Tuesday, March 25, 2008

Medicare Costs - the Biggest Leadership Challenge

Today the Bush administration confirmed the prediction made one year ago: the Medicare hospital fund will be exhausted in 2019.

The looming collapse of Medicare is probably the best test of the mettle of John McCain and whoever becomes the Democratic nominee. Politics as usual will dictate a wishful thinking approach. Republicans will invoke market solutions. Unfortunately, as powerful as markets are, the evidence that market forces will solve the health care cost dilemma is on a par with evidence for the tooth fairy. Democrats will invoke preventive care and chronic disease management, sprinkled with attacks on corporate greed. As valuable as prevention and disease management are, and as egregious as some corporate behavior has been, the likelihood that these will make Medicare solvent is south of nil.

There is no pain-free way to solve runaway health care costs. In addition to using markets wisely and managing disease well, by 2019 we will have to learn to make do with less. Sometimes less is better (even though we don't believe it, as shown by the recent study demonstrating that expensive placebos are more effective than cheap ones). But sometimes less is worse, a very unpalatable political message.

A real national leader will help us come to grips with painful truths. In the 32 weeks between today and election day we the people should press those who want to be our leaders to talk turkey about Medicare. I don't think we can expect a candidate to talk explicitly about rationing, but we should harry them to get beyond wishful thinking, smoke, and mirrors. Eleven years isn't a lot of time for us to accomplish the needed learning.

Monday, March 24, 2008

Patients, Social Networking, and Moral Complexity

While returning to Boston from New York on Amtrak yesterday, I read a fascinating New York Times article about an internet startup - "PatientsLikeMe."

Like many other health innovations, PatientsLikeMe starts with a personal story. In 1998, Stephen Heywood, 29 years old, developed amyotrophic lateral sclerosis. His older brother, an MIT graduate, quit his job to work on a cure, initially founding the ALS Therapy Development Institute, a not-for-profit enterprise that "uses entrepreneurial spirit and techniques to aggressively seek out, develop, and deliver promising therapies to slow, arrest, and cure ALS."

PatientsLikeMe is a cross between social networking sites like MySpace and a medical startup. It invites patients with specific conditions (thus far ALS, HIV, Multiple Sclerosis, Parkinson's Disease, and, recently, "Mood" conditions) to share their experiences of symptoms and treatments. The distinctive feature of the site is software infrastructure that pools the patient reports and presents "findings" in easy to follow graphic form. The site includes brief stories from individual patients as well.

The aim - "providing a better, more effective way to capture valuable results and share them with patients, healthcare professionals, and industry organizations that are trying to treat the disease" - is important. Patients gather information from other patients anyway, and a networking site potentially that lets them extend their opportunity for learning, as from the 1801 ALS patients who are part of the "community," offers a lot.

Clinicians worth their salt also learn from patients. It never would have occurred to me to tell patients with schizophrenia who were experiencing auditory hallucinations and talking back to them that carrying a cell phone could help them look less "crazy" on the street, if one of my patients had not told me of the technique.

But it doesn't require Karl Marx to see the risk in a business model that invites partnering with industry. Word of mouth is potent advertising. It will be nothing short of miraculous if drug and device companies do not seek to influence the statistics, just as they influence CME activities. (As an example, see my October 4 posting about how the "Healthy Mothers, Healthy Babies" site endorsed fish consumption in pregnancy in the wake of a $60,000 donation from the National Fisheries Institute).

Many physicians fear "disintermediation" - the process by which patients circumvent the "middleman" role, gather their own information, and develop their own plans for treatment. This is wrong. The emerging web ventures are like medications, with varying constellations of potential benefits, harms, true claims, and baloney. Physicians can provide a distinctive service as knowledgeable, honest brokers - encouraging patients to use PatientsLikeMe and other new ventures, but educating them about risks, side effects, and false claims.

The web situation is one of moral complexity, with multiple opportunities for benefits and harms, combined with tremendous uncertainties. But that is what medicine has always involved!

Friday, March 14, 2008

I'll be back on March 24

I will be in DC & NYC for the next 10 days. I look forward to posting again on Monday March 24.

Best to all!

Tuesday, March 11, 2008

Elliot Spitzer, Health Care, and the Placebo Effect

The big topic of conversation today has been – “should Elliot Spitzer resign?”

In principle I don’t think he should, any more than I thought Bill Clinton warranted impeachment for his folly with Monica. Spitzer is certainly guilty of poor judgment. And, as someone who prosecuted a prostitution ring as Attorney General, he is guilty of profound hypocrisy. But let him or her who has never committed hypocrisy cast the first impeachment vote. There is far too much sanctimoniousness about private life and far too little accountability for true derelictions of duty in U.S. political dialogue.

So how do I account for my sense that if Spitzer were the leader of a health organization, resignation would be called for? Perhaps my reaction is simply old fashioned medical narcissism. I know that I am capable of seeing health care as even more special than it is. But I think there is more to the reaction.

In a famous New York Court of Appeals case (Meinhard v Salmon, 1928) Justice Benjamin Cardozo defined fiduciary responsibility this way:

Many forms of conduct permissible in a workaday world for those acting at arm's length, are forbidden to those bound by fiduciary ties. A trustee is held to something stricter than the morals of the market place. Not honesty alone, but the punctilio of an honor the most sensitive, is then the standard of behavior.

Health care clinicians and health organizational leaders (including those who are not clinicians) are responsible for being healers. The healer role requires a "punctilio of honor the most sensitive..." The expectation of healing is the power that underlies the placebo effect. Health organizations, like clinicians, are looked to for healing. If Spitzer headed a hospital or medical group, he would have to go.

I don't think this places health care on a pedestal. The same expectations apply to other social roles, such as judges. Airline pilots and airlines have even more life and death responsibility, but it is the pilots' skills, and not our suppositions about their characters and private lives, that is the source of our trust.

Some of those I spoke with agreed that our political culture is itself hypocritical and overly sanctimonious, but felt that Spitzer has made it impossible for himself to govern, by defining himself as a uniquely ethical crusader. His ability to lead may depend on a view of him as "healer," not just "politician."

If Spitzer stays in office his public humiliation may ultimately make him a more effective political leader. As Governor his effectiveness has been reduced by being seen as a holier-than-thou bully. Shame could help him learn to use his talents in a more collaborative, less arrogant, manner.

Sunday, March 9, 2008

Teaching Medical Ethics - (Individual Virtue and Organizational Integrity)

The topic for a recent class in the Harvard Medical School course on "Medical Ethics and Professionalism" was truth telling. (See this earlier post for a description of the course.)

The case the students found most challenging involved what to say about a medical error:

"An 80 year old man with severe hypertension comes into the hospital in a hypertensive crisis. Confused by an ambiguous label, you administer 1,000 mgm of a medication rather than the intended dose of 100 mgm. Shortly thereafter the patient's blood pressure drops. Despite resuscitative efforts, he dies. You conclude that you accidentally administered a fatal dose. What do you say to the family?"

The students were deeply torn. They felt the family had a right to know what had happened. Unless the family said something like "Dad was ready to go…the only thing we want to know is whether he suffered…”, they should be informed of the facts. But they feared that disclosure would destroy their careers.

Some felt they would/should disclose the truth no matter what the consequences. Others felt that prudence called for withholding the information, but felt some shame at having reached this conclusion. It looked like a question about the individual - who had good ethics and who didn't.

But when we reviewed the experience at the Lexington, Kentucky, Veterans Affairs hospital in systematic disclosure of medical errors, we shifted from seeing the case as an ethical biopsy of the individual to a broader view. Starting in 1987, the Lexington facility began a systematic program of disclosure. It accumulated important empirical evidence: (1) patients and families want to know the truth; (2) disclosure appeared to reduce malpractice litigation and payouts; and, (3) staff felt good about the policy.

The case we considered focused on the physician as an individual. At Lexington, the system responds. A harried intern would not be left out on a limb, Hamlet-like, anguishing over whether "to be (ethical) or not to be." The actual disclosure would be done by senior staff, and only after a thorough investigation.

I took two major points from the discussion. First, integrity should not be seen simply as a characteristic of individuals. The organizations we are part of can facilitate or impede our penchant for doing the right thing. Second, this observation has a bearing on the debate over the value of teaching ethics. Skeptics argue that if family life and experience haven't instilled virtue, a semester-long course won't do it either. But the usefulness of ethics education doesn't rest on the question of whether a class can alter one's character. If our students, and we, become more self-understanding with regard to motives and temptations, we can demand that the organizations that we are part of support our doing the right thing.

Ethics education may not alter our characters, but it can help us become skillful self-observers and effective organizational activists. That's not a bad accomplishment!

Monday, March 3, 2008

Lily-Livered Approaches to Health Care Cost Containment

In a recent JAMA article on the trade-off between cost and coverage, the always prescient Zeke Emanuel (my candidate for CMS director in the next administration) concludes "It's the Health Care Costs, Stupid." Here's the gist of Emanuel's argument:

"Without controlling health care costs, any attempt at universal coverage will be transient. Sustainable expansion of coverage to all Americans requires credible changes in the rate of health care inflation...In the strange calculus that is American politics, the more politically salient issue of costs may provide a better way to achieve the comprehensive reforms necessary to cover the uninsured than the hitherto futile direct moral appeal."

Unfortunately, the presidential campaign to date suggests that U.S. political discourse on health care costs continues to be lily-livered. The predominant approaches being proposed by both parties are wish fulfillment, magic, and blind faith.

Articles today and yesterday in the New York Times explain why both parties prefer the fairy dust approach to cost containment:

The toxic politics of appearing to support any rationing of care has kept candidates in both parties from seriously confronting the overuse and misuse of health care.”

the need for cutbacks is not a popular theme for political candidates wooing voters who want more care at a lower cost.”

John McCain promises that market forces, which have brought us unceasing cost increases, will reverse the cost trend if he is elected. (If you cling to the hope that markets will save us, read Robert Kuttner on "Market-Based Failure - A Second Opinion on U.S. Health Care Costs" in last month's New England Journal.)

Barack Obama and Hillary Clinton suggest that investing in prevention, electronic medical records, and disease management for chronic illness, will do the job. But as important and desirable as these actions are, they won't rein in the cost trend either.

We can't wait for political leaders to show us the way out of the cost morass. In the 23 years since John Kitzhaber was elected president of the Oregon Senate, no politicians have stepped forward to take the baton of educative leadership about access, cost, and rationing, from him. We need to create the conditions that will allow effective political leadership to emerge. This involves two key components:

1. More and better information on comparative clinical and cost effectiveness. We can't make progress on costs without persuasive information about how to achieve desired outcomes in less costly ways.

2. A political strategy for using this information. This is not a matter of developing ever more complex financing proposals, but rather, finding ways to make open discussion of cost containment and rationing less "toxic." Conservatives have shown how to do this with the "death tax" campaign.

Some years ago, as part of a panel on rationing, a member of the audience challenged me by asking "Are you going to market your health plan by saying 'we ration care better than anyone else'?" For a moment I was nonplussed, but then I channeled Karl Rove and responded - "I would say 'we produce more health for every penny you invest than anyone else.'"

If a political clod like me, who couldn't even get elected to high school student council, could develop a communication strategy for detoxifying talk about health care costs and rationing, the political pros could show us the way if they put their minds to it.