Treating the Poor - No Good Deed Will Go Unpunished

Physicians and teachers are the focus of a major societal effort to reward excellence, encourage improvement, and weed out poor performers. The intent of these efforts is noble and good, but they also entail major risks.

Since biblical times, many health professionals have been drawn to caring for disadvantaged, vulnerable populations. I see this in applicants for the primary care residency program for which I am part of the faculty. These young physicians are among the best, the brightest, and the most idealistic.

But a recent article in JAMA - "Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings" - suggests that they may be heading for trouble!

A research team studied 162 primary care physicians in the Massachusetts General Hospital system. All were hired and credentialed by similar criteria. They shared the same compensation plan, had similar staffing resources and the same advanced electronic medical record system. This was an experienced group, averaging almost 19 years from medical school graduation.

The researchers created a composite quality score based on 9 HEDIS measures commonly used for quality assessment. On the basis of these measures, they grouped the physicians into thirds. Then they adjusted their results for patient variables - age, sex, number of comorbidities, race/ethnicity, primary language spoken, and insurance status. When these adjustments were made, 6 in 10 physicians changed more than 5 percentiles and one third change more than 10. 14.3% of the bottom third increased in ranking to the middle third. 25% of the middle third moved into the top or bottom category. The 34 primary care physicians whose quality rankings increased by more than 10 percentiles were more likely to be practicing at community centers, with larger panels, a higher proportion of minority, non-English speakers, and more who were uninsured or insured through Medicaid.

A quality ranking system that did not adjust for patient variables would have penalized PCPs who work with a poor, vulnerable population. If quality rankings drove differences of income, the system could worsen health disparities by diverting resources away from patients with greatest need and rewarding physicians for avoiding these patients.

In evaluating teachers, systems have been developed that take student vulnerability into account. If a district or state looks at all students at the same level of vulnerability, it can compare teachers in relation to the same student "inputs." That's the meaningful comparison, rather than comparing teachers in the inner city or poor rural areas to teachers in the wealthiest suburban systems.

It's vital to measure our performance in health care and work to do the best that can be done. But if we apply physician ratings without careful attention to patient panel characteristics, we'll prove once again that no good deed will go unpunished!

Nicholas Kristof on "Tussling Over Jesus"

Readers who have followed the controversy within the Catholic Church over the abortion done at St. Joseph's Hospital in Phoenix to save a pregnant woman's life should read Nicholas Kristof's powerful op ed in today's New York Times.

Kristof correctly locates the St. Joseph's controversy in the struggle in every faith group between dogmatic fundamentalists and compassionate humanists. "Faith group" is not limited to religions. The controversies about the U.S. Constitution between strict constructionists and those who - correctly - recognize that the Constitution was designed to be a living document, rests on the same dynamic.

Here are the key paragraphs from Kristof's piece:

To me, this battle illuminates two rival religious approaches, within the Catholic church and any spiritual tradition. One approach focuses upon dogma, sanctity, rules and the punishment of sinners. The other exalts compassion for the needy and mercy for sinners — and, perhaps, above all, inclusiveness.

With the Vatican seemingly as deaf and remote as it was in 1517, some Catholics at the grass roots are pushing to recover their faith. Jamie L. Manson, the same columnist for National Catholic Reporter who proclaimed that Jesus had been “evicted,” also argued powerfully that many ordinary Catholics have reached a breaking point and that St. Joseph’s heralds a new vision of Catholicism: “Though they will be denied the opportunity to celebrate the Eucharist, the Eucharist will rise out of St. Joseph’s every time the sick are healed, the frightened are comforted, the lonely are visited, the weak are fed, and vigil is kept over the dying.”

Hallelujah.

(My own posts about St. Joseph's can be seen here, here, here, and here. My most recent post on the topic shares Kristof's admiration for the noble Catholic traditions of commitment to the poor and to social justice.)

Ground Rules for the Single Payer Debate in Vermont

The national debate about health reform has been dominated by sloganeering. Polling suggests that the public does not understand the drivers of health care costs or the amount of redundancy, waste and harm in the system. The Obama administration has concluded that it should have done more to educate the public and shape the debate.

The states are the key laboratory for health reform now. I've written about how Vermont is giving serious attention to a single payer proposal (see here). Nationally, that concept has been largely off the table, shot down by slogans about "socialized medicine" and "government takeover of health care."

I was happy to see an editorial in the Burlington Free Press suggesting ground rules for how political debate should proceed (for overseas readers - Burlington, with a population of 40,000, is the largest city in a small state). Here are the key passages:

The most important task before advocates of health care reform is to explain the proposals put forward by the state consultant in a way that ensures the debate remains focused on the facts...Vermonters deserve an informed discussion about the future of health care in our state. As those who pushed through national health care reform discovered, how the Shumlin administration and lawmakers explain the plan will be as important as what is in the plan.

On one extreme are the many people suspicious of an expanded role for government in their lives and have little faith that government can do things better. On the other are those who feel that everyone has a right to adequate health care and that can only be achieved under a government-run system.

There is nothing constructive in an exchange of heated rhetoric designed to stoke fear or that attempts to demonize the other side. There is no point in coming to a conclusion before all sides fully digest the proposed changes and explore the issues.

The drive toward single-payer health care system for the state is, perhaps, the most ambitious and among the most controversial item on Shumlin's agenda. Understanding the proposals and how they will affect Vermonters is the first step to any meaningful discussion. The matter is too important to be left to nasty sound bites and empty slogans that bear little resemblance to the issues on the table.

Newly elected Governor Shumlin is the crucial player in determining whether a serious innovative proposal is given thoughtful attention and a fair chance at being implemented and tested in action. At 620,000, Vermont is approximately 1/500th of the U.S. population. If the state can apply the thoughtful process the Burlington Free Press suggests, it will be doing a disproportionately important job for the entire country!

Dr. Andrew Wakefield's Fraudulent Claims about Autism

This month the British Medical Journal (BMJ) published a three part series by Brian Deer, detailing the fraud by which Dr. Andrew Wakefield led parents to see the MMR (measles, mumps and rubella) vaccine as a potential cause of autism.

In 1998, Wakefield and 12 colleagues published a paper in Lancet - "Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children." The article presented 12 cases from the Royal Free Hospital in London, alleging that a severe form of autism and gastrointestinal disorders closely followed administration of the MMR vaccine.

Wakefield's "findings" catalysed a massive anti-vaccine movement in the U.K., U.S. and elsewhere, and suits against the vaccine manufacturers for injury. Unfortunately, as Deer's seven years of research documented, Wakefield's conclusions were not simply wrong, they were based on fraud and driven by rampant financial conflict of interest.

Prior to the "study" reported in Lancet, Wakefield had gone onto the payroll of a lawyer who was preparing to sue vaccine manufacturers for causing autism. Families of developmentally disabled children who believed their children had been injured by MMR were solicited to bring the children to the Royal Free Hospital. Intrusive tests that were not clinically indicated were performed on the children. And, as a massive investigation by the General Medical Council (GMC), conducted nine years after publication of the original article demonstrated, the case reports were distorted and outright falsified to support the "conclusion."

Deer details the business ventures that Wakefield and the Royal Free Hospital concocted, to profit from diagnostic tests Wakefield had patented that purported to allow diagnosis of MMR-induced injury. He also describes, in painful detail, presenting his findings in 2004 to Lancet, only to be met with what appears to have been a coverup.

Deer describes being fought against, blocked from gaining access to sources, and sued, during his long journalistic crusade. The GMC investigation ultimately confirmed all of his conclusions. Wakefield and one of his co-authors were stripped of their medical licenses.

Wakefield's fraud has caused multiple injuries, including: (1) distressed parents of children with autism have been duped into believing the cause of their childrens' disorder is known; (2) uptake of MMR has declined, with episodic outbreaks of all three conditions as a result; and (3) public skepticism in research integrity has been intensified.

Sadly, as the U.S. is seeing with regard to the lies about a government plan to create "death panels," it's vastly more difficult to impugn false claims than to make them in the first place. Initial comments on Deer's BMJ articles include many defenses of Wakefield as the victim of a campaign to hide the truth about vaccines, not as the disgraced perpetrator of fraud that he is.

(For Brian Deer's remarkable articles see here, here and here. And for an accompanying BMJ editorial see here.)

Physicians Treating Family Members

Randy Cohen, who writes "The Ethicist" column for the New York Times, is my ego ideal for this blog. I admire his down to earth,humorous way of responding to the questions put to him. Yesterday Randy responded to an interesting medical ethics situation:

My elderly aunt became ill and phoned me, a physician, to ask if she should call an ambulance. I surmised that she was severely dehydrated. From my hospital, I took a bag of saline, IV tubing, an IV lock and a needle. An unsuspecting nurse handed me the tape that secures the needle. I gave my aunt these fluids at home, and she soon felt better, as did I: my stealing $50 worth of medical supplies saved the taxpayers more than a thousand dollars for an E.R. visit. Did I do right? E.G., NEW YORK

I love the hint of zany hijinks in the words “an unsuspecting nurse.” I respect your concern for your aunt and admire your ingenuity in curbing costs, but — there is a but — I am wary of your conduct. You were deceitful with your own hospital and imprudent in taking over your aunt’s treatment.

One doctor, the medical director of a large public hospital, e-mailed me to say: “We frown upon treating family members. It’s incredibly difficult to be objective in the best of circumstances.” He added: “The aunt’s bedroom is not the optimal environment for diagnosis or treatment. This physician took many shortcuts and may have done his aunt a great disservice by not performing a complete assessment.” He makes a persuasive case that while your diagnosis was correct, it was not certain to be: your aunt might have had other problems requiring a more drastic response.

Your altruistic pilferage, while thrifty, was ethically dubious, requiring you to betray the trust of your co-workers. The medical director I spoke to suggests a less buccaneering alternative: “If he had asked for the supplies, his hospital would have undoubtedly given them to him.”

The real solution to such problems is to arrange health care so as to avoid so stark a dilemma, perhaps by providing local clinics or health professionals who make home visits, changes unlikely to occur any time soon. Given the current circumstances, I should offer a word in your defense from another doctor, Paul R. Marantz, director of the Center for Public Health Sciences at Albert Einstein College of Medicine, who acknowledged that what you did was stealing, but said in an e-mail that “purloining $50 (more likely $20) worth of medical supplies while saving hundreds (more likely thousands) seems a good choice compared with the more burdensome alternative of a visit to the E.R.” I agree that those who practice medicine in imperfect institutions might — must — sometimes choose imperfect actions, but believe that your supply-room raid still fell short.

Randy's response to E.G. is right on. The question E.G. asked - about the materials he took from his hospital - is easy, but trivial. It's wrong. He should have asked, and the materials probably would have been given. And who hasn't taken pens and the like from their workplace?

The question E.G. should have asked was about treating his own aunt. As the public hospital medical director correctly reported, this is a practice the medical establishment "frowns upon," since family relationships can distort objective judgment and lead to errors in treatment. But given what happens to frail elderly folks who come to emergency rooms, the medical director's claim that "The aunt’s bedroom is not the optimal environment for diagnosis or treatment," is dubious. The home environment often provides clues that are invisible in the emergency room. And the medical director's conclusion - "This physician took many shortcuts and may have done his aunt a great disservice by not performing a complete assessment" is also dubious.

Sometimes a "complete assessment" turns up non-obvious findings that allow for effective treatment. But all-too-often, a full court press emergency room workup leads to finding "incidentalomas" - ostensibly "abnormal" findings that have no clinical meaning. The radiology report may say "I cannot rule out XYZ." Even though there is no reason to have suspected XYZ, finding an incidentaloma may lead to further tests and procedures, all of which can have side effects.

For me, the key ethical question is about care, not cost. A lot of money is wasted by unnecessary emergency room visits, but E.G. shouldn't try to balance the health care budget on the back of his elderly aunt. If saving money was his motive, I'd chastise him.

But if E.G. had experience allowing him to make a probable diagnosis for his aunt, and if he knew her to be a frail person for whom an emergency room visit stood a high chance of being traumatic and a source of avoidable harms, I believe he gave proper balance to the competing values. Treating our family members is, on average, a bad idea. But the rule of thumb isn't an absolute - it can be outweighed by other values, such as protecting his aunt and allowing her to be ministered to in the safest and most congenial manner.

Saving money for the health system wouldn't have been a reason for treating his aunt at home, and it's not the justification for what E.G. did. But from my reading of the story, E.G. did the right thing, though by imperfect means.

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.)

States are the Hotbed for Medical Ethics

On Tuesday, by voting to repeal the Patient Protection and Affordable Care Act (ACA), all 242 Republicans in the House of Representatives proved the truth of Winston Churchill's famous comment about us Yanks - "Americans can always be counted on to do the right thing...after they have exhausted all other possibilities."

The law is a prototypical legislative sausage - it's the best we could do at the time given the virulent politics of health care. I'm not a political pundit, but I anticipate that Tuesday's piece of Republican theater will backfire on the party in 2012.

But what is clear is that the states are emerging as the crucial laboratories for health system reform. It's symbolic that on the same day that the Republicans voted in favor of marching backwards to our failing status quo, the Vermont legislature received a bold proposal to create a distinctive state-based single payer system.

Here in New England, Massachusetts, New Hampshire and Vermont, are all hotbeds for creative efforts to get a grip on our failing health system. Massachusetts has achieved the highest level of insurance for any state, using an approach that includes a individual mandate. New Hampshire is conducting a vigorous pilot program of accountable care organizations. Vermont is entertaining a single-payer proposal that has been kept off the federal table by two dreaded words - "socialized medicine." And, with luck, "red" states will test out market-based reform ideas in serious ways.

We can't reform the health system without engaging with deep questions of values: what level of our resources should be allocated to health? how do we balance individual responsibility for our own health with communal responsibility for the vulnerable? what level of health services should a civilized society guarantee to its members? These, and many others, are serious ethical questions, and people of intelligence and good will can differ in their responses.

At the state level, especially in states with relatively small populations, it's easier to keep the political debate at a thoughtful, civil level. Nationally, that's been much more difficult, as evidenced by the "death panel" fiasco. I know from leading classes and meetings on ethics topics that it's crucial to create a safe space for gathering facts, identifying key values, explicating conflicts among the values, designing options, and making choices. As a country of 300 million, tremendous diversity, and limited public understanding of health system complexities, we've done poorly. At the state level, we're doing better. That's where the key learning is likely to occur.

(If you're interested in more on Massachusetts, New Hampshire, and Vermont, there are tabs for each of the states on the blog.)