Thursday, May 29, 2008

The Ethics of the Hospital Safety Net (3)

This is the third in a series of occasional postings about the U.S. safety net system. (See previous posts here and here.)

Yesterday I met for two hours with staff at a safety net social organization in the Boston area. A small group of medical colleagues and I are scoping out a volunteer project to help the staff address mental health issues that impede work with their clients around the organization’s social mission.

The meeting provided a window onto the frayed condition of the health system safety net, and the heroism of those who work to plug the gaps.

The organization receives referrals of severely disadvantaged young adults from public agencies. It acts in the Statue of Liberty spirit, receiving all comers, unscreened. That’s what it means to be part of the safety net.

Recently a client who was secretive about substance use experienced a severe reaction to heroin and had to be rushed to the hospital. Later that day, after successful treatment of the drug reaction, but without any information from the hospital, the client returned. (Presumably the hospital was hamstrung by well-intentioned but clumsy privacy regulations.)

A staff member commented – “we aren’t a hospital, and we’re not health professionals, but society asks us to take care of situations like this.” We discussed other clients whose mental health and substance abuse conditions created challenges for the organization. Our discussion focused on how staff can best process the emotional demands of their stress-laden work, and on ways to promote development of new skills.

My colleagues and I were overwhelmed with admiration for the work done by the organization and its staff. We were all physicians. Regarding the medical ethics, the sixth principle in the AMA code of ethics states:
"A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."
Not so for the people we were sitting with. They could choose not to have a job, but otherwise they had no choice of whom to serve. That receptiveness created the safety net for their clients and the state

By chance I wrote this post in a classroom at Harvard Medical School while the first year students were writing their final exam essays for the "Medical Ethics and Professionalism" course. Classes, articles and lectures are all good sources of learning. But the students and their teachers know that the crucial ethical learning occurs in their front-line care for sick people and efforts to improve the organizations and systems that provide health care.

I left yesterday's meeting wishing that more political and health system leaders would sit with front line safety net workers, and, better yet, have experiences working side by side with them. It is hard to come into contact with the nitty gritty realities of human need without being changed.

For health system leaders, it would be harder to insist on the necessity of providing a high cost technology that provides minimal benefit after seeing our underfunded safety net system up close. For political leaders, it would strengthen their understanding of the opportunity costs of runaway health system expenditures, and perhaps their readiness to tackle the knotty political challenge of reallocating our societal resources. Allowing a bloated health sector to starve the social sector is not something we should accept.

Monday, May 26, 2008

Let's Stop "Fighting" Cancer

Judy Foreman's column in today's Boston Globe addresses one of my pet peeves - the ubiquitous metaphor of "fighting" cancer.

The term has been all over the news in the context of Senator Kennedy's condition. Foreman explains what's wrong with the fight talk this way:
"Cancer is not a football game. It's more of an involuntary dance with a partner you didn't choose...

It's not that I think that Ted Kennedy should sail quietly off into the sunset with the word 'ACCEPTANCE' emblazoned on his shirt. Certainly not yet. I think that he should, and no doubt will, muster his considerable intellectual, emotional, spiritual, political, financial, familial, and social power to deal with his cancer on all fronts...

The fighting metaphor is insidious because it subtly and not so subtly implies that if you fight, you can 'win.' And if you don't fight hard enough, you 'lose' and are therefore a 'loser'...

So I would change the mantra [from 'Fight, Ted, fight'] to 'Breathe, Ted, breathe.' Sail your boat. Kiss your wife and your kids. Trust your doctors. Keep doing the work you love."

An old joke speaks to the world view behind all the talk about fight. "In India, death is seen as a potential step away from reincarnation and towards Nirvana. In Europe, death is seen as an existential tragedy we all must face. In the U.S., death is seen as optional."

In my practice, some people with terminal illnesses like to be thought of as "a fighter." For them the term is a good one to use. But in my experience this group is a minority. For some, an illness like cancer is "a wake up call" to fix unsettled areas of life. For others it is "a release."

Our uncritical use of "fight" and "battle" is related to the uncritical way in which we squander resources on low-yield and even no-yield health services. Even worse, it is related to what medical students and residents working in hospitals call "flogging" patients with treatments that no one wants but which take on a momentum of their own.

When I was growing up, boys were taught that only "sissies" give up the fight and say "uncle." That macho approach to life may be well suited to trench warfare, but it is not a good guide for a health system.

Sunday, May 25, 2008

Health Care Reform and Ethics in Oregon

Keep watching the Oregon health care reform process. I expect that Oregon will be teaching new lessons about health system policy and ethics very soon.

The Oregon Health Fund Board, which was appointed in the fall of 2007, will present a comprehensive reform plan to the Governor and legislative leaders in the fall of 2008, with the aim of legislative action in the 2009 session. The process couldn’t be more different from the Clinton reform effort – open all along the way, always with an eye on building political support.

The Committee developing the Essential Benefits Package has proposed a “basement level” package – a floor for universal coverage in Oregon. The guiding principles point in a more ethical direction than we are accustomed to. Here's what stands out for me:

1. “All parts of the body are treated equally.” This means that mental and dental services compete for coverage on equal footing with other physical health conditions, rather than being selectively disadvantaged.

2. Oregon will continue to use its famous prioritized list process to guide coverage. Paradoxically, the reason the state can end arbitrary exclusion of "mental and dental" is because it has the guts to set limits on coverage openly, in accord with its judgment of the value a service provides.

3. Oregonians describe the state as having two populations - a liberal, communitarian-minded group centered in the area between Portland and Eugene, and a highly individualistic-minded group from the more rural areas of the state. The reform plan draws on both sets of values. The focus on covering all Oregonians reflects the communitarian strain. The focus on asking individuals to take responsibility for themselves - through deductibles - reflects the frontier individualism strain.

4. While I haven't seen the details, the blending of communitarianism & individualism shows up in the approach to the deductible. Basic diagnostic services, comfort care, and effective interventions for costly conditions will not be subject to the deductible. But the further down the prioritized list a service falls, the higher the cost sharing will be.

Oregon has been cultivating a distinctive health care ethic of "tough love" for twenty years. Its determination to be explicit about rationing reflects toughness. The state doesn't pretend - as so much U.S. health policy does - that limits can be avoided. Its determination to cover all citizens and to emphasize comfort care reflects love.

Oregon has also been distinctive in the degree to which it has drawn Oregonians into deliberation about the health system. For twenty years it has asked citizens all around the state about their values for health care. I saw this process in action at the statewide conference on ethics and health care reform last month. Leaders from the Health Fund Board sat with ethicists, community physicians, and a range of ordinary citizens for two days, chewing over ideas for reform and the values connected to the reform process. There have been open meetings all around the state doing the same thing.

Bringing individualism and communitarianism together into an ethic of tough love hasn't been done by the professional ethics community. It has come from recurrent conversations at all levels of the population, orchestrated over many years. I may be a cockeyed optimist, but I think that in the next 12 - 24 months, the other forty nine states will be learning from Oregon again!

Monday, May 19, 2008

Apology, Ethics, and the Law

An article about apology in yesterday's New York Times - "Doctors Start to Say 'I'm Sorry' Long Before 'See You in Court'" - reminded me of one of my pet peeves - the way physicians go limp in relation to the law.

The article summarizes a well-known trend in medicine - the recommendation that physicians acknowledge errors and apologize to patients who have been injured. It directs readers to the website of SorryWorks!, an organization that advocates for "disclosure, apology (when appropriate), and upfront compensation (when necessary), after adverse medical events."

For readers not familiar with the new paradigm for handling adverse events, here is how SorryWorks! defines it:

Step 1 - Initial Disclosure - is all about empathy and re-establishing trust and communication with patients and families in the immediate aftermath of an adverse event. Providers say "sorry" but no fault is admitted or assigned. Providers take care of the immediate needs of the patient/family (food, lodging, counseling, etc) and promise a swift and thorough investigation. The goal is to make sure the patient/family never feels abandoned. In the spirit of good customer service, pull the patient or family closer to the providers and institution.

Step 2 - Investigation - is about learning the truth. Was the standard of care breached, or not? We recommend involving outside experts and moving swiftly so the patient/family doesn't suspect a cover-up. Stay in close contact with the patient/family throughout the process.
Step 3 - Resolution - is about sharing the results of the investigation with the patient/family, and their legal counsel. If there was a mistake, apologize, admit fault, explain what happened and how it will be prevented in the future, and discuss fair, upfront compensation for the injury or death. If there was no mistake, continue to empathize ("we are sorry this happened"), share the results of investigation (hand over charts and records to patient/family and their legal counsel), and prove your innocence. However, no settlement will be offered and any lawsuit will be contested. SorryWorks! is compassion with a backbone.

The New York Times article explains how ill-advised recommendations from malpractice lawyers, combined with a lily-livered tendency in the medical profession to think too little about ethics and too much about law, led to the need for a "new paradigm" made up of what should have been old hat practice:

For decades, malpractice lawyers and insurers have counseled doctors and hospitals to “deny and defend.” Many still warn clients that any admission of fault, or even expression of regret, is likely to invite litigation and imperil careers.

My pet peeve comes from ethics consults and ethics workshops. Physicians often start by asking - "what's the law here?" I do my best to keep calm in responding - "let's start by figuring out what we think is the right thing to do, and then ask - 'how can we do it consistent with the law?'"

My strongest personal lesson about dealing with adverse outcomes occurred several decades ago. I was briefly involved with the psychiatric care of a college student who was experiencing acute and severe depressive symptoms. The student's family was in a crisis situation and the student felt that returning to college (at some distance) would help the depression resolve. After we explored this together, I agreed, and added "if it doesn't work out as we hope and expect, go to the infirmary right away."

Tragically, things did not go as I predicted they would. The symptoms did not lift. The student went to the infirmary, was admitted, but left and committed suicide.

I met with the student's family for a couple of hours. I listened to their feelings about the death. I cry easily, so it wasn't difficult to see my reactions. The family challenged me - why hadn't I done things differently? I said that in retrospect I certainly would have, and explained what my thinking had been at the time and why I did what I did. It was one of the most painful sessions in my career.

Some years later I got a message from a lawyer to call about the "X family." I gulped and returned the call, thinking I was about to be sued. The lawyer explained that family was bringing action against the college and wanted him to get information from me, but had instructed him - "make sure not to bring Dr. Sabin into this action."

The importance of direct communication with patients and families after an adverse event should be a no-brainer. How could we possibly not do it? And it doesn't take a law degree to understand how to express sadness and concern without saying, as in the Guys and Dolls song - "sue me, sue me, shoot bullets through me..."

Expressing sadness when a patient suffers is good manners, good ethics, and good medicine. The fact that my profession let foolish legal considerations choke natural empathy and human solidarity needs to be treated as an error to learn from. The lesson I have drawn is that ethics comes first. Then law.

Saturday, May 17, 2008

Ethics of the Big Lie in DTC Advertising

Last week I argued that while - in my view - the societal consequences of direct to consumer drug advertising (DTC) are, on balance, more bad than good, our deeply held first amendment value on free speech is the trumping value in deciding whether or not to allow DTC.

An article in the forthcoming May 22 issue of the New England Journal of Medicine -"DTCA for PTCA -Crossing the Line in Consumer Health Education?" takes the issues a step further. Drs. Boden and Diamond, both cardiologists, discuss an advertisement for a coronary stent manufactured by the Cordis Division of Johnson & Johnson that was aired during a New York Jets/Dallas Cowboys football game on Thanksgiving Day. DTC for drugs is well established. DTC for devices like stents is new.

The article describes in detail the characteristic way in which the device is presented in an overly rosy manner. It article is written in a scholarly and balanced manner that is far removed from the emotional dynamite of DTC. The authors speak in the careful manner of academic experts, as in their conclusion that "a device is being promoted to millions of people who are ill equipped to make judgments about complex therapeutic issues that even specialists continue to debate."

I deliberately chose an unbalanced title for this posting to make a point. If, as I believe we should, we follow our national commitment to maximum free speech in allowing DTC, we need equally vigorous emotional dynamite in response. As important as academic counter-detailing is for the education of physicians, evidence-based academic prose won't move the public. We need emotional counter-detailing for public education.

Well-informed, hard-hitting blogs that track commercialism in health care like the Carlat Psychiatry Blog, Health Care Renewal, and Hooked present timely postings about advertising lies. As good as Boden and Diamond's New England Journal article is, it appeared six months after the Thanksgiving TV ad for the stent.

At a Harvard Medical School ethics forum a few years ago one of the speakers presented a professionally developed TV advertisement on overuse of antibiotics that featured a movie star talking about why she didn't use antibiotics when her baby had a cold. But who will buy air time for ads like this?

YouTube is a start. But the audiences are still small. "Big Pharma, big bucks," a high quality nine minute story, has only had 7,000 viewers. Bill Maher's anti-Pharma rant has done better - 270,000 viewers.

If a 10% - 20% surcharge on advertising fees paid for by the drug and device industry was levied, it could fund substantial advertising to promote rational use of drugs with the same emotive force that is currently driving overuse, misuse, and economic waste. This is a policy option that needs to be explored. Free speech is an important value. But so are public health and not bankrupting Medicare!

Tuesday, May 13, 2008

Giving Ethics Education a Bad Name

Three months ago I described "A Ridiculous Use of Medical Ethics Teaching" - a case where a recurrent offender was "sentenced" to ethics education in response to continued bad practice.

Today's Washington Post gives another example of the same phenomenon. A Rockville pediatric dentist, Dr. Ophir Alalouf, had his license suspended for performing "extensive dental treatment without clinical justification," at times without authorization from parents.

Dr. Alalouf agreed to a one year suspension of his license. What stuck me is this detail - if he completes a series of courses and exams, the suspension will be shortened.

Everyone in my entire immediate family is involved with education. Education matters. But not as an enforcement policy to correct a pattern of unethical action. This is a 19th century view - that contemplating scripture, whether in penitentiaries or insane asylums - would tame the savage beast of errant action. (David Rothman's "The Discovery of the Asylum" tells this story well.)

If we continue the fantasy that sitting in ethics class will "cure" recurrent violations by mature clinicians we will give ethics education a bad name and fail in our responsibility to protect the public.

Monday, May 12, 2008

Controlling Health Care Costs in Massachusetts

An interesting an important drama about health care costs is coming soon to Massachusetts.

A bill proposed by Senate President Therese Murray that will require annual hearings about the drivers of the health care cost trend is making its way through the Massachusetts legislature. The Senate version would locate provider and insurer hearings in different venues – the Division of Health Care Finance and Policy for providers and the Division of Insurance for insurers.

On Friday, Bruce Bullen, COO of Harvard Pilgrim Health Care and formerly Massachusetts Medicaid Commissioner proposed that the Massachusetts Health Care Quality and Cost Council should conduct the hearings. The Council is part of the Massachusetts Health Care Reform process, charged with promoting transparency about quality and cost and containing the cost trend.

Bullen's proposal is sensible. Any serious effort to get a grip on costs must bring providers and insurers together. Providers structure care. Insurers structure payment. They need to work together. Otherwise we'll be stuck with the kind of finger-pointing that became so familiar in the 1990s.

A recent article by leaders of Partners HealthCare System, the largest provider organization in New England, on "Options for Slowing the Growth of Health Care Costs," correctly states that "the value obtained for health care expenditures must be enhanced." We know from the collapse of insurer-driven managed care, however, that value-enhancement must come from the provider community.

The first approach to cost containment the Partners leaders propose is payment reform - such as capitation and case rates. They recognize that all of these approaches "are potentially disruptive to providers whose businesses are based on fee-for-service payments." Effective payment reform will require providers and insurers at the same table - neither can make it work on their own.

Getting providers and insurers to work together is a necessary but not sufficient condition for cost containment. They will need to articulate and embrace a more communitarian ethic than has governed our thinking about health care to date. Insurers must be sensitive to the provider community's historical commitment to the well-being of individual patients. Providers must be sensitive to insurer responsibility for the care of insured populations, and for being stewards of the funds entrusted to them by employers and individuals.

In my posting on May 2 I described how, when I asked physicians “if you were the czar of your field and your orders were cheerfully followed, how much money could you save with no loss of quality?,” no one ever said less than 25%. Payment arrangements like capitation and case rates can facilitate this process, but only providers can make it happen.

There will be tremendous pushback against any interventions that cause economic pain. This is what drives our capitalistic economy and isn't peculiar to health care. Dealing with the pushback will require skillful political leadership. But unless we endorse an ethic of population health alongside of individual benefit we wont even be able to open the dialogue.

Friday, May 9, 2008

Drug Advertising - What the Public Thinks

If you want a balanced analysis of the pros and cons of how the U.S. public thinks about direct-to-consumer (DTC) drug advertising, yesterday’s testimony to the House Committee on Energy and Commerce by Mollyann Brodie, Vice President and Director of Public Opinion and Media Research at the Kaiser Family Foundation, is the place to start.

DTC drug advertising is a prototypical good-versus-good conflict. Kaiser Foundation surveys show that the public is torn about DTC. Everyone has an opinion, since 91% of adults have seen or heard prescription drug ads!

53% see DTC as mostly a good thing. 40% see it as mostly bad. 67% agree with Pharma’s claim that “prescription drug ads educate people about available treatments and encourage them to get help for medical conditions they might not been aware of.” But 66% think DTC encourages people to take drugs they don’t need, and 77% say that DTC makes drugs too expensive.

Surveys tell us what the public thinks about right and wrong, not what is right and wrong. But the Kaiser Family Foundation findings have important practical implications.

I believe that if we could study the actual impact of drug advertising we would find it to be largely bad, with relatively little accurate education of consumers about health conditions and treatments, and much unnecessary medication use and cost without benefit. But we won't be able to do those studies - it's too hard and too expensive.

Free speech is as deeply held as any American value. That's why the first amendment prohibits "abridging the freedom of speech." Pharma's claim that freedom of speech protects DTC will prevail, and even though I don't like DTC, I think it should prevail.

But the first amendment doesn't prevent regulation of how DTC is conducted, and the public is moving towards readiness to endorse tighter controls. 43% believe the government should do more to “make sure statements about benefits and side effects made in Rx drug ads are not misleading.” Whereas in 1997 33% trusted DTC most of time time, in 2005 only 18% did so, and 34% hardly ever or never trusted ads.

In good-versus-good conflicts like this one we could continue arguing until the cows come home without reaching a consensus. Some will make free speech the top value. Others will give preference to the public's health. But the polls point towards a potential compromise that would respect both key values. With good leadership we could tighten regulation so that truly educative DTC was allowed but duplicitous DTC was not.

This isn't the direction the Bush era FDA has been going in. (See previous posts here and here.) But along with free speech, the right to chuck out an administration is another deeply held American value!

Thursday, May 8, 2008

Medical Ethics, Etiquette, and Checklists

Here's what Dr. Michael Kahn learned from his recent hospitalization - "patients may care less about about whether their doctors are reflective and empathic than whether they are respectful and attentive." (His engaging article is in this week's New England Journal of Medicine.)

Dr. Kahn makes a good point. Manners matter! Many of his comments ring true:

When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that "he just stared at his computer screen," "she never smiles," or "I had no idea who I was talking to."

Dr. Kahn goes on to apply the Pronovost checklist concept to first meetings with a hospitalized patient:

1. Ask permission to enter the room; wait for an answer.
2. Introduce yourself, showing ID badge.
3. Shake hands (wear glove if needed).
4. Sit down. Smile if appropriate.
5. Briefly explain your role on the team.
6. Ask the patient how he or she is feeling about being in the hospital.

I think Dr. Kahn is half-way correct.

In the 1980s, in what was then the Harvard Community Health Plan HMO, the leadership introduced what was ultimately called the "smile memo" for support staff: when the patient is within 6 feet of the desk, make eye contact and smile.

But when the directive, taken from service industries like retail stores, arrived at the front desks, the support staff said - "this is an OK idea - but why doesn't it apply to how the doctors and supervisors treat us?" (They didn't mention the nurses, most of whom apparently had good manners!)

They were right. Of course they should be expected to show good manners in dealing with patients. But asking them to do this focused their attention on the fact that they were not consistently treated with comparable respect. That led to a shift in the project - from putting the spotlight on the support staff as the starting point to focusing on how well the higher status folks supported the support staff in their difficult work.

I guarantee that the same thing will happen with Dr. Kahn's proposal. Of course he is right that a physician's behavior counts. As an teen-ager I fought against my mother's constant reminders about manners, but over the years I have been grateful that she knocked many good habits into my resistant adolescent self. Considerate behavior and good manners should be on automatic pilot for everyone who deals with patients.

Pronovost's checklists were about washing hands and draping patients. No one asked why the hospital didn't wash its hands or cover itself. But a checklist of mannerly interactions with patients will - and should - focus on whether the hospital or clinic walks the talk in dealing with its own staff.

A checklist of etiquette alone won't improve the experience of patients. But trying to implement one could trigger useful scrutiny of the ethics and manners of the organization itself.

Tuesday, May 6, 2008

Massachusetts Health Care Reform - Access and Cost

Measured by access, Massachusetts Health Care Reform is doing very well. But unless the state can get a grip on costs the reform effort will go down the tubes.

As of its second birthday in April, 340,000 - 52% of the formerly uninsured - now have insurance. One third are enrolled in private insurance - 17,000 in the non-subsidized "Commonwealth Choice" program, and the rest through their employers. 174,000 are in subsidized "Commonwealth Care," with half being fully subsidized and half paying between $35 - $105 (for individuals - correspondingly more for families). The rest are newly enrolled in Medicaid.

This year was budgeted at $472 million, but because of higher than expected enrollment in the subsidized program, a supplemental allocation of $153 million was required. For next fiscal year the Governor has requested $869 million instead of the $725 million originally projected. (Details are available in the April report from the Massachusetts Health Connector.)

Unfortunately, progress in dealing with cost has not matched progress on access. The Annual Report of Quality and Cost Council, a key part of the reform program, details an ambitious plan, but shows few accomplishments. A cost/quality website for consumers central to the strategy. Assessing quality is obviously crucial for a health system, but if the website turns Massachusetts citizens into discerning consumers who drive cost down and quality up I'll eat the report.

The most promising idea in the Quality and Cost Council plan is to aggregate claims data from all Massachusetts insurers. If this is accomplished, and if Massachusetts leadership chooses to use the comparisons such a data base would allow (two big "ifs"), Massachusetts would be able to get serious about managing costs.

We can't realistically expect political candidates to talk seriously about cost containment and making tough choices. If we had a nickel for every invocation of the market's invisible hand, acting through individual consumers who shop prudently for care, armed with new information, we could pay for the uninsured.

As I said in the May 4 post, the most promising sources of educative leadership are large businesses and the states. Massachusetts is proud of what it is accomplishing for access. Knowing that all that it has gained will be for naught without serious grappling with cost could trigger some real leadership. Let's hope so!

Sunday, May 4, 2008

Why We're So Ineffective in Controlling Health Care Costs

Two recent publications show with painful clarity why we are so unable to moderate the cost increase trend.

The New England Healthcare Institute's (NEHI) aptly-titled report on waste ("How Many More Studies Will it Take?")defines waste as "health care spending that can be eliminated without reducing the quality of care." The report summarizes studies suggesting that up to 30% of the $2.3 trillion we spent on medical care in 2007 is waste, and identifies five root causes of waste in clinical care: (1) variation in the intensity of care; (2) lack of compliance with evidence-based guidelines; (3) limited adoption of clinical information technologies; (4) failure of primary care systems to provide timely access; and, (5) underuse of cost-effective diagnostic tests.

"1994 All Over Again? Public Opinion and Health Care" in this week's New England Journal tell us why the 462 articles (1998 - 2006) about waste in NEHI's Compendium have had so little effect. Although 61% believe that individual Americans spend too much on health care (I'm surprised this number isn't higher), 70% believe that the government spends too little! Only 11% think the government spends too much!

In other words, even though it's totally clear to experts that waste is a significant component of high and rapidly rising health care costs, a large majority of the population endorses increased spending!

So what do we do?

Research, like the 462 studies that are in the NEHI Compendium, is crucial.

But as the NEHI report makes so clear - our problem dealing with waste is not from too little information.

The missing ingredient is educative leadership. There are innumerable constituencies for increasing expenditure - manufacturers of drugs and devices, advocacy groups for particular diseases, all those whose earnings come from providing health care services, and more.

The only natural constituency for tackling waste is the payer community. That community, however, is fragmented into public and private insurers, employers who insure their employees, and individuals who pay out of pocket. Those who profit most from the $2.3 trillion expenditure have thus far controlled public understanding. They have succeeded in portraying insurance companies as greedy "bean counters" and the federal government as incompetent and only likely to make things worse.

The two most promising sources of educative leadership are employers who continue to insure their employees and state governments that are required to balance their budgets.

The business community has come nowhere near using its potential to be businesslike about health care waste. As health care costs continue to drive insurance costs upward, there is potential for employers and employees to collaborate in understanding the cost trend better and working to influence it.

States are caught between increasing costs for Medicaid and state employees and declining revenues. As I said in a recent posting on specialty drugs, states are the most promising source for more rationality in health policy.

The NEHI report is a valuable contribution. But unless business leaders and state governments take the ball and run with it, the next 462 research reports on waste won't make any more difference than the 462 NEHI has summarized!

Friday, May 2, 2008

Learning how to Ration

Over the years I have posed this question to physicians I respect in a wide range of medical specialties – “if you were the czar of your field and your orders were cheerfully followed, how much money could you save with no loss of quality?” No one ever said less than 25%. Lots said more. Many commented that quality could be improved at the same time.

Last month an article in the New England Journal of Medicine on “Options for Slowing the Growth of Health Care Costs” listed 12 approaches, 10 of which are familiar and widely discussed.

Given that we know how to contain costs, why have we been so powerless to do anything?

The last two options in the NEJM article – rationing - give a clue about our stunning inability to get a grip on costs. The authors write - “Should other options fail to provide sufficient cost reductions, policymakers may be forced to consider various forms of rationing.”

I think they have it backwards.

Cost containment hurts. We won’t make serious efforts until not doing it hurts more. That means being ready to start rationing in an explicit fashion. When we understand that the alternative to serious cost containment is more and more explicit rationing we’ll be readier to bite the bullet. As long as explicit rationing is off the table, cost containment will just get lip service and hand wringing.

A Wall Street Journal article – “Weighing Which Babies Get a Costly Drug” – shows how we can start learning how to ration despite the pablum our political leaders (always excepting Oregon) feed us about achieving painless cost containment through electronic medical records and magical market forces.

Synagis (Palivizumab), an antibody to protect against RSV (Respiratory Syncytial Virus) in children under two, is given as a series of monthly injections, usually five. A full course can cost up to $6,000. Synagis reduces the frequency of hospitalization, but not mortality, in vulnerable infants.

In 2003 the Committee on Infectious Diseases & the Committee on Fetus and Newborn of the American Academy of Pediatrics published a policy for use of Synagis, signed by 38 distinguished pediatricians. In a remarkably straightforward way, the first paragraph states:

…immunoprophylaxis should be reserved for use in infants and children at greatest risk of severe RSV infection because of the high cost of this intervention.

Three years later, RAND studied the cost-effectiveness of Synagis in premature infants without lung disease, one of the groups of concern with regard to increased vulnerability to RSV. The study concluded:

...the current recommendations for the use of palivizumab as RSV prophylaxis in premature infants without chronic lung disease are not cost-effective by today's standards. Our analyses support the implementation of more restrictive guidelines for RSV prophylaxis for these infants...

I can't offer expert assessment of the American Academy of Pediatrics guidelines or the RAND study. But I can say that that they are just the kind of studies and deliberations we would need to conduct explicit rationing in an ethical manner.

Major insurance coverage policies largely follow the AAP guidelines and associated studies. Aetna, for example, posts its coverage criteria on the web. As an ethics wonk I was impressed with the wording of the Aetna policy, especially the recurrent use of "Aetna considers Synagis medically necessary for..." rather than "Synagis is medically necessary for..." (emphasis added) By using "considers" Aetna acknowledges that it is making a policy judgment based on its assessment of when the value provided by Synagis warrants its use. That's rationing.

The bottom line is that without using the dreaded "r" word, our society is beginning to learn how to ration. When we become bold enough to say it out loud and practice it more widely we will be energized to work at cost containment in a serious manner.