By temperament I'm an optimist, but Republican pronouncements on health care, like Mitt Romney's proposal for privatizing the Veterans Health system, challenge that stance. Paul Krugman has a powerful op ed on this latest piece of Republican disinformation in today's New York Times.
The Veterans' care system was radically reengineered in the 1990s. It now consistently outperforms the private sector on measures of quality and cost. As Krugman points out, that violates Republican theology. When facts and faith collide, something has to give. Romney isn't dumb, so the differential diagnosis is (1) faith in markets that is so strong he'll deny facts or (2) garden variety political duplicity - (i.e., expeditious lying).
(See this piece in yesterday's Daily Kos for details about the VA program and the Republican knee-jerk assault on public programs.)
Showing posts with label VA. Show all posts
Showing posts with label VA. Show all posts
Monday, November 14, 2011
Monday, October 11, 2010
ACOs, Rationing, and Medical Ethics
Magic bullets come and go in the world of health policy, but the accountable care organization (ACO) is likely to be a durable reform. Except for group practices like Geisinger, Harvard Vanguard, and Kaiser Permanente, systems like the VA, and local communities in which independent practitioners have established cooperative collaborations, health care has been grotesquely uncoordinated in the U.S. ACOs speak to that structural lesion.
Title III of the Patient Protection and Affordable Care Act puts ACOs forward as an innovation to promote the quality and efficiency of health care. "Efficiency" isn't controversial. Doing a second MRI because the results from the first one aren't available is pure waste. But not doing an MRI when a plain film, or a careful physical examination and history, could be "adequate," is more complex. Some would call that "efficiency" or "evidence based practice." Others would call it "rationing." But there's no uncertainty about how to label not offering an effective, and desired, service - that's definitely rationing.
In the October 6 issue of JAMA, Dr. Robert Brook of RAND has an important brief article - "What if Physicians Actually Had to Control Medical Costs?" As a thought experiment, Brook imagines that enough money is available for a physician to treat 100 patients with condition A or condition B. Treating each patient costs $1000, and only $100,000 is available. Epidemiological data predicts that the physician will see 100 patients with A and 100 patients with B. The benefit of treating A is four times the benefit of treating B. What should the physician do?
Brook believes, and I agree, that even when we have wrung all efficiency savings out of health care, there will still be beneficial interventions physicians want to provide, and patients want to receive, that our society will not be prepared to pay for. He argues, and I agree, that the medical profession is unprepared for engaging with this eventuality:
No one wants to go first in discussing rationing. To do so would invite savage, know-nothing political attack. But it's important for public deliberation about how to ration in a clinically guided, ethically justifiable and potentially socially acceptable manner to get underway. Accountable Care Organizations are an ideal setting for physicians and patients to join together in this kind of what if scenario planning.
Title III of the Patient Protection and Affordable Care Act puts ACOs forward as an innovation to promote the quality and efficiency of health care. "Efficiency" isn't controversial. Doing a second MRI because the results from the first one aren't available is pure waste. But not doing an MRI when a plain film, or a careful physical examination and history, could be "adequate," is more complex. Some would call that "efficiency" or "evidence based practice." Others would call it "rationing." But there's no uncertainty about how to label not offering an effective, and desired, service - that's definitely rationing.
In the October 6 issue of JAMA, Dr. Robert Brook of RAND has an important brief article - "What if Physicians Actually Had to Control Medical Costs?" As a thought experiment, Brook imagines that enough money is available for a physician to treat 100 patients with condition A or condition B. Treating each patient costs $1000, and only $100,000 is available. Epidemiological data predicts that the physician will see 100 patients with A and 100 patients with B. The benefit of treating A is four times the benefit of treating B. What should the physician do?
Brook believes, and I agree, that even when we have wrung all efficiency savings out of health care, there will still be beneficial interventions physicians want to provide, and patients want to receive, that our society will not be prepared to pay for. He argues, and I agree, that the medical profession is unprepared for engaging with this eventuality:
Policy makers discuss controlling medical costs, and academics publish articles analyzing cost-control approaches. But physicians seem oblivious to the possibility that, sooner or later, care will need to be explicitly rationed. Physicians who actually order the health-related diagnostics or treatment for which taxpayers pay must decide how they will cope with explicit rationing. Will there be a physician plan or health professional plan to deal with the eventuality of explicit rationing? Should planning begin now instead of waiting until the decision is imminent?There's no way that the need for rationing could have been part of the federal health reform process. We're not yet mature enough as a body politic to deal with that piece of reality without going ballistic about "death panels." But wishful thinking and political immaturity don't change the fact that rationing happens now, will have to be acknowledged in the future, and is an ethical requirement, not an abomination. Brook concludes, and I again agree:
...an explicit plan for rationing needs to be developed. But who will do it, and how?Physicians (and other health professionals), patients and the wider public should be the "who?" And with regard to "how?," the experience of the Didcot practice in the U.K. provides a model of deliberative process. With help from two ethicists, the general practice group created guidelines for the practice, reviewed them with members of the practice, and made them public.
No one wants to go first in discussing rationing. To do so would invite savage, know-nothing political attack. But it's important for public deliberation about how to ration in a clinically guided, ethically justifiable and potentially socially acceptable manner to get underway. Accountable Care Organizations are an ideal setting for physicians and patients to join together in this kind of what if scenario planning.
Monday, May 4, 2009
Ethical Challenges in Veterans Administration Healthcare Facilities
The April issue of the American Journal of Bioethics has a valuable piece of ethics research from the VHA.
To understand the challenges faced by Veterans Administration facilities, the authors conducted focus groups with patients (32) and managers (38), and semi-structured interviews with managers (31), clinicians (55) and ethics committee chairpersons (21). They found that all parties were deeply concerned about the ethics of the enterprise. There was no evidence whatsoever to support the common view held by clinicians that they are concerned with values while bureaucratic "beancounters" are concerned with business and the bottom line.
But the issues that most concerned the groups varied:
The good news for those concerned with strengthening the culture of ethics at health care organizations is the fact that everyone saw health care as a value-driven mission. The bad news is the danger that health organizations could become Towers of Babel, with all groups speaking about ethics and values but unable to communicate with each other.
The VHA National Center for Ethics in Health Care has developed and is beginning to implement a very promising approach to the Tower of Babel danger - the IntegratedEthics program.
Anyone interested in the ethics of organizations should read the 15 page VHA report. Page 5 of the report has a useful picture of an "ethics iceberg." At the surface are the visible decisions and actions that are carried out every day - respecting/not respecting patient preferences, returning/not returning telephone calls, etc. Immediately under the surface are the organizational systems and processes that shape decisions and actions - such as ethics consultation, staff education and supervisory systems. At the deepest level, least directly observable but most powerful, is the ethical environment and culture of the organization.
What's most distinctive about the VHA approach is the way it links components of the organization that usually live in separate silos. In my teaching about ethics I've used the heuristic device of 3 "As" to describe the components of ethics in organizations. The VHA conception suggests a practical way to make them work together:
To understand the challenges faced by Veterans Administration facilities, the authors conducted focus groups with patients (32) and managers (38), and semi-structured interviews with managers (31), clinicians (55) and ethics committee chairpersons (21). They found that all parties were deeply concerned about the ethics of the enterprise. There was no evidence whatsoever to support the common view held by clinicians that they are concerned with values while bureaucratic "beancounters" are concerned with business and the bottom line.
But the issues that most concerned the groups varied:
- Managers worried about how to distribute resources fairly among the different components of the facility and what kind of process to follow in doing this.
- Clinicians worried about providing high quality care with limited resources and balancing duty to patients with the obligation to be stewards of VA resources.
- Ethics committee chairs were most concerned with improving end-of-life care and ensuring that patient preferences were honored.
- Patients had as their top priorities receiving respectful and caring treatment from all staff and improving service quality.
The good news for those concerned with strengthening the culture of ethics at health care organizations is the fact that everyone saw health care as a value-driven mission. The bad news is the danger that health organizations could become Towers of Babel, with all groups speaking about ethics and values but unable to communicate with each other.
The VHA National Center for Ethics in Health Care has developed and is beginning to implement a very promising approach to the Tower of Babel danger - the IntegratedEthics program.
Anyone interested in the ethics of organizations should read the 15 page VHA report. Page 5 of the report has a useful picture of an "ethics iceberg." At the surface are the visible decisions and actions that are carried out every day - respecting/not respecting patient preferences, returning/not returning telephone calls, etc. Immediately under the surface are the organizational systems and processes that shape decisions and actions - such as ethics consultation, staff education and supervisory systems. At the deepest level, least directly observable but most powerful, is the ethical environment and culture of the organization.
What's most distinctive about the VHA approach is the way it links components of the organization that usually live in separate silos. In my teaching about ethics I've used the heuristic device of 3 "As" to describe the components of ethics in organizations. The VHA conception suggests a practical way to make them work together:
- Analysis (What's the right thing to do?) Ethics committees/ethics consultation concentrate on answering these analytical questions.
- Administration (How do we make it easier to do the right thing?) This is the responsibility of the various components of operations management.
- Advocacy (Let's make sure that we all embrace the same values and ideals.) This is the values leadership for which the CEO and her team are crucial.
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