more!"

I told him he'd made my day. He was doing just what the architects of high deductible health plans were hoping for. I said "if more people did what you do it would keep us doctors on our toes! We recommend a lot of things out of habit and they don't really need to be done. Do you encourage friends to ask questions the way you do?"

He did. A woman friend's gynecologist was recommending expensive tests on a regular basis. She didn't know why - "I just do what the doctor tells me I need to do." He said "you've got to ask!" When she did it turned out that the tests were really optional. She thanked him.

In 2009 approximately 23 million Americans had plans like the one my swimming companion had. If five percent asked questions the way he did that would be a million people. If that million persuaded five friends to do the same we'd be up to five million. To paraphrase the late Senator Everett Dirksen - "a million people here, a million people there - pretty soon we're talking real public education."

I spent thirty-five years of my practice life with a not-for-profit HMO. I think a group practice of that kind, in which patients and clinicians collaborate in planning the wisest way to use resources, is ideal. But that model didn't catch on widely, which is one reason consumer directed plans are selling like hotcakes.

I really admired and learned from my swimming companion. He was just a smart guy who thought for himself - not a health policy geek like me. If we had a groundswell of people like him who approached health care like prudent consumers it would be the strongest possible force for health reform!

Wednesday, July 21, 2010

Continuity of Care

As I read the final paragraphs of "A Doctor Discovers a Patient in the Mirror" by Dr. Ellen Feld, an internist who teaches at Drexel, in yesterday's New York Times, I teared up.

In psychiatry teaching, lots of attention is paid to using our emotions as "data" for understanding our patients. In ethics teaching, lots of attention is paid to developing the logical rationale for our conclusions. As a psychiatrist who teaches ethics I find that I do both.

Dr. Feld describes how she found a lump in her breast, tried to deny it was there, visited her gynecologist, had a mammogram, an ultrasound, and then a biopsy. Here are the paragraphs that got me teared up:
For the next 48 hours, as I wait for her call, I feel suspended, hanging from a strap cinched too tightly around my chest. Waiting to hear just how bad the news is. Waiting to hear when I will move forward and to what unfamiliar places I will go.

When she does call, much of the conversation is a blur, but I remember three things she tells me with immeasurable kindness: that the lump is malignant, that she will take care of me, and that she and I will know each other until one of us dies.

I am transformed — from a ridiculously healthy person to one with a life-threatening diagnosis, from someone who does not go to doctors to someone who does, from a doctor to a patient. My life path has veered off a sunny road into a dark and treacherous jungle. I feel dazed and disoriented from the wrenching metamorphosis, but so lucky to have this woman walking beside me holding a compass.
I asked myself the question I ask my students - "put your tears into words - what do they tell you?"

I haven't yet had the kind of health experience Dr. Feld describes so movingly. But even though psychiatrists aren't dealing with cancer, in my practice I've so far had the privilige knowing my patients "until one of us dies." The longest time that has involved is forty-four years.

In my third year of psychiatry residency we spent six months in a "walk-in clinic," where patients could come without an appointment to be seen for an initial visit. We were told "the person you see is your patient until the two of you agree on another plan." I'm still in contact with people I know from walk-in clinic days. (Two years ago I wrote a post about one of them.)

Judging from my own experience, and what I've heard from innumerable colleagues, the experience Dr. Feld writes about with such sensitivity is as meaningful for the doctor as it is for the patient. The patient may have the illness, but we share the fact of vulnerability and mortality. What a privilige it is (using Dr. Feld's words) to walk alongside of fellow human beings, responsible for carrying a shared compass.

The tears were for gratitude for the privilige of being allowed to care for patients, and hope for receiving what I've been allowed to offer when my own time comes.

Tuesday, July 20, 2010

Managed Care and Accountable Care Organizations

I recently received the following note from a mental health clinician I know to be clinically excellent and fair-minded as well:
I am aware a number of providers are disturbed with their experiences with [XYZ Managed Behavioral Health Organization] and I wanted to share my experience. Basically, the reviewer was belligerent from the get-go and I had no chance to present my experience. I felt like a defendant on the witness stand with the D.A. confronting me. I still don't know the result of the review, but it certainly was unprofessional and unfair to my patient and painful to me.
I thought of Yogi Berra - this was deja vu all over again!

In the 1990s I studied managed mental health care the way an anthropologist would - I sat with clinicians as they spoke with managed care reviewers and sat with managed care reviewers as they spoke with clinicians. What my observations showed was good people brought into conflict by a flawed technology that came into being to fill a vacuum my colleagues and I had created.

We clinicians were schooled to believe that it was unethical to consider anything other than the interests of our individual patients. This was often said with a kind of smug theological certainty, with the implication that only a moral imbecile or callous monster could disagree. "Doctor," I often replied, "that's an admirable view. Since it's unethical to consider anything but the interests of your patient, that means if your patient needs a heart transplant and you are the only good match, you would be a donor."

In these exchanges I often thought of my hero from college days - Socrates. The colleagues I had this exchange with felt I was pulling a fast one on them and trying to make the worse appear the better cause. For defending the aims of managed care as ethical I was at risk for being fed a jug of hemlock.

In all of my practice years I never experienced third party telephonic review. In my public sector role we had an explicit budget we had to work within. And in my not for profit capitated medical group role we again managed ourselves within the budget set by the capitation we received.

Since costs must be contained, there are only four choices for a health system. (1) Manage via the market, with individuals buying their own care. (2) Provide insurance, with each doctor/patient dyad deciding what should be paid for. (3) Enlist medical expertise in allocating funds via what is now called "accountable medical organizations." Or, (4) ask insurers to do the job for us via third party review.

When clinicians responsible for providing care to their patients and reviewers responsible for managing the available funds are connected by an 800 number, the kind of fiasco my colleague describes is inevitable. Clinicians tell each other about unreasonable reviewers. Reviewers tell each other about feckless clinicians. Distrust builds.

The reviewer described in the note I received could have been a bad apple put into the wrong job, but also could have been a well-intentioned person, who had seen many examples of bad practice, and was overly vigilant.

In the 10 - 15 years since physicians and the public revolted against managed care we've come closer to recognizing that if we don't want the economy to go down the tubes, costs must be managed. In the next 10 - 15 years we'll see a burgeoning of "accountable medical organizations," in which clinicians and patients learn to co-manage resources. The required new learning won't be easy, but if we do the job well we'll be following the Institute of Medicine's urging to cross the quality chasm!

Sunday, July 18, 2010

The New Abortion Providers

Today's New York Times Magazine features a superb article about "The New Abortion Providers." But before I write about it I have to acknowledge a conflict of interest. The author, Emily Bazelon, is my daughter in law.

Emily describes how young physician leaders, mainly women, are training residents and fellows in abortion procedures and family planning. Their aim is to offset the retirement of current abortion providers and to bring abortion services back into mainstream medicine.

I was blown away by the reflectiveness and moral courage of the physicians who were interviewed for the story. Providing abortion services requires tremendous courage. "Pro-life" terrorists have murdered 8 Americans and assaulted 153. If Al Qaeda did the same in a foreign country we would probably bomb or invade! If I were a newly trained OB/GYN physician I don't know if I would have the guts to include abortion in my practice.

Despite terrorism and the hate-laden rhetoric of the "pro-life" protesters who surround abortion clinics, the new abortion providers show respect for colleagues who oppose abortion in a civilized manner. One physician who does abortions only up to nine weeks explained “It was a way of being respectful, because I know that not everyone agrees with me and what I do.” Another handles all the arrangements and does the billing himself for the abortions he provides in his general OB/GYN practice because of the views of the beloved nurse who works with him:
When I talked to Ann [the nurse] — Ray [the physician] offered her his office chair while he saw a patient — she said that when Ray took over the practice, she and the office manager, another woman in her 60s, weren’t sure if they would stay. “We didn’t want a young doctor with attitude,” Ann said. “We’re too old for that. But we gave him a chance. And he has exceeded our expectations wildly. I thank God every day, because he’s so good with the patients. I’m just blessed. Other than the little termination thing — ” she made a small box with her fingers and then moved her hands to her left, as if to set the box aside.
The New York Times piece mentioned an extraordinary article by Dr. Lisa Harris - "Second Trimester Abortion Provision: Breaking the Silence and Changing the Discourse" - that I would never have seen otherwise. Dr. Harris describes the experience of doing an abortion for a woman who was 18 weeks pregnant when she was herself 18 weeks pregnant with her first child, and moves from her personal experience to broad moral reflection:
I went about doing the procedure as usual, removed the laminaria I had placed earlier and confirmed I had adequate dilation. I used electrical suction to remove the amniotic fluid, picked up my forceps and began to remove the fetus in parts, as I always did. I felt lucky that this one was already in the breech position – it would make grasping small parts (legs and arms) a little easier. With my first pass of the forceps, I grasped an extremity and began to pull it down. I could see a small foot hanging from the teeth of my forceps. With a quick tug, I separated the leg.

Precisely at that moment, I felt a kick – a fluttery ‘‘thump, thump’’ in my own uterus. It was one of the first times I felt fetal movement. There was a leg and foot in my forceps, and a ‘‘thump, thump’’ in my abdomen. Instantly, tears were streaming from my eyes – without me – meaning my conscious brain - even being aware of what was going on. I felt as if my response had come entirely from my body, bypassing my usual cognitive processing completely. A message seemed to travel from my hand and my uterus to my tear ducts. It was an overwhelming feeling – a brutally visceral response – heartfelt and unmediated by my training or my feminist pro-choice politics. It was one of the more raw moments in my life.

...What do we do when caught between pro-choice discourse that, while it reflects our values, does not accurately reflect the full extent of our experience of abortion and in fact contradicts an enormous part of it, and the anti-abortion discourse and imagery that may actually be more closely aligned to our experience but is based in values we do not share?...I want to make the case that honesty about abortion work can be the basis for a stronger movement – one that makes it easier for providers and the teams they work with to do all abortions, especially second trimester abortions."
Dr. Harris is spot on. Dodging the moral complexity of abortion will weaken the feminist "pro-choice" perspective. Recognizing that complexity makes for a more mature, small "c" catholic moral position.

If Ann, a "pro-life" grandmother who goes to Mass every week, and Ray, a young physician who includes abortion in his practice, can work together in mutual respect, there's hope for ameliorating our national nightmare about abortion policy!

Friday, July 16, 2010

Single Payer System for Vermont

Vermont is the second smallest state in the U.S. (2009 population - 621,000), but from the perspective of health reform, it's the most interesting!

This year the state passed Act 128 - "An act relating to health care financing and universal access to health care in Vermont." The act is remarkably readable. It's especially worth looking at the sections on "Findings" (1-4), "Principles" (4-6), and "Goals of Health Care Reform" (6-9).

Vermont is a no-BS state. The bill doesn't pussyfoot around the problem: "The escalating costs of health care in the United States and in Vermont are not sustainable...Only continued structural reform will provide all Vermonters with access to affordable, high quality health care."

When Vermont talks about "structural reform" it means something, as in 2000, when it was the first state to legalize same sex civil unions. The Assembly specified nine principles that health reform must satisfy:

  1. "All Vermonters must have access to comprehensive, quality health care."
  2. "The state must ensure public participation in the design, implementation, evaluation, and accountability mechanisms in the health care system."
  3. "Primary care must be preserved and enhanced."
  4. "Every Vermonter should be able to choose his or her primary care provider, as well as choosing providers of institutional and specialty care."
  5. "The health care system will recognize the primacy of the patient-provider relationship, respecting the professional judgment of providers and the informed decisions of patients."
  6. "Vermont’s health delivery system must model continuous improvement of health care quality and safety and, therefore, the system must be evaluated for improvement in access, quality, and reliability and for a reduction in cost."
  7. "A system for containing all system costs and eliminating unnecessary expenditures, including by reducing administrative costs; reducing costs that do not contribute to efficient, quality health services; and reducing care that does not improve health outcomes, must be implemented for the health of the Vermont economy."
  8. "The financing of health care in Vermont must be sufficient, fair, sustainable, and shared equitably."
  9. "State government must ensure that the health care system satisfies [these] principles."
Act 128 creates a Commission charged with proposing three models to the Assembly by the end of the year. One is a government run, publicly financed, single payer system. Another involves a state run public option that would compete with private insurance. A third will presumably be some form of "market" system, most likely modelled on Massachusetts.

The Commission has hired Professor William Hsiao, a brilliant economist based at the Harvard School of Public Health to lead the design process. Bill Hsiao has worldwide experience working with governments to reform health systems, most recently in Taiwan. Here's an excerpt from a recent interview:
Q: What’s the most important lesson that Americans can learn from the Taiwanese example?
A: You can have universal coverage and good quality health care while still managing to control costs. But you have to have a single-payer system to do it.
Jonathan Gruber, Professor of Economics at MIT, will work with Dr. Hsiao. Gruber is central to the Massachusetts model of reform, which will most likely be the third design model.

My wife and I have spent most of every summer in Vermont since 1992, when she began teaching at the Breadloaf School of English. We've come to love the state. As a small state with a small population, Vermont has sustained a relatively thoughtful and civilized political climate. It will be able to consider alternative models without fear that the two magical words Republicans brandish on the national scene ("socialized medicine") will induce terror and bring rational inquiry to a dead stop. (Bernie Sanders, formerly Representative and now Senator from Vermont, identifies himself as a socialist!)

Our head-in-the-sand national political process made the single payer concept a non-starter in the recent health reform process. Vermont is perhaps the likeliest segment of the U.S. to give the single payer model serious consideration. And Bill Hsiao has the knowledge and experience to make the concept feasible.

Act 128 envisions legislative debate and decision in 2011 and implementation to start by July 2012.

Stay tuned!

Thursday, July 8, 2010

Grandma and her Robot

I'd never heard of Paro, a six pound robot modeled on a baby harp seal, until I read about him (for me, Paro is a "he") in the New York Times on Monday. Paro was developed in Japan for use with the elderly, especially those with dementia. If you go to the company website you can see videos of nursing home residents holding and petting Paro. A man, who is said to have been non-communicative, is shown singing to Paro.

Paro has internal sensors, responds to his name, and apparently can adapt to the preferences of the person interacting with it. The robot was developed in Japan, which has a rapidly expanding "old/old" population, as a source of therapeutic contact.

So - is Paro a humane creation or another sign of our loss of humanity? Is he an ethically acceptable invention or a monstrosity? The Times discussed the ethics of Paro with Sherry Turkle, Professor of Psychology at MIT:
As the technology improves, argues Sherry will only grow more tempting to substitute Paro and its ilk for a family member, friend — or actual pet — in an ever-widening number of situations.

“Paro is the beginning,” she said. “It’s allowing us to say, ‘A robot makes sense in this situation.’ But does it really? And then what? What about a robot that reads to your kid? A robot you tell your troubles to? Who among us will eventually be deserving enough to deserve people?”
Last year I wrote about these questions in a post about CosmoBot, a 16 inch tall robot used in treating children with severe autism:
Experimenting with robot caretakers could seem like an ultimate form of dehumanization. In my view, the robots themselves are ethically admirable. The ethical uncertainty is how we humans use the robots. Ventilators are a kind of primitive robot carrying out a single repetitive function. When we use them well we help sick people recover and save lives. When we use them mindlessly (robotically) we flog patients and prolong the dying process.
Perhaps I have a bit of the robot in me - I'd say exactly the same thing again!

As I kid I loved Ray Bradbury's story "Marionette's, Inc.," in which a husband who wants to leave his wife but doesn't want to hurt her purchases a robot of himself. On the last night before departure he feels a tender anticipatory sadness and puts his head against her chest. He hears a robotic "tick, tick," not a human heart.

There's no doubt that technologies like Paro or the robots in Bradbury's story could undermine deeply held human values. If we give grandma a Paro and stop visiting her we're committing a moral wrong, even if grandma takes just as much pleasure in Paro as in our visit. We owe grandma our best human effort, and we owe ourselves a commitment to learn all we can from her.

Sherry Turkle is right to imagine the possibility of a slippery slope of progressive detachment from those we should be closest to. That could happen, and probably has already happened, since Paro has been marketed since 2004, and more than 1,000 are in use in Japan. But Eileen Oldaker, the focus of the New York Times story, used it to supplement the loving visits she made to her mother. Paro was an add-on, an extension of her caretaking attention, not a replacement.

I'm comfortable with the argument I'm making here, but I'm aware of an apparent inconsistency with my views on gun control. The NRA argues that guns aren't bad, bad people misuse them. They're right. But for me the magnitude of harm bad people create with handguns and automatic weapons justifies restricting access to them. My impression is that thus far the Paros and CosmoBots of the world have done much more good than harm. If we see an epidemic of Paro-induced neglect of the elderly like the epidemic of gang shootings we've recently seen in Boston, I'll be on the side of Paro-control.

Wednesday, July 7, 2010

Don Berwick, Medicare, and Congress

I'm in the hills of central Vermont, but by the wonders of satellite I just read that President Obama plans to make a recess appointment of Don Berwick as director of the Centers for Medicare and Medicaid Services.

As anyone with the slightest familiarity with health care knows, Don has been a visionary leader and teacher for decades. I'd had the probably quixotic hope that hearings might allow him to improve public understanding and our national political dialogue on quality, safety and value in health care. And, in a less elevated spirit, I'd looked forward to the Republican chorus of no-sayers making fools of themselves in the eyes of all of the health organizations Don has helped and inspired, many of them tucked away in red states.

But the appointment is a crucial step forward. In our cockeyed mix of private and public programs, CMS is the closest we come to a national voice. It's the crucial player in the health reform process. Don Berwick is the right person at the right time to be at the helm!

Monday, July 5, 2010

Massachusetts and the Future of Health Reform

If Massachusetts predicts the future of U.S. health reform - and I believe it does - there's a wild ride ahead!

In April, Governor Deval Patrick, who faces a tough re-election campaign in November, dramatized his friendliness to small business and job creation by having his insurance commissioner turn down the rate proposals made by health insurers. An observer commented that as economic policy, this made as much sense as drawing a line in the sand to turn back the tide. Massachusetts insurers are largely not for profits that operate on a one percent margin. What drives the cost increases is the combination of provider and patient behavior.

Governor Patrick's Republican opponent is Charlie Baker, who did a brilliant job as CEO of Harvard Pilgrim Health Care for ten years. By blasting insurers Patrick was trying to apply shock therapy to runaway costs, but he presumably also hoped to tarnish one of Baker's main credentials.

That piece of politics was round one.

The insurers appealed, and two weeks ago the appeals unit in the Division of Insurance reversed the rate denial its own Commissioner had issued to Baker's former organization. It concluded that the rate increases were "actuarially sound" and reflected the actual trend of utilization and charges, a conclusion that everyone who knew anything about Massachusetts health care already shared.

Now Massachusetts is tiptoeing into new waters. Throughout the national health reform process insurers have been portrayed as greedy, profiteering villains. This is a harder line to take with the low margin, not for profit Massachusetts insurers. Last week a Boston Globe editorial blasted insurers for a new reason - not bargaining hard enough with providers!

I've never been part of the bargaining process, but my guess is that the criticism is correct. In the context of (a) the national backlash against managed care, (b) provider consolidation, which gives them more bargaining power, and (c) public demand for wide access, (d) insurers have been in a relatively weak bargaining position nationally.

Now the political system is starting to ask insurers to take a leadership role in solving runaway costs. This is a big shift from blaming them as cause of the problem.

This is a plausible strategy in Massachusetts. The major insurers are locally based not for profits. It's going to be a harder move to make in states where national for profits are dominant.

If I were advising Governor Patrick I would urge him to bring together insurers, major provider groups, the medical society, consumer representatives, economists, policy leaders, and the business community, and give them an "assignment" - to get the state on a trajectory to bringing health costs in the state to a specified, tolerable level. I'd have him convene the group himself and then turn leadership over to a respected, non-political, public figure.

Finger pointing is the commonest political move these days, but it won't get us anywhere in health care, a societal system we're all part of. We have to learn to manage the system. That will take change on everyone's part. If the Governor can launch this process he'll deserve re-election. If he limits himself to finger pointing and rhetoric he'll be looking for a new job on November 3.