Friday, June 27, 2008

Too Scared to Change

Curbing the rise in health care costs is the most important policy objective for the U.S. health system. Without cost containment we will not solve the problem of the uninsured. And as health costs continue to rise, the health sector destroys health-promoting elements such as greater wages, better education, and a cleaner environment.

The ultimate paradox is that our ever-increasing expenditures on health care are, in the long run, reducing overall population health and quality of life for society!

There are more than enough good policy proposals for reining in health care costs. The basic impediment is that we – the body politic – are afraid of change. Our fears are like musical instruments for all of the economic interests that are threatened by constraining expenditure – they can play on our fears and thereby undermine (thus far) even the wisest of policy proposals.

The most recent Kaiser Family Foundation publication – “Moving Away from Employer Based Coverage: Don’t Forget Public Opinion” – adds to our understanding of the barriers to change. There isn’t much to say on behalf of anchoring a health insurance system in employment except that it happens to be the way we manage the process in the U.S. But when a Kaiser Foundation tracking poll asked how people felt about the prospect of shifting to employer based insurance to self selected (individual) insurance, 60 % - 80 % felt that the shift would make things worse for them.

In presenting the report, Drew Altman comments:

Health reformers have learned the hard way in the past that whatever the appeal of policy proposals on their merits, they ultimately have to be acceptable to the public or they will not fly...It is an old law of health reform that despite frustrations with the health care system and a general desire among the public for reform, the burden is always on reformers who would change how people get their health care and health insurance today. That’s why the easy answer -- though not necessarily the right one -- is to assure people that they can keep what they have today.

Fear of fundamental change has led political leaders to opt for incrementalism. But incrementalism, like patching the Titanic, doesn't work. Findings like the Kaiser Foundation tracking poll suggest that we should only expect to see a combination incrementalism and wishful thinking in political campaigns. Whether or not moving to individual purchase of health insurance is a good idea, the poll tells us that genuinely fresh ideas are too risky. The most we can hope for between now and November is education of the public about the causes of cost escalation so that after the election we may be better prepared to respond to bolder leadership.

Wednesday, June 25, 2008

Secret Shoppers in Medical Practice

The fact that the AMA House of Delegates was planning to consider the use of “secret shopper ‘patients’” at its meeting earlier this month elicited a lively debate in Virtual Mentor, the AMA Journal of Ethics.

Dr. James Loden, founder and president of a vision center in Nashville, defends the use of secret shoppers on the basis of the ethical imperative to monitor and improve quality and the business imperative to compete effectively. (Dr. Loden’s practice competes with 53 eye specialists in the area and depends on patient to patient recommendations.) Secret shoppers offered a way to check on how his team, and he himself, performed when not being observed by others. He found that some staff was not following the expectation that they would explain to patients what was being done, and that he was leaving the exam room without asking if his patients had other questions. To make secret shoppers as secret as possible, Loden recommends that the decision to use them be made by the head of the practice and practice manager alone.

Dr. Richard Frederick, an emergency physician in Illinois, sees the use of secret shopper patients as unethical. Medical practice depends on trust, whereas the secret shopper methodology is based on deceit. And, if secret shoppers are sent into busy emergency departments, they could potentially block access for patients with true emergencies.

I think wise practice leaders will reject both these positions. The right first step is to engage colleagues – physicians, nurses, and support staff – in discussing how well the practice is serving its patients. Is it soliciting feedback? If not, why not? If the practice lacks crucial information for self-management, would secret shoppers provide what is needed better than other approaches? If so, I would proceed.

The primary value to be considered in deciding whether to use secret shoppers is quality of care. The secondary value is trust within the practice group. I can picture a situation in which (a) a practice has identified problems for which (b) secret shoppers might provide important information but (c) some members of the practice agree with Dr. Frederick that the methodology is intrinsically wrong.

In this situation I would recommend “processing” the disagreement within the practice group. The key issue is deepening the practice’s commitment to learning from their patients’ perspectives, not simply getting the secret shoppers’ observations. The wise practice leader will ask her anti-secret shopper colleagues – “if this methodology still offends you, how do you suggest we get the information we need…?

The idea of secret shoppers appeals to those who understand that medicine is an “industry,” with “customers” and “production processes.” The idea offends those who understand that medicine is a noble profession with long traditions of self scrutiny and self regulation. Both perspectives are correct. Neither is adequate without the other.

Even if a practice does not use secret shoppers, simply considering the idea can help those of us in clinical practice to step outside of ourselves and imagine our practice as it might appear to a trained observer.

The AMA Council on Ethical and Judicial Affairs presented an excellent report on secret shoppers to the AMA Delegates. (It has been referred to a further committee.) In my view the report hits the ethical nail on the head:

Physicians have an ethical responsibility to engage in activities that contribute to continual improvements in patient care. One method for promoting such quality improvement is through the use of secret shopper “patients” who have been appropriately trained to provide feedback about physician performance in the clinical setting. A sound secret shopper program should include the following elements:

(1) All relevant parties, especially those to whom secret shoppers will be making unannounced visits, should be notified that this mechanism is being implemented in their practice setting.

(2) The information collected by secret shoppers should be used only to identify areas of improvement and not as a basis for punitive actions. Third parties should not have access to information collected by secret shoppers that includes personally identifying data.

(3) Feedback from secret shopper “patients” should not be relied on as the sole source of data for evaluating clinical performance.

(4) The use of secret shopper “patients” should not be implemented in a manner that adversely affects access to medical care by legitimate patients. For example, the need for urgent care (such as in the emergency department setting) must always take precedence over secret shopper “patients.”

Monday, June 23, 2008

Self-Insured Employers and Health System Reform

We Americans cherish the right to carry guns. But what about the right to carry a paunch?

Waistlines Expand into a Workplace Issue” in yesterday’s New York Times describes early efforts by a small number of U.S. employers to take a public health approach to their employees’ weight status. When PSEG, a New Jersey utility company, recognized that overweight employees were likelier to experience musculoskeletal injuries, it began to offer weight control and nutrition programs, and provided a small financial incentive for employees to fill out a personal health assessment.

Compared to Japan, the PSEG program is public health lite. Japan recently passed a law requiring companies and local governments to measure the waistlines of all people between 40 – 74, to identify those whose girth exceeds the governmental target of 33.5 inches for men and 35.4 inches for women. If those who exceed the limit have not lost weight in three months they will be given diet education, with reevaluation after six more months.

More and more employers are turning to self insurance. This creates the potential for more employee engagement with the issue of health care costs. Better self-management of wellness, health, and medical utilization, are crucial requirements for success in improving quality and cost.

In recent years we have seen significant improvement in the degree to which patients and physicians collaborate in planning care. But the U.S. has had little success in engaging citizens in co-managing the health system itself. U.S. political culture is not going to allow employers to measure our waist size anytime soon. But there is significant potential for steps forward in rational governance of the health system via self insured employers.

The U.S. has moved steadily away from seeing health and health care as community responsibilities. Insurance has gone from being community rated (the same cost for all enterprises) to being experience rated (if my employees cost less, I pay less). Now we are trying to shift financial risk to individuals themselves.

Self-insured employers (the employer takes the financial risk for utilization, with third party administrators handling claims and other backroom insurance functions) are small communities. Whether the employee group is local, as in a utility company, or multinational, employees have a shared interest in the success of the organization. Employees are well-positioned to understand that health costs involve trade offs against other items of importance, such as compensation, benefits, and success of the business itself.

With skillful leadership, self-insured companies could engage employees in co-managing the company's health plan. This is a more promising approach than the individually-focused, "skin-in-the-game" use of deductibles that is currently fashionable. If I have a heart attack, the deductible will not prod me to shop for cost-effective care. But if my employer engages me in considering the cost of insuring me and my fellow employees, and I see that lower cost providers may provide high quality care, I will have a "duh" experience. Why should we - my fellow employees and I - pay more than is required to be well cared for?

If the U.S. was designing a health system from scratch, we would not ask employers to be insurers as well. But that's the way it is. If self insured employers and employees work together to manage the employer's health plan, we can make some local progress in making our cockeyed health system function better.

Sunday, June 8, 2008

I'll be back on June 16

I spent last week in London (I wrote the two posts before leaving) and will be in a little village in Italy in the foothills of the Maritime Alps this week. I'll be back to the blog on June 16.

Best to all!

Thursday, June 5, 2008

Hospital Organizational Ethics

The Journal of Medical Ethics recently published an interesting study from the University of Toronto Joint Centre for Bioethics - "Clinical Ethicists' Perspectives on Organizational Ethics in Healthcare Organizations."

The authors interviewed clinical ethicists at eight academic hospitals, four general hospitals, and one community-based care agency in the Toronto area. The participants were asked about the organizational ethics issues their organizations were facing, how these issues were being addressed, and how effective the process was.

The participants identified four major organizational issues:

1. Resource allocation. Canadian hospitals are financed by global budgets negotiated with the provincial health plan. A fixed budget highlights trade off decisions. The ethicists identified having a fair process - a topic my colleague Norman Daniels and I have written about extensively - as a key organizational need. One interviewee commented:
"How do we make decisions about resources in terms of money, as well as staff, and how do other resources get distributed? What model or models of distributive justice or resource allocation...ought we to be considering."
2. Moral distress and organizational moral climate. In the research and consultation I have done, questions like "what keeps you up at night?" and "what do you feel best...and worst about in your work?" have been very productive. Moral distress isn't an infallible sign of an organizational ethics issue. Lucifer was distressed by the conditions in heaven, but that is taken reflect moral failing in Lucifer, not heaven. But investigating moral distress will have high yield for identifying ethical hot spots in an organization.

The ethicists identified seven factors contributing to a positive moral climate: alignment of decisions with the hospital's stated values; transparency about management processes, decisions and actions; staff involvement in organizational decision-making; opportunities to raise difficult ethical issues safely; public recognition of admirable achievements; respectful relationships among staff; and fair employment practices.

3. Conflict of interest. Interestingly, the ethicists felt that by and large the hospital policies on financial conflicts set limits on monetary conflicts, and that non-finacial conflicts - prestige, personal advancement, etc were more problematic.

4. Clinical issues with a significant organizational dimension. Clinical ethicists and clinical ethics committees are increasingly encountering major organizational components to issues that are defined as "clinical." The examples cited include decisions about access to care for uninsured patients, decisions related to disclosure of medical error, and a range of issues arising in end-of-life care.

The authors conclude that "the extent to which 'clinical ethics' cases were embedded with an organizational dimension...suggests that the common distinction between clinical and organizational ethics may be overdrawn in the practice of direct patient care...Where once the clinical ethicist's role focused primarily on ethics in discrete clinical or research relationships, its focus is expanding to include ethics in a broader range of organizational relationships and issues."

That's the reason I started this blog!

Monday, June 2, 2008

Technology Running Amok

My colleague and friend Muriel Gillick’s important article - “The Technological Imperative and the Battle for the Hearts of America” – ends as follows:

Instead of waiting until the rate of [Medicare] expenditures becomes intolerable and then instituting draconian cutbacks in covered services, we have the opportunity to start now to shape the development and diffusion of medical technology, the principal determinant of the growth in costs. The story of the LVAD [Left Ventricular Assist Device] gives us a model of when and how to intervene.

How right she was!

A case study in the January/February issue of the Hastings Center Report tells the story of Mr. P, a 62 year old man with severe congestive heart failure. Eight months earlier he had an LVAD implanted as a “destination therapy,” told by his doctors that the device would improve his capacity for self-care and allow him to lead a more active life. This didn’t happen. Instead, things went from bad to worse. For five months after surgery Mr. P was in the intensive care unit, with one complication after another. Now, after three months at home, he no longer wants to live in the state he is in, and has asked to be readmitted to the hospital to have the LVAD turned off. He knows that he will probably die within a few hours after the device is silenced.

The case asks – “should Mr. P’s physicians accede to his request and disable his LVAD?”

In the Hastings Center format, two ethicists comment on the case. One saw the situation as reflecting the right of a competent person to decline treatment – here the implanted LVAD. The other reached this remarkable conclusion:

Once the patient leaves the hospital, the LVAD ceases to be a medical treatment and becomes effectively part of the patient himself, much like a transplanted organ or even a native one…We would not remove a patient’s biological heart, transplanted or native, simply because the patient was suffering greatly from heart failure and did not want to go on; nor should we disable his LVAD.

The logic of this argument is coherent and elegant, but the position brings to mind Schopenhauer's comment about a view that he felt called for a cure, not a refutation!

Not only has Medicare run amok in its approach to approving new technologies with no attention to the opportunity costs entailed, but now we can envision the device itself clamped onto the recipient in perpetuity. We are in the process of letting Medicare devour the common good. Before long we we will let the new technologies devour their recipients.

What next!