A Blog Post about Harvard Pilgrim Health Care

I just came upon this post by Paul Levy, who until recently was CEO of the Beth Israel Deaconess Hospital, about Harvard Pilgrim Health Care, where I direct the ethics program. Paul's excellent and very widely read "Running a Hospital" blog has been renamed - "Not Running a Hospital."

It's a very thoughtful post, with an illuminating follow up comment from Eric Schultz, the CEO of Harvard Pilgrim.

(For an earlier post about the Harvard Pilgrim ethics program, see here. For a Health Affairs article on the program, see here.)

The Ethics of Using Placebos in Clinical Practice

The most interesting research study you may ever read about was published last month in PLoS - "Placebos without Deception: A Randomized Control Trial in Irritable Bowel Syndrome."

Placebos have been the focus of much attention in medical ethics. We know that placebos can produce positive effects in many conditions, but it has been believed that deceiving the patient was necessary for a placebo to be effective. Clinicians (and students in ethics classes) confronted what appeared to be a choice between helping patients feel, and be, healthier, and truthfulness in the clinical relationship.

Many years ago I was referred an elderly Russian woman who, after a severe stroke, was left with a severe anxiety state. None of the "conventional" interventions I tried helped her at all. At that point her daughter asked me to give her a placebo and to tell her that the placebo would help her. In as non-judgmental a way as I could muster I said "In the U.S. we believe we should be truthful with our patients and don't like to deceive them." The daughter replied - "You're being self-centered. That's your way. I'm recommending what we would do in Russia!"

I thought she had a point. I checked with a colleague who treated many Russian immigrants. He confirmed that his Russian patients saw benign deception as something good doctors would, and should, do.

I decided to do what the daughter had requested. The pharmacy my practice used was surprised to be asked about placebos, but could make one available. But at this point the family moved, so I didn't get to see if we could alleviate her symptoms with an impressive looking sugar pill.

Still longer ago, as a 25 year old medical intern I was, alas, much more cavalier. In my clinic I had a patient who was chronically agitated by what I thought were trivial matters. When my most likely inept efforts at counselling produced no results I gave her a bottle of brightly colored placebos I'd gotten from the pharmacy and told her they would calm her nerves. (I wish I could say I conducted a deep ethical analysis before going ahead, but that would be a deceptive claim.)

My patient did indeed experience reduced anxiety. To my surprise, her diabetes also came into better control. I've never doubted the power of the placebo effect since then.

In the project reported in PLoS, patients with IBS were invited to join a study in which they would receive "either placebo pills, which were like sugar pills which had been shown to have self-healing properties" or no treatment. Those who were randomized to the placebo group were told (1) the placebo effect is powerful, (2) the body can automatically respond to taking placebo pills like Pavlov's dogs who salivated when they heard a bell, (3) a positive attitude helps but is not necessary, and (4) taking the pills faithfully was critical.

You can guess where this is heading. Over the three week trial, symptoms and overall quality of life improved substantially more in the placebo group than in the control group. In the context of the study, deception wasn't necessary.

However well the findings hold up in the efforts at replication that are sure to follow, the study points in a clear clinical and ethical direction. Clinicians who (a) believe that placebos could help their patients, but (b) also believe that deliberate deception is to be avoided except in unusual circumstances, can (c) prescribe a placebo with a clear explanation of the kind given in the study.

I've always thought it was shortsighted to use the word "just" before the words "placebo effect." The placebo effect is powerful and real, whether it is mediated by mental state, endorphin secretion, or some other set of mechanisms. We don't say "it was just the surgery" when a patient's life has improved post-operatively. The word "just" suggests our dis-ease and ambivalence about use of placebos.

If we can harness the power of suggestion and the power of truthfulness at the same time, it will make for a real advance in clinical practice!

WikiLeaks and Medical Ethics

WikiLeaks, the secure website that publishes documents leaked by whistleblowers, has been front page news since it published 92,000 secret Pentagon documents from Afghanistan. Its founder - Julian Assange - is a fascinating person. He, and the WikiLeaks venture, have a lot to teach about organizational ethics. (My information and quotes come from a terrific New Yorker article about Assange by Raffi Khatchadourian.)

My goal for this blog (and for much of my work) is the same as Assange's - to improve the ethical performance of organizations and public agencies. But our world views and methodologies are so different that I fear Assange would describe me as he described physicists at a conference he attended - "sniveling fearful conformists of woefully, woefully inferior character."

I operate from the quality improvement perspective - the belief that most people in health care want to do the right thing, but may be impeded by faulty systems, which include intellectual/ethical constructs as well as production processes. My methodology is analysis, teaching, and advocacy.

Assange's world view is much darker. Here's how Khachadourian describes it:

He [came] to understand the defining human struggle not as left versus right, or faith versus reason, but as individual versus institution. As a student of Kafka, Koestler, and Solzhenitsyn, he believed that truth, creativity, love, and compassion are corrupted by institutional hierarchies, and by “patronage networks”—one of his favorite expressions—that contort the human spirit. He sketched out a manifesto of sorts, titled “Conspiracy as Governance,” which sought to apply graph theory to politics. Assange wrote that illegitimate governance was by definition conspiratorial—the product of functionaries in “collaborative secrecy, working to the detriment of a population.” He argued that, when a regime’s lines of internal communication are disrupted, the information flow among conspirators must dwindle, and that, as the flow approaches zero, the conspiracy dissolves. Leaks were an instrument of information warfare.

Assange learned this outlook early. His mother "believed that formal education would inculcate an unhealthy respect for authority in her children and dampen their will to learn." She told Khatchadourian "I didn't want their spirits broken." When Assange was eleven his mother separated from his stepfather, who she feared was part of a dangerous cult. "Assange recalled her saying, 'Now we need to disappear,' and he lived on the run with her from the age of eleven to sixteen." By the time Assange was fourteen they had moved thirty-seven times.

Assange's mission is to expose injustice, and injustice is everywhere. Because he sees injustice and exploitation as the basic truth about the world, the default position for organizations and governments, he rejects the Hippocratic injunction to "first, do no harm." His precept is "first, fight tyranny!"

His mission is to expose injustice, not to provide an even-handed record of events. In an invitation to potential collaborators in 2006, he wrote, "Our primary targets are those highly oppressive regimes in China, Russia and Central Eurasia, but we also expect to be of assistance to those in the West who wish to reveal illegal or immoral behavior in their own governments and corporations." He has argued that a "social movement" to expose secrets could "bring down many administrations that rely on concealing reality—including the US administration."

Assange does not recognize the limits that traditional publishers do. Recently, he posted military documents that included the Social Security numbers of soldiers, and in the Bunker I asked him if WikiLeaks’ mission would have been compromised if he had redacted these small bits. He said that some leaks risked harming innocent people—"collateral damage, if you will"—but that he could not weigh the importance of every detail in every document. Perhaps the Social Security numbers would one day be important to researchers investigating wrongdoing, he said; by releasing the information he would allow judgment to occur in the open.

To those for whom harm perpetrated against individuals by government and large organizations is the default expectation, primum non nocere is Pollyanna foolishness.

Assange's ethic is that of public health, not clinical medicine. His passion is for social justice, and in pursuing that aim, individuals will inevitably be injured.

Societies need ferocious warriors for justice like Assange, but his stance of constant vigilance and deep suspiciousness come at a high cost - isolation, fear, and vulnerability to despair. Societies also need gentler leaders who expect imperfection, meet individuals and organizations where they are, and ask them to become better, more in tune with their ideals.

That's the Yin and Yang of organizational ethics!

Gay Bashing, 12 Step Privacy, and Journalistic Ethics

Lavender, "Minnesota's GLBT Magazine," recently created a firestorm of ethical controversy when it published an article outing a Lutheran Pastor known for tirades against homosexuality as a gay person struggling to remain chaste.

Reverend Tom Brock, Associate Pastor at Hope Lutheran Church in Minneapolis, regularly denounced homosexuality on his daily radio program. Last summer, when another branch of the Lutheran Church began to discuss the possibility of ordaining gay and lesbian clergy in committed relationships, a tornado tore off the roof of the meeting hall. Reverent Brock interpreted this as a message from God, condemning the idea of ordining non-chaste gays. Until recently his preaching about the tornado could be seen on youtube.

When it was rumored that Reverend Brock was attending a support group for men struggling against homosexual desire, Lavender sent John Townsend, an "undercover" reporter, into the group. Townsend reported on what Reverend Brock said in the group - most notably, about his experience on a preaching mission to Slovakia: "I fell into temptation. I was weak. That place has this really, really weird, demonic energy. I just got weak, and I had been so good for a long time. Things had been going so well for a long time. There’s a lot of gypsies there."

Clearly Brock is one of the many hypocrites who publicly attack the rights of homosexuals while secretly living a homosexual life. He's entitled to deal with his own sexuality in whatever way he chooses (as long as he is not harming others), but once he takes a public anti-gay stand and claims to know God's will his own conduct is fair game. The Lavender article was exposing a duplicitous public figure, not outing a private person. I see no basis for faulting Lavender's revealing these facts about Reverend Brock.

But what about going into a 12 step meeting on false pretenses and reporting on what transpired? Lavender published where the meeting occurred, what time it started, the name of the priest who led it, and unattributed comments from other participants. This was wrong. The participants are entitled to privacy, which is part of the ethos of 12 step programs.

The Lavender article is a vintage good versus good ethical dilemma. Scrutinizing public figures who denounce others is valid journalism - a public good. But privacy for a support group turned to in good faith by people doing the best they can in their lives is also a good thing.

The situation calls for a nuanced moral response. We should thank Townsend and Lavender for taking the issue of the integrity of public figures seriously. But we should chastise Townsend and Lavender for violating the legitimate expectations of the participants in the support group.

It's much easier, though, to see situations as all black or all white. That, alas, is the direction public and political discourse are taking.

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.

Should Therapists Snoop in Their Patient's Facebook Site?

A colleague recently asked me this question:

What do you think about therapists going to a patient's Facebook site if that site is open to the public, not just to people who the patient has friended? My younger colleagues think it's OK - like reading about your patient in the newspaper. It doesn't feel right to me but I'm not sure why?

What a terrific question!

From the perspective of privacy ethics there's nothing wrong with going to the Facebook site. After all - the patient has structured it so that anybody can come to the site to see what's there. In that limited way the younger colleagues are right - it isn't a violation of privacy.

But it matters what kind of a clinician we're talking about here. If a primary care physician was working with a patient on a self-management problem like difficulty sleeping or weight loss and was getting nowhere, I wouldn't fault her for going to the Facebook site as long as she was prepared to tell the patient about it, as in:

I've been troubled about why we're not making any progress in what we're working on - I just don't get it. So instead of running more tests I went onto your Facebook site. I think I can see what our problem is...

But what about a psychotherapist doing the same thing? Here I think the younger colleagues are missing the boat. Psychotherapy isn't just a matter of gathering information as part of the effort to solve a problem. The relationship itself is at the heart of the effort. The commitment on both sides is to use the experience of the relationship on behalf of the treatment goals. It wouldn't be surprising for the patient to see if the therapist has a Facebook site, but it would be important for the patient to bring the fact of the search into the therapy. What did the patient's curiosity focus on? What did what he found mean to him? What feelings were associated with the process?

If the therapist and patient were talking about the patient's self-presentation on Facebook it would be fine for the therapist to say - "would it be OK for us to look at it together right now?" That would lead to collaborative inquiry. But it wouldn't be OK for the therapist to go to the site covertly. What was the therapist looking for? Why didn't he bring up whatever the question was with the patient? If the therapist has a question he should ask it. If he goes to Facebook instead it suggests that he feels an impediment to direct work with his patient. That's what's key - not the information on the Facebook site.

Wendell Potter on For-Profit Health Insurance

Wendell Potter, who retired last April from his job as head of communications for the CIGNA health insurance company, has been in the news since then as a whistle-blowing critic of the insurance industry. Today I belatedly read his June 24 testimony to the U.S. Senate Committee on Commerce, Science and Transportation (see here) watched his July 10 interview with Bill Moyers (see here).

Potter is especially clear about the way short term considerations drive the behavior of for-profit insurers:

The top priority of for-profit companies is to drive up the value of their stock. Stocks fluctuate based on companies’ quarterly reports, which are discussed every three months in conference calls with investors and analysts. On these calls, Wall Street investors and analysts look for two key figures: earnings per share and the "medical-loss" ratio - the ratio between what the company actually pays out in claims and what it has left over to cover sales, marketing, underwriting and other administrative expenses and, of course, profits.

To win the favor of powerful analysts, for-profit insurers must prove that they made more money during the previous quarter than a year earlier and that the portion of the premium going to medical costs is falling. Even very profitable companies can see sharp declines in stock prices moments after admitting they’ve failed to trim medical costs. I have seen an insurer’s stock price fall 20 percent or more in a single day after executives disclosed that the company had to spend a slightly higher percentage of premiums on medical claims during the quarter than it did during a previous period. The smoking gun was the company’s first-quarter medical loss ratio, which had increased from 77.9% to 79.4% a year later. (slightly edited)

The problem with investor ownership and for-profit insurance isn't the people. Over the years I've studied a number of for-profit companies. The people I dealt with and observed seemed just as caring and idealistic as their counterparts in the not-for-profit world.

And the problem isn't profit per se. Although in most of my years of clinical practice I was paid as a salaried member of a not-for-profit group, I did ten years of fee-for-service practice. As a solo psychiatrist I typed my own bills and gave them to my patients each month. They brought a check to a subsequent appointment and handed it to me. This ritual made it crystal clear that I was running a for-profit enterprise, albeit a tiny one.

I was entirely comfortable with the ethics of my for-profit practice. I set my fees and could lower them if I chose to do so. When discussing fees I said "the aim is to make an arrangement that is fair to both of us." The owner of the enterprise (me) and the investor/purchaser (my patient) could look each other in the eye. Parsing what mutual fairness entailed was often part of the therapeutic process.

Public companies are large, impersonal structures. In particular, the equity owners are investors guided by economic rather than caretaking values. They're not challenged by looking the patient directly in the eye and having to see and take responsibility for the impact of corporate decisions.

I run the ethics program at a not-for-profit health insurance company. Like all other participants in the U.S. system we're subject to market pressures for efficiency. I think that's a useful pressure, just as the pressure to make treatment affordable for my fee-for-service patients was. But we're not subject to quarterly conferences with investors whose only concern is with financial performance.

If you look at the video you'll see that Potter looks "corporate" and speaks calmly. His clear discussion of the structural impact of equity ownership on the health system is a valuable contribution. I hope we hear reverberations of his analysis in President Obama's speech tomorrow night!

Immigrant Health and Heart Transplants

I'm still jet lagged from 2 1/2 weeks in Europe, so when I woke up in the dark this morning I sought out the online New York Times for solace. Two articles yielded a larger story about health reform.

Eric De La Cruz was a student and part time disc jockey and graphic designer in Las Vegas in his early 20s when the symptoms of progressive cardiomyopathy - weakness of the heart muscle - began to cause symptoms of heart failure. The condition steadily got worse, and it became clear that the only hope for Eric would be a heart transplant. But neither of his employers provided health insurance. And, surprisingly, when he applied for Social Security disability benefits, which would have made him eligible for Medicare, he was turned down.

Eric did qualify for Medicaid, but in Nevada Medicaid covers heart transplants only up to age 20. At this point his sister began a Twitter-based effort to raise money, and within two weeks $1 million had been offered! Eric went to the University of Southern California for evaluation, but his condition was too far advanced, and he died on July 4.

The second article was from Massachusetts. The recession-driven shortfall in revenues and the requirement that the state stay within its budget necessitated cutbacks in the state's health reform program. (The program has led to the lowest uninsured rate in the U.S. - 2.6% compared to a national average of 15%.) The legislature decided to cut most of the $130 million dedicated to 31,000 legal immigrants. But by scrounging up some additional funding and developing a stripped down set of benefits, a relatively comprehensive insurance package will still be available to the legal immigrant group. It won't cover dental, hospice, or skilled nursing care, and will require higher copayments for non-generic drugs, but it would have covered a heart transplant for someone with Eric Cruz's condition.

After his death, Eric's sister Veronica De La Cruz said:

If my brother had been able to buy health insurance, he would never have been in this situation. No one should ever have to go through what we’ve been through. Eric should still be alive.

Veronica is half right. In a wealthy country like the U.S., a healthy young person like Eric should be eligible for a heart transplant. A heart might not be available, but that would be a tragedy, not an injustice.

Ben Kieckhefer, a spokesman for the Nevada Department of Health and Human Services, described the the state's policy clearly and honestly:

All insurance plans decide what things they are going to cover and what things they are not going to cover. Everyone in the state Medicaid program recognized the difficult situation the family was in, but we can’t just start covering something for one individual case.

Unless there is some form of universal or near-universal coverage, as through a single payer system or a requirement that individuals purchase insurance (as in Massachusetts) Eric would not - and should not - have been able to buy insurance. If we allow ourselves to wait until a need appears before we get insured, free-riding would be the rational choice for the individual to make, and insurance costs would be stratospheric in no time.

Affordable insurance depends on social solidarity, with the healthy contributing more than they receive and the sick receiving more than they contribute. In the U.S., however, talking about "solidarity" invokes fear of the other dreaded "S" word - "socialism."

And as the stories from Massachusetts and Nevada show, viable insurance also entails the equally dreaded "R" word - "rationing." Health systems must set limits. A society (like the U.S.) that refuses to ration in a thoughtful, ethically-guided manner, will (like the U.S.) end up rationing in a thoughtless, unethical manner. Whether a society prefers to limit high cost/high tech interventions as Nevada has done, or more mundane but nevertheless valuable services as Massachusetts chose to do, is the kind of policy decision that requires thoughtful democratic deliberation. Sadly, thoughtful deliberation is currently being drowned out by strident advocacy, pervasive misunderstanding, and lies.

(To read more about Eric De La Cruz see here. For the Massachusetts story, see here.)

Outing the Rorschach Inkblots (2)

A few weeks ago I wrote about the controversy surrounding the publication in Wikipedia of the ten Rorschach inkblots accompanied by the most common responses. (See the original post here.) Now two psychologists have filed complaints with the Saskatchewan Medical Society against Dr. James Heilman, the emergency room physician who posted the images.

Here's the gist of the complaints (see here for more details):

One of them, Andrea Kowaz of the College of Psychologists of British Columbia, complained that by including the inkblots on Wikipedia, Dr. Heilman was violating the test’s secrecy and that if he were a psychologist his behavior would be “viewed as serious misconduct.”

The other letter, from Laurene J. Wilson, a psychologist at Royal University Hospital in Saskatoon, echoed the concern about the test’s security but added that Dr. Heilman “shows disrespect to his professional colleagues in psychology and disparages them in the eyes of the public.”

Dr. Wilson said she had read interviews with Dr. Heilman in which he “refers to psychologists as undertaking practices akin to a magic show with smoke and mirrors.”

I side with Dr. Heilman.

Dr. Kowar accuses Dr. Heilman of "violating the test's secrecy." But the test is just a series of inkblots and an interpretive system. Secrecy is a commitment psychologists make about the test and an aspiration they hold for it. The commitment is a piece of professional self-regulation and isn't binding on others. And a visit to Amazon will show that the secrecy cat is long since out of the bag. All the major texts on Rorschach interpretation are readily available. The idea that the images and the theories about how to interpret responses are secret is a naive fantasy, and the claim that a professional society's code of ethics applies to people outside of the profession is muddled thinking.

Dr. Wilson raises a more vexing question - what do professionals owe to each other in terms of public respect or disrespect? Putting aside the fact that psychology and medicine are different professions, professional etiquette has long demanded that physicians speak of each other respectfully in public. At best this expectation avoids undermining patient respect for doctors who deserve to be respected. At worst it protects colleagues from justified criticism and prevents action to protect patients from harm.

I don't agree that competent psychologists are conducting "practices akin to a magic show with smoke and mirrors" any more than I see emergency room doctors as butchers, even though some psychologists are presumably smoke and mirror charlatans and some ER doctors are probably dangerous butchers. If Dr. Heilman spoke this way and I were part of the Saskatchewan Medical Society I would point out that public trust is crucial for the health professions. He should be free to make reasoned and evidence-based critiques of medical (including psychological) practices, but name calling is demeaning to him as well as to those the names are aimed at. Respectful debate can improve practice and will enhance public trust that the health professions are doing their best to get things right. Name calling does nothing for quality and makes professionals look like children squabbling in a sandbox.

This, however, does not rise to the level of being an ethical violation. I'll be surprised if the Saskatchewan Medical Society concludes otherwise. The Society usually responds within 60 days, so stay tuned!

Outing the Rorschach Inkblots

There's been a free-for-all at Wikipedia over the publication of Herman Rorschach's famous inkblots.

When the article initially reproduced one of the ten images controversy began to bubble, with psychologists describing the action as an irresponsible threat to the integrity of the test itself. At this point Dr. James Heilman, an emergency room physician at Moose Jaw Union Hospital in Saskatchewan posted all ten, along with the most common interpretations printed underneath each.

I spent several hours today reading the fascinating and often vitriolic exchange on the Wikipedia talk page. It's a tectonic encounter between two cultures - the let-it-all-hang-out openness of the web banging against a concept of professionalism as a self-regulating societal resource. So far they're largely talking at each other, but the argument they're having could provide the basis for an excellent ethics class.

Sometimes the Wiki folks get hot under the collar ("only fascists withhold data") but the basic thrust and strongest argument echoes John Milton's Aeropagitica:

I cannot praise a fugitive and cloistered virtue, unexercised and unbreathed, that never sallies out and sees her adversary, but slinks out of the race where that immortal garland is to be run for, not without dust and heat.

The Wiki perspective is that people have the right to know about as important a cultural phenomenon as the Rorschach test and to think about it for themselves.

The psychologists in the discussion are on strongest ground when they argue that (a) publishing the Rorschach images accompanied by (b) the commonest responses could (c) undermine the validity and usefulness of a test that (d) contributes to psychiatric treatment, court proceedings, and other socially important activities.

The discussion contains a lot of back and forth about the validity of the test itself. Some of the Wiki folks argue, in effect, "the test is worthless, so what's the problem with publishing the images and interpretations?" The psychologists respond by citing research studies they see as showing the value of the Rorschach test. But this pi - - - ng contest isn't the important part of the debate.

I'm not an expert on psychological testing, but in my practice I had enough occasion to see the results of testing of my patients to believe that in skillful hands the Rorschach has a real contribution to make. And I understand the psychologists' concern that the Wikipedia article can lead to gaming of the test by people who want to appear sicker than they are to avoid legal prosecution or healthier than they are to get out of a hospital and, at worst, commit suicide.

But even if the psychologists are right, and the publication of the images along with modal responses weakens the test, we're in a radically different world than when Herman Rorschach published "Psychodiagnostik" in 1921. There's simply no way of keeping knowledge about how the test is interpreted secret from the public. As one of the Wiki folks said - "the horse is not only out of the barn - it is in the freaking next country..." I don't think that's a bad thing - certainly not for society, and even for psychological testing itself.

Hypnosis started as an authoritarian stage technique ("you are in my power...!"), but by the time I first studied it in the early 1970s it had evolved into a highly collaborative "permissive" format, in which therapist and patient designed the approach together. (See here for a discussion of the ethics of hypnosis.) If the publication of the inkblots has any of the impact the psychologists fear I expect that they will develop new ways of giving and interpreting the test, as by talking with the person being tested about what they know about the test and encouraging them to put aside what they've read and heard to use the inkblots for a constructive purpose.

It may be easier to game the test than in the past, but Wikipedia didn't create this risk. If I were coming to court and knew I would be examined by a prosecution psychologist it wouldn't take me long to thumb through the Yellow Pages for psychologists to help me case the tests I'd be confronted with. Psychological testing will have to evolve on the basis of more collaboration and openness than has been true in the past, just as hypnosis had to evolve from an authoritarian to a permissive format.

With the publication of the Rorschach materials, psychologists are experiencing what other health professionals have already encountered - the "empowered" patient, and a skeptical public. Adapting to these changes isn't easy for professionals, but I think doing so is respectful of our patients and ultimately makes us more effective in our mission. But even if I'm wrong about this, as the Wiki participant said, the horse is in the freaking next country, so we don't have much choice!

Patient Access to the Doctor's Notes

With funding from the Robert Wood Johnson Foundation, the Beth Israel Deaconess Hospital in Boston is starting an "open notes" study, in which the patients of 100 physicians will be able to read their doctor's notes on line. I read about the study in an excellent article in today's Boston Globe. Here's the essence of the article:

Researchers hope to learn whether the notes prove more useful than objectionable. They hypothesize that access to doctors’ notes will improve care partly because patients will become more knowledgeable about their treatment and about their doctors’ instructions.

Studies show that “patients remember precious little about what happens in the doctor’s office,’’ said Dr. Tom Delbanco, a Beth Israel Deaconess internist and a co-investigator.

The Robert Wood Johnson Foundation gave Delbanco and his colleagues $1.5 million for the project because doctors have “strong differences of opinion about this. But there is almost a religious character to the debate. It’s uninformed by evidence,’’ said Stephen Downs, an assistant vice president at the foundation. It will be the largest study yet on the issue, he said.

I think it's a great idea!

For the last 10 years of my psychiatric practice at Harvard Vanguard Medical Associates I wrote my own notes directly into an electronic medical record. Although I'd been taught as a resident not to make notes while with the patient, I'd found that waiting until after the appointment or the end of the day resulted in more meager notes. Luckily I'd learned to touch type in middle school, and was able to keep the keyboard on my lap and maintain eye contact while I typed.

But from residency itself I always wrote my notes with the assumption that the patient would read them. The discipline this imposed was useful. As an example, it helped me in relating to people with paranoia. I didn't write "Mr. Jones is paranoid and delusional," but rather "Mr. Jones believes extra-terrestrials have implanted a chip in his brain. He understands that I do not share this view. We discussed why I believe taking anti-psychotic medication would help him in his life..."

I found that people with paranoia appreciated that I recognized the possibility that (in this example) extra-terrestrials might be causing mischief, but that I found this extremely unlikely. We could frame using medication as a hypothesis - "whether or not there is a chip in your brain, I believe that you will sleep better and be less afraid after a few weeks..." rather than as the equivalent of "you're crazy and I'm sane so you should do what I say..."

Writing notes with the patient in the office allowed for discussion of what should be said. With someone I'll call Mr. Jones, it had taken quite a bit of time to elicit a clear picture of how much alcohol he used and how alcohol might be affecting his mood and his physical health. I explained why I thought it was important for his primary care physician to know about his alcohol use. We sat together in front of the terminal to compose my note. Mr. Jones baulked at the word "alcoholism," but accepted "alcohol problem." This wasn't just a piece of collaborative writing and editing - it was an integral part of the treatment process.

Open notes create a different set of problems for primary care physicians than for psychiatrists. PCPs do much more recording of findings and documentation of potential differential diagnoses. PCPs are appropriately concerned with how best to write about the numerous "rule outs" that must be thought about for symptoms that are almost certainly benign. But the challenge of how to write about uncertainties and improbable possibilities may ultimately help the medical profession deal better with uncertainty. In my own care I'd much prefer to read "I believe this headache comes from tension and does not reflect any other underlying cause - I asked him to call me next week if the symptoms persist - we could consider further testing then," rather than "to rule out a brain tumor I have referred him for a CT scan..." In this way open notes might help reduce the defensive medicine and overuse of resources that are so rampant in medical practice today.

This is a research project very worth following. Hats off to the Robert Wood Johnson Foundation for recognizing the potential value in a disciplined study of the domain!

Seeing the Hippocratic Oath in a New Light

I've always had trouble with the second paragraph of the Hippocratic Oath:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

It's not the exclusively male focus of the oath that bothers me - there's been an opportunity for change in the 2500 years since the oath was written! What turned me off was interpreting the paragraph as a promise to protect our guild. Guild protectionism is the worst aspect of the AMA and medical specialty societies.

But last night I came to a different view. I attended the graduation of the residency in Primary Care and Population Health, sponsored by the Brigham & Women's Hospital and Harvard Vanguard Medical Associates, a program I teach in. If you're interested you can read about the program here. (If you go to the website, I'm in the blue shirt, third from the left.)

The graduation was a love-in. The four graduating residents received their diplomas from the outpatient preceptors they had worked with for three years. The preceptor described the resident. The resident described the preceptor. They hugged. Then the graduating residents said something about each of the juniors and interns, and the juniors spoke about the graduates. Most of the comments included funny stories, but the essence was talk about the qualities of the individual being discussed as a caring, committed physician.

I've thought a lot about the concept of "medical calling" and where - in secular settings - the calling comes from. (See here for a previous post on the topic.) What the graduation brought home for me is how much the calling that physicians profess is based in mutual affirmation within a group. The ceremony, with its repeated emphasis on clinical excellence, rapport, empathy and care was like a prayer service, in which fundamental values were affirmed again and again.

Those who come to health care from a religious faith perspective can explain their sense of calling in terms of their religious beliefs. But the experience of calling can be just as strong in an atheist. Some of the force comes from each person's psychology - whatever in their development and their genetics sparks devotion and caring. The graduation ceremony brought home to me just how much group solidarity around these shared values contributes to the sense of calling. It's not each person alone - it's "us."

I see Hippocrates' second paragraph differently now. It's about cultivating a family of caretakers, not about guild protectionism.

Responding to Medical Mistakes in India

For anyone interested in (a) India and (b) medical ethics, (c) the Indian Journal of Medical Ethics (IJME), which is available online, is the key resource.

During my recent stay in Mumbai (I'm in Bhopal now) I met with Sandhya Srinivasan, the executive editor. I learned that IJME was born out of activism. In 1992 a group of reform-minded physicians contested the Maharashtra state medical council election on a platform of "ethical medical practice." The slate lost badly. But the reformers created a newsletter for discussion of ethical issues and promotion of ethical practice. Over time the newsletter became the IJME.

I am especially interested in how the interplay of modernization and tradition in Indian medicine affects ethical norms. By U.S. standards Indian physicians are on a pedestal. I was told that many of the poor see the doctor as "a God on earth." But at the same time western values embodied in concepts like informed consent, physician-patient collaboration, and open acknowledgment of medical mistakes are increasingly part of public discourse.

What happens when "physician as God on earth" meets "physician as collaborator"? The most recent issue of IJME provides a window onto this question.

Dr. Ashok Sinha, a private practitioner in Agartala, the capital of Tripura (a small northeastern state bordering on Bangladesh) discusses - in thoughtful and personal terms - how to respond to poor practice on the part of colleagues. Here are the first two paragraphs of his engaging commentary:

"One of the major ethical issues that I face very often in my practice is whether to criticise my colleagues or not. Complaints, criticism and condemnation lead to terrible consequences and never help anyone, they say. I am told that my colleagues are to be treated like my siblings and I should never criticise them in front of patients.

That seems logical enough. We may or may not agree with a particular diagnosis offered by fellow physicians, and it is not necessary that either of us would be right every time. But to criticise him or her in front of the patient would degrade the whole medical community. Even the patient would be in doubt about whom to trust. Moreover, very often this criticism is fuelled by competitive one-upmanship. Rather than bettering our performance to get ahead, we used the tactic of putting the other fellow down..."

Dr. Sinha reports that "sometimes I spoke out and made myself unpopular, and sometimes I did not, and hated myself for it." But his dominant ethical perspective is that "while we must have loyalty to the profession and the medical community, what about loyalty to patients?"

Dr. Sinha's discussion is followed by two commentaries. Ann Sommerville, head of ethics at the British Medical Association, argues that "in case individual integrity is not enough, doctors also have a duty to take action if they witness evidence of colleagues failing...lessons should be learned, future errors avoided and natural justice dispensed to patients who have been inadvertently harmed." Prabha Chandra, Professor of Psychiatry at the National Institute of Mental Health and Neuro Sciences in Bangalore, concurs. His emphasis, however, is on the need for a practical learning curve regarding how to talk with physicians and patients about mistakes.

The trio of articles strike me as precisely on target. The broad values of honesty with patients and professional responsibility for assessment of practice and self-regulation, do not appear to be culture-bound or limited in their relevance to the west. But values require practical implementation. There is currently very little teaching of medical ethics at medical schools in India, and professional societies do not have strong traditions of self-regulation. I expect the medical community to endorse Dr. Sinha's framework of values, but as Dr. Chandra points out, there is substantial research and skill-development to be done to put that framework into action.

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!

Straight Talk About Rationing in the British National Health Service

We Yanks can only gasp with admiration at the candor of National Health Service leadership and the British media on the resource allocation practice that dare not speak its name in the U.S. - rationing.

Two recent articles in The Independent (here and here) describe at length how UK patient advocacy groups have blasted NICE (National Institute for Health and Clinical Excellence) for refusing to cover certain expensive pharmaceuticals.

"Rationing" is a dirty word in U.S. public discourse. Sadly, almost all U.S. political leaders (with the exception of former Oregon Governor John Kitzhaber) speak of rationing as a moral crime, only contemplated by "uncaring bureaucrats" or "greedy insurance companies." In The Independent, journalist Jeremy Laurance describes rationing more accurately as an ethical imperative:

"NICE is a rationing body, established in 1999 to ensure the cash-limited NHS gets best value for money from the profit-driven pharmaceutical industry. It aims to establish not only whether a drug is effective, but whether it is more effective than existing drugs and, if so, whether it is worth the extra price (£1,000 spent on a cancer drug means £1,000 less for nursing care for cancer patients).

NICE is merely a mechanism for sharing out a limited budget. The real argument should be between the people (who want the drugs), the pharmaceutical companies (who set the prices) and the Government (who fixes the NHS budget)."

The Independent articles go further. The ostensibly grassroots patient advocacy groups that have blasted NICE receive substantial support from the pharmaceutical industry. For example, the National Kidney Federation, which called NICE's turning down four kidney cancer drugs "barbaric, damaging and unacceptable," receives half of its budget from industry. Here's what Laurance has to say about conflict of interest for the advocacy groups:

"The extent of the drug companies' support for the smaller charities has led to criticisms that supposedly grassroots patient organisations are puppets of the pharmaceutical industry, being used to bludgeon NICE into making the drugs available on the health service. A positive decision by NICE on a drug not only guarantees sales to the NHS but can influence global markets worth billions of pounds.

Yet none of the charities named has criticised the high prices charged by the pharmaceutical companies for their products in their recent campaigns.

Timothy Statham [chief executive of the National Kidney Federation] said 'We receive sponsorship from as many of the renal industries as we can possibly sign up. We take the view that by having all the pharma and machine-maker companies on board, we cannot be subjected to overbearing influence by any one of them.'

That leaves unanswered the question of whether accepting funding from any company compromises a group's ability to question the behaviour of the industry as a whole. The way in which NICE is pilloried by patient groups, while the drug companies are ignored, suggests a reluctance to bite the hand that feeds them."

The Independentcited an August interview with Sir Michael Rawlins, chairman of NICE. Rawlins and his agency are accustomed to attack. Their government sanctioned role is to make evidence-based tough decisions. Perhaps the Kidney Federation's term "barbaric" got his goat. His response was polite, but clear: "We are told we are being mean all the time, but what nobody mentions is why the drugs are so expensive...We have a finite amount of money for healthcare, and if you spend money one way you can't spend it in another."

Transparency and candor don't make painful decisions any less painful. But the U.S. should take pages from the British book. If we can't talk honestly about resource limits and rationing we will continue our spiral of out of control costs, massive numbers of uninsured citizens, and mediocre health indices.

Let's hope that the recent meltdown of the financial sector will help us in the U.S. move out of La-La Land into the real world in our approach to health and health care.

Business Ethics and Comparative Effectiveness in Health Care

Although no one designing a health system from scratch would create the hodge podge of employer-based insurance and thousands of insurance companies we have in the U.S., that's what we've got.

Two weeks ago, in a posting about the Hanniford supermarket chain, I expressed the hope that self-insured employers would become crucial learning laboratories about resource allocation and comparative effectiveness for the U.S. health system. This week news from two large Wyoming coal mines convinces me that this hope isn't a pipe dream.

Foundation Coal and Peabody Energy have been shopping for specialty care for their employees, making use of comparative effectiveness information. Here's a story from Foundation:

"Ken Ferguson, 54, maintains the bulldozers and heavy trucks that haul coal at the Belle Ayr mine near Gillette, Wyoming. In return, his employer, Foundation Coal Holdings Inc., provides his family with the best medical care it can buy.

Ferguson's wife, Shanna, had her colon removed last year because of chronic inflammatory disease. Foundation sent her 700 miles away to the top-ranked Mayo Clinic in Rochester, Minnesota. The company covered the $85,000 bill for the operation and follow-up reconstructive surgery and even paid for Ken's motel.

`I was at the best place with the best doctors possible,' said Shanna, 50. `And we saved money.'

So did Foundation...`Would we have saved money if Shanna did the operation locally? Maybe,' said David Crowder, a retired surgeon hired by Foundation and Peabody to cut health costs. `But would the operation have gone as well? Unlikely. It's costs down the road you have to look at.' "

Crowder used HealthGrades, a Colorado-based company that provides information on hospital quality and cost, to advise Foundation and Peabody.

What strikes me is the synergy between individual and company interests here. Ken and Shanna are happy with the care Shanna got, and the fact that (a) they saved money, and (b) Ken's employer did too. The mining company is a microcosm of wider society. Individuals want to be as healthy as possible, and society wants its members to thrive and not to go broke supporting this aim.

When health plans tried to manage care in the 1990s they were shot down for intruding on patient choice and physician autonomy. The fact that the best health plans were doing this on behalf of individuals and employers, and that better quality at lower cost served all stakeholders got overlooked in the frenzy of criticism.

For the U.S. to get a grip on its over-costing under-performing health system we need to accomplish two things. First, we need to think of our health system in terms of both numerator (individual needs and wishes) and denominator (population needs and wishes). Second, in seeking the best balance of individual and population interests, we need to use information on comparative effectiveness - both quality and cost.

We're nowhere near doing that yet in private insurance or our large public programs. But self-insured companies are moving in that direction. Each company is small, but the lessons we can learn from Hanniford, Foundation and Peabody are large. And lessons coming from the business sector, rather than the ivory tower of arcane health policy, will be listened to.

Henry Paulson and Health System Trust

The national debate about Secretary Paulson's bailout proposal offers some lessons for the health system. Here are three that jump out for me:

1. Trust in our institutions is supremely important. Economists tell us that the market is crashing not because of an intrinsically fatal illness but because investors have lost trust.

2. Whatever the merits of Secretary Paulson's $700 billion bailout proposal might be, the widespread loss of trust in the administration he is part of undermines the persuasiveness of the policy he recommends. As one of many examples, from today's New York Times:

"[Senator] Durbin, in a speech on the Senate floor, angrily recalled that the administration had similarly requested swift approval of its plan to attack Iraq. 'Just as we should have asked more questions about weapons of mass destruction six years ago before we found ourselves in this war,' Mr. Durbin said, 'we need to ask questions today about where this is leading.'"

We know that treatments are better adhered to when patients trust their physicians, and that trust adds to a medication's therapeutic impact. In psychiatry there is an old concept of "institutional transference" - when patients trust the institution where they receive their treatment, everything goes better.

Those of us in health care who work with organizations - and that's most of us now - are enhanced (and made more effective) or diminished (and made less effective) by the conduct of our colleagues and our organizations. I believe that Secretary Paulson is acting in good faith, but he is significantly less effective and persuasive than he might be because of the disgraceful behavior of the administration he is part of in the run-up to the Iraq war.

3. The reaction to Secretary Paulson's proposal tells us something about executive compensation. Even if the argument that the stratospheric compensation investment bankers receive (a) is needed to attract the best brains and (b) produces more value for investors and society, (c) that argument cannot be extended to health care. Those who make use of health institutions - hospitals, insurance, and even individual medical practices - experience those institutions as tainted by greed when they learn of the enormous bonuses executives receive. We want to see health care as a calling, not a cash cow. The economic argument about how markets set compensation fails to recognize the degree to which our institutions are more than market entities - they are organizations that must embody, in their own way, the virtues of a calling.

Should Health Insurance Cover Services for Autism - an Ethical Analysis

A whole course in health system ethics could be built around the issues raised by an article in yesterday's Boston Globe about insurance coverage for autism services. I've taken four slightly altered snippets from the article and followed them with comments (in italics):

1. "The nation's largest autism advocacy group, Autism Speaks, is planning a legislative push in 20 states, including Massachusetts, to require private insurance companies to pay a portion of the intensive, expensive educational treatments that many medical professionals say are a child's best chance to overcome, or just learn to cope with, profound and lifelong developmental and learning disabilities."

In a democratic society advocacy groups like Autism Speaks play the crucial role of organizing and amplifying individual interests into a voice that can be heard in the political arena. The fact that the services being requested are expensive will cause headaches for program managers, but autism is a serious impairment, and advocates can make a legitimate claim that a just society will not make access to services contingent on the wealth of the individual family. But it isn't yet clear whether society's obligation belongs in the health sector.

2. "'If my son couldn't hear and needed a cochlear implant, we wouldn't be asking the school system to take responsibility,' said Jack's mother, Judith, coordinator of the New England lobbying effort for Autism Speaks. 'As a society, we have to acknowledge that autism crosses a line from an educational issue to a medical one. Jack was diagnosed by a neurologist, not a schoolteacher.' [Another parent added] 'we are talking about medical treatments prescribed by medical doctors, and covering them like any other medical treatments.'"

This argument is rhetorically powerful, but flawed. The fact that a physician makes the diagnosis doesn't tell us what social sector should be responsible for responding to the need. A physician may correctly diagnose arthritis and prescribe exercise in a warm swimming pool. The exercise may help tremendously, but that doesn't mean that health insurance must provide the pool or pay for access.

3. "But private insurers are balking at the proposed requirement, especially coverage of applied behavior analysis programs, which involve a weekly regimen of more than 30 hours of intense, often one-to-one, positive reinforcement techniques for teaching children how to speak, play, learn, and function in the world. They say applied behavior analysis programs are relatively new and unproven, and not effective for all children. ABA teachers are not licensed in many states, and insurers contend that the therapy system is still too new to be regulated sufficiently...But parents of autistic children are determined to get their youngsters into programs that offer even a glimmer of hope."

If I had an autistic child I too would want any service that offered a glimmer of hope. But societies must set standards for how strong the evidence for that glimmer is. The judgment requires empirical analysis - what do we know about the effectiveness of the intervention? But the judgment also involves value judgments - how strong must the evidence be? how much benefit must the intervention offer?

But if what the article cites is all insurers are saying, it is just a matter of time until some form of behavioral education comes under health insurance, since there will almost certainly be techniques that will be shown to provide benefit. I want to see children with autism have access to effective rehabilitative services, but I'm not at all convinced that the service belong in the health sector, as opposed to the education sector.

4. "Requiring insurers to pay for educating autistic children would 'drive up costs for everyone, said Dr. Marylou Buyse, president of the Massachusetts Association of Health Plans...Paul Andrews, director of government services for the Massachusetts Association of School Superintendents [said] 'Special-needs costs have escalated so high that it has reduced the amount of funding we can spend on regular education.'"

These comments show something fundamental about the health sector. There is no budget! If we add autism services, costs go up. But unlike health, the school system has a budget. If we add autism services, something has to come out. Some people argue that health is "priceless" and costs should not be considered. But that view is misguided ethics and faulty facts. Health is tremendously valuable. But it's not the only value. And we know that for every 1% increase in health care costs (the impact advocates say providing autism services would have) 150,000 people lose their health insurance. Legislators who vote to mandate new coverage that will "only" increase costs by 1% should recognize that while they are providing benefit for one group through the mandate, they are harming another group, who will be pushed out of the insurance system.

Autism advocates are smart to push for coverage under health insurance, since unlike education, the health sector currently has no explicit budget, so the cost of adding new expenditures is hidden, as in the form of an ever increasing population without insurance. At some point we will have to wise up and set budget limits for health care, the way we do for every other sector of society. At that point advocates, whether for autism or a new cancer treatment, will have to argue that their services are of such value that they should take funds away from other services. Arguments of this kind are volatile and painful, but we will have to have them.

My guess is that behavioral treatments will ultimately be shown to produce significant improvements for children with autism. I certainly hope so. In terms of managing our societal resources, I think these interventions should be part of the education sector. I'll be prepared to support increased taxes for education if that's what it comes to.

Medical Tourism and Medical Ethics - At Home and Abroad

I'm a clinician and an academic. For insights into medical ethics, health policy and the health system, I typically turn to case reports and research studies, not to the source of this posting - supermarkets!

Hannaford is a 125 year old supermarket chain, with 27,000 employees ("associates") and 164 stores in the northeast. Since 2000 Hannaford has been part of the Dehaize Group, a 141 year old Brussels-based food retailing company with 2,700 stores in 7 countries (Belgium, Germany, Greece, Indonesia, Luxembourg, Romania, and the United States).

Like many large companies in the U.S., Hannaford is self-insured for its health insurance. (For non-U.S. readers - "self-insured" companies pay for the health care costs of their insured employees themselves, and hire insurance companies to handle typical insurance functions like paying claims. It is usually cheaper for the company to provide health insurance this way.)

Hannaford made the news in January by offering incentives to its employees to have procedures like hip and knee replacement done in Singapore, which delivers comparable quality at a significantly lower cost. Peter Hayes, director of health benefits at Hannaford, reported that "after the announcement, I got calls from several U.S. hospitals offering to match Singapore on pricing." Now Hannaford offers the same incentives to employees who travel to U.S. hospitals that meet quality standards at a price that is competitive with Singapore.

Anyone at all knowledgeable about health policy knows that the U.S. incurs sky-high costs but provides mediocre quality. Until self-insured companies began to act on this information by encouraging employees to seek care abroad, the national reaction has been nil. Self-insured companies like Hannaford are familiar with outsourcing business functions that can be done more cheaply elsewhere, so outsourcing medical care wasn't a far out idea for them. Now hospitals around the U.S. are noticing the loss of business and are taking price competition seriously.

One reason the U.S. health system is in such a mess is fragmentation. The population is divided into hundreds of thousands of employer groups, unions, etc., the cost of whose care is covered by thousands of different insurers. We think more and more in individual terms. The way the system is organized makes it hard to get the big picture. Unlike virtually every other developed country, no one takes overall responsibility for population health.

This is what makes Hannaford so interesting. The parent company is based in Belgium. According to Hayes:

"Hannaford's new coverage policy was prompted by stinging criticism from its European owners. For them, medical costs and outcomes in the United States just don't add up. [They said] look at what they're spending in the United States. It's two or three times what they're spending in any other industrialized country. But if you look at quality, [the U.S.] is ranked dead last. So the Europeans said, 'why is health care going up at this extraordinary rate in the United States?'"

I've come around to the view that our employer-based health system, which is so dysfunctional in so many ways, may be the most promising source of learning and reform. Employees are part of a community - the company they work for - and are in a better position to understand the cost and quality of their health care and the impact of cost on wages and corporate success. We in the U.S. have fought tooth and nail against facing the need to make trade offs in health care. But employees can understand that higher costs trade off against lower wages and possibly even loss of a job. And they can see the implications of having joint replacements at their local tertiary hospital or, assuming comparable quality, at lower cost in Singapore.

I don't think anyone designing a health system from scratch would create the hodge podge of employer-based insurance and thousands of insurance companies we have in the U.S. But as of 2008 that's what we've got. If we wait for reform to come from the top down we may still be waiting when Godot finally arrives. But as more self-insured companies enagage seriously with health system dynamics, we may see important learning emerging from the ground up.

Oregon Moves Ahead with Health Care Reform

On September 3 the Oregon Health Fund Board (OHFB) posted a draft of its health care reform proposal - "Aim High: Building a Healthy Oregon." The OHFB will receive comments at a series of public meetings around the state and through written submissions during the month. It will then revise the draft into a final report to Governor Kulongoski and the legislature.

I won't try to summarize the very readable 78 page report. But if the legislature enacts the major recommendations, Oregon will again be in the forefront of health policy and health care reform.

Here are five of my initial observations about the proposal:

1. The proposal is ambitious, and recognizes that tinkering with the current system will accomplish nothing. Although it is replete with practical action steps, the proposal envisions "educative leadership" as a crucial necessity -"Your Board, on behalf of all Oregonians, believes that in order to address [the failings of the current system], we must transform our thinking about health care." In former governor John Kitzhaber, Oregon has a model of what "educative leadership" can mean.

2. The central paradigm in current U.S. health policy is competition and consumerism. Our thinking about health care is atomistic, focused on individuals making choices about treatment and benefit plans, with providers competing with each other to sell themselves. The Oregon proposal focuses on improving the health of the entire population, and emphasizes collaboration more than competition, as in its concept of "learning collaboratives":

Sharing by those doing the delivery of care with each other is a key tool to improve the delivery of care. Improvement efforts are at the core of collaborating with those doing similar types of work to understand how to look at systems of clinical settings and improve the quality and efficiency of each step...Learning collaboratives allow healthcare providers and their clinical staffs to share information about quality improvement and best practices."

3. The proposal retains private insurance, but it envisions a strong role for state government, largely through its proposal for an Oregon Health Authority. The overarching strategy for the Authority "...is for the state - in partnership with communities - to act as a smart purchaser, an integrator of health care and community services, and an instigator of community-based innovation." Whereas Medicare Part D forbids Medicare from using its purchasing power to bargain over prices, the Oregon proposal would have the Oregon Health Plan (Medicaid) and the public employees plan, which together would represent 1,000,000 people, more than 1/4 of the state population, use the leverage prohibited to Medicare.

4. Oregon received world-wide attention for its use of a prioritized list of health services to conduct an open, explicit rationing process. The proposal envisions using the prioritized list, but rather than bifurcating its benefits into covered/uncovered, it would institute a system of value based benefit design. Services that provide substantial benefit would be covered in full. Services less well supported by evidence or more optional in nature, would require progressively more cost sharing. All this would be put onto a graded basis in accord with individual income level.

5. The states are clearly where the current action is in U.S. health policy. States are learning from each other. Massachusetts, Minnesota, Vermont and other states figure prominently in the rationale for the Oregon proposal. My impression is that the systematic dissing of government that has dominated the national scene since the start of the Reagan presidency has less force at the level of state government. In particular, the ethical imperative to get a grip on health care costs appears to be more discussable within states. State governments are required to balance their budgets, making the fantasy that only greedy insurance "bean counters" care about cost harder to sustain in state-level discussions.

I hope that we will be able to welcome Oregon back into its earlier leadership role in health policy as the current reform process proceeds!