Friday, April 30, 2010

Jury Convicts John Odgren of First Degree Murder

After a relatively short 12 hour deliberation, a Massachusetts jury found John Odgren guilty of first degree murder. Odgren, who was 16 at the time of the crime, will receive a mandatory sentence of life in prison without possibility of parole.

Unless jurors speak with the press we won't know about their reasoning. But the verdict suggests that they set a high bar for the insanity defense. There was no doubt that Odgren is a severely disturbed young person. As part of Asperger's syndrome he was obsessed with fantasies of violence, and testimony suggested a significant degree of paranoia. But testimony also showed that he had ruminated about how to commit a "perfect murder" - ruminations that were carried out in the killing of 15 year old James Alenson.

From the published account of the prosecution's psychiatric expert's testimony, it appears that the prosecution relied on a common sense form of argument. If Odgren was in a state that prevented him from comprehending the wrongness of his actions or from governing himself, the expert said, we would expect those characteristics to show themselves after the crime.

This didn't happen. Odgren was quoted as saying "What have I done?" and seeking help for Alenson.

I imagine someone on the jury asking "is there anyone on this panel who has never done something we knew to be wrong?" The jury's analysis may have been that while the fantasies of violence and the unrealistic fears Ogdren suffered from were different from the more ordinary temptations and impulses that are common in life, they should have been resisted (their ethical analysis) and could have been resisted (their factual analysis).

It's heartbreaking to contemplate James Alenson's death. But Ogdren's situation is also tragic. The testimony left no doubt that he suffered for most of his 16 years before the murder, and will now spend a lifetime in jail. I hope that as he, and his brain, mature, he will find ways of using his intelligence to do something positive in prison, and for the wider world. He might be able to provide some understanding of what could help prevent tragedies of this kind from happening in the future.

Wednesday, April 28, 2010

Massachusetts Murder Trial Goes to Jury

On January 19, 2007, John Odgren, a 16 year old sophomore at Lincoln-Sudbury Regional High School in Massachusetts, fatally stabbed 15 year old James Alenson, a freshman he had never met. Yesterday, after a three week trial, the case went to the jury.

Odgren, who has been diagnosed with Asperger's disorder, a form of autism, has a "near genius" IQ of 140. He had been in special needs programs since he started school, but had recently been "mainstreamed." He was described as obsessed with violent fantasies and had spoken in class of how to commit a "perfect murder."

There is no question about the basic fact that Odgren attacked Alenson with a large knife he had brought from home. The question the jury will have to decide is whether Odgren should be held responsible for what he did, or found not guilty by reason of insanity.

Here are excerpts from today's Boston Globe:
A Middlesex Superior Court jury yesterday began deliberating the fate of a teenager who was described as both a methodic murderer and a student whose mental sickness drove him to kill, punctuating a high-profile three-week trial that raised questions about the treatment of mental illness in schools and in the courts.

Defense attorney Jonathan Shapiro urged jurors to consider the teenager’s lifetime of mental illness and find him not criminally responsible, by reason of insanity, in the stabbing of student James Alenson in a bathroom at Lincoln-Sudbury Regional High School three years ago.

But Dan Bennett, assistant Middlesex district attorney, called Odgren a calculating killer who thought he was planning the perfect murder, only to see Alenson stumble out of the bathroom and spoil his plans for escape. It was then that Odgren showed regret for his actions, Bennett said.

No one disputed that Odgren stabbed Alenson or that he suffers from mood disorders, depression, anxiety, and Asperger’s disorder, a form of autism and a neurological condition that causes one to lack the social and emotional skills to interact properly with others.

But whether he knew what he was doing and whether he had the ability to control himself — the guidelines in criminal responsibility — will be at issue in jury deliberations.

Three mental health specialists testified for the defense that he was legally insane at the time of the killing, but one psychiatrist testified for prosecutors that Odgren was aware of the consequences of his actions.
I wanted to discuss this murder trial in a blog about ethics because as I see it, the task facing the jury in reaching its verdict is not deciding what the facts were but rather how to interpret them.

Massachusetts takes its definition of "insanity" from the American Law Institute Model Penal Code:
a person is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law.
There's no doubt that John Odgren suffers from a serious "mental disease or defect." But did that prevent him from knowing that (a) killing James Alenson was wrong and (b) controlling his behavior? And how much "capacity" must he have to be held responsible? Answering those questions involves values as well as facts.

In psychiatric practice I often explored the issue of responsibility with my patients. Assessing with them how much they could steer the course of their own lives and how much they were steered by an ailment that robbed them of self governance was an important part of treatment. Exploring the question was often "therapeutic" in itself, since it involved a respectful view of them as potentially capable of "rational" action despite their illness.

When discussing aberrant behavior with patients and their families I sometimes said "just because X has schizophrenia doesn't deprive him of the right we all have to act like a jerk!" X usually appreciated this attitude. Better to be seen as "acting like a jerk" than to be dismissed as "what can you expect from a nut!"

I've never met John Odgren, and while I followed the trial in the newspaper, I didn't hear the testimony. I'm not sure how I would vote if I was on the jury. But I'd approach the deliberation with the background attitude that psychiatric illness - even severe illness - doesn't necessarily erase our ability to steer our conduct and our responsibility to do so.

Sunday, April 25, 2010

Psychiatrists should talk with patients, not just give pills

My psychiatrist friend Danny Carlat has an important and deeply moving article in today's New York Times Magazine.

Danny describes the pendulum swing for psychiatry - going from a "brainless" phase, in which psychological factors were seen as the cause of all psychiatric troubles, to its current "mindless" phase in which "chemical imbalance" is looked to as the explanatory factor. Danny referred to my cohort of psychiatrists - who were trained with a strong psychological grounding in the 1950s - 1970s but were able to incorporate the advances in psychopharmacology that have emerged in the last 20 years as a "golden" generation, able to offer "the full package of effective psychiatric treatments to patients."

Danny started his residency training in 1992, which means that he emerged into a world that made "split treatment" the expectation. Psychiatrists made diagnoses and prescribed medications. Psychologists, social workers, and psychiatric nurses provided psychotherapy.

Happily, my career did not involve that model. I had a large panel of patients in my practice. I did psychotherapy and, when medication was called for, prescribed it. When patients began to ask if I was a "psychopharmacologist" I was puzzled. We wouldn't ask a primary care doctor if he was a prescriber. Talking with patients, getting to know them as full human beings, and conducting whatever form of psychotherapy was called for, and, at the same time, assessing their symptoms, thinking through the diagnosis, and prescribing any medication that was called for - that's what it meant to be a psychiatrist.

Danny's superb article discusses all of this with eloquence and depth. But what's most moving is how he weaves in his own life story. His mother suffered from a severe mental illness. During his junior year in college she committed suicide. "Psychiatry," he tells us, "then became personal, a way for me to come to terms with her illness."

After discussing the flaws in the "split treatment" model, Danny describes the kind of integrated treatment that I had the good fortune to be able to apply. But he doesn't just talk in the abstract - he makes the topic as personal as could be. Here's how the article ends:
During my mother’s last months, she isolated herself from her family, so I don’t know what kind of treatment she was receiving before her death. But I do know what kind of treatment I would have hoped for her. She needed medication to combat her paranoia and the emotional pain of her depression. She needed someone who could expertly probe her thought process, in order to understand the fateful logic that led her to conclude that the only solution was to end her own life. She needed treatment that was intensive and exquisitely coordinated.

Such care is not always capable of saving damaged lives. But it is the best that we can do. It’s what we owe our patients — and ourselves.
I couldn't agree more!

I encourage readers to follow the link to Danny's article. It's full of hard-earned wisdom!

Monday, April 19, 2010

Why We Need Wise Primary Care Physicians - A (small) Personal Experience

Last week, while working at my desk at Harvard Medical School, my left foot started to hurt. I stood up. The foot felt like it was on fire.

I took off my shoe and sock. There was an obvious swelling on the back of my foot, somewhat blue, looking like a bruise.

But I hadn't twisted my ankle and nothing had fallen on my foot. I'd been sitting at my computer, writing. I decided to wait. Maybe the pain would just go away on its own.

But instead of getting better, it got worse.

My skills at general medicine are rusty, but I tried to figure out what was happening. Injury seemed the likeliest source of foot pain, but I couldn't remember an injury. Could I have some kind of bleeding problem? I didn't have any other bruises so that didn't seem probable. Some years ago a friend had died of a rare muscle sarcoma that first showed up as a painful swelling. But that's a VERY rare condition, and I couldn't imagine it popping up so quickly.

I put my foot up, finished my work, and hobbled to my car to go home. I put an ice pack on the swelling and sat with my foot up. I was able to work at home the next day, and did more or less the same thing.

Meanwhile, my wife spoke with friends at the college where she teaches. They seemed worried. They imagined various terrible possibilities. Had I seen my doctor?

In medical school my most influential teachers conveyed an approach I applied all through my own years of practice. In an emergency, act now. In non-emergent situations, when it's not clear what's going on, apply what the old timers called "tincture of time" (see here and here) - waiting, combined with tempered optimism and availability.

That's what I did.

In 36 hours, tincture of time did the job.

If I didn't have my own (rudimentary) primary care skills I might have gone to a doctor (assuming I had one, which, happily, I do), or, if worried enough, to an emergency room. I expect that a good primary care physician would have done just what I did.

But an overly rushed physician, or one practicing under the spell of defensive medicine, might have done this:

Or this:

I didn't need a primary care physician last week - I was able to be one to myself. But most of the population hasn't gone to medical school and done a year-long internship in general medicine at UCLA. I'd like to picture the thought process I went through, the common sense measures I applied, and the TLC I was able to give myself, as available to all at the other end of a phone call or in an office visit.

We need wise primary care physicians!

Thursday, April 15, 2010

Tea Party and Health Reform

Yvonne Abraham, a columnist for the Boston Globe, attended the Tea Party gathering yesterday on the Boston Common. Abraham reported a fascinating interview with Donna Tripp, a 55 year old Massachusetts resident. In what follows, I've interspersed my comments in italics:
Like everybody else at the rally yesterday, Tripp hates, hates, hates the health care overhaul recently signed into law.

"This country is taking a hard right turn for socialism,’’ she said. “I don’t want to be told to buy a service I don’t want. America is about freedom of choice."

Tripp, 55, already lives in a state that requires everybody to buy health insurance, but she refuses to do it.
As I've discussed in previous posts (here, here , and here), the cumbersome and confusing requirement that individuals acquire insurance or pay a penalty is actually a tax in drag. We in the U.S. are so averse to taxation that Massachusetts (2006) and the federal government (2010) chose not to finance the quest for universal coverage through a general tax. The mandate isn't a requirement to purchase a consumer good - it's an awkward effort to create a public funding stream without making it obvious that it's really a form of taxation. As I've said before, unless one opposes universal access to coverage, the alternative to the mandate as some form of single payer tax. Donna Tripp knows this and doesn't evade the issue!
"I’m healthy," she said. When her husband went to Canada for prostate cancer treatment five years ago, they paid $25,000 out of pocket.

But what if she got really sick — if she needed, say, heart bypass surgery, which could cost more than $100,000?

"I’d mortgage my house,’" she said. And if that wasn’t enough?

"I guess I’d die," she said. "But under our Constitution, I should be able to take that risk."
Donna Tripp deserves credit for being consistent! She understands and accepts the consequences of choosing to be uninsured. Of course, when the need for bypass surgery or a potentially curable cancer actually emerged, Ms. Tripp might feel differently. But she instructs us in advance to respond - "Donna, we'll miss you, but it was your choice!"
More likely, Tripp would get her treatment, and if she couldn’t afford to pay for it, the rest of us would pick up the tab.

That’s how this country is set up: According to the preamble in the little Constitution the kind man gave me, we are all about promoting "the general Welfare."

Or maybe that’s the country we used to live in.
As a country we're not prepared to do what Donna proposes - let people sink or swim in accord with their ability to pay for health care. We're all free to refuse any proposed health care interventions, but as Yvonne Abraham points out, the Preamble of the Constitution commits "We the People of the United States, in Order to form a more perfect union [and] promote the general ordain and establish this Constitution..." As a civilized society we're finally moving towards universal health protection, which, like education, is a basic component of "general Welfare." The Declaration of Independence likewise committs us to promoting "life, liberty and the pursuit of happiness."

It's hard to pursue happiness when we're dead from a potentially curable condition!

Donna Tripp, like all Americans, is entitled to reject life saving bypass surgery. But our Constitution requires us to make medical care available to her and her fellow citizens, just as it requires us to "insure domestic Tranquility [and] provide for the common defense."

Wednesday, April 14, 2010

The Latest Republican Posturing on Health Reform

Ever since South Carolina Governor Mark Sanford turned down $700 million in stimulus funds just prior to visiting his sweetie in Argentina, Republicans have been competing with each other to see who is fiercest in fighting the federal government.

Georgia insurance commissioner John Oxendine is the most recent entrant into the "my resistance is longest and fiercest" contest. In an effort to distinguish himself from other candidates in the Republican gubernatorial primary, Commissioner Oxendine has refused to create a high risk insurance pool for Georgians with medical conditions that make access to insurance overly expensive.

Oxendine says his refusal is not political. Here's the opening of his letter to Secretary Sebelius - decide for yourself:
I am in receipt of your April 2 letter detailing the first step in the recently enacted federal takeover of the United States health care system.

The new federal health legislation was hastily drafted behind closed doors and passed as a result of numerous back room deals in defiance of the will of a majority of the American people. The legislation represents nothing less than a government takeover of approximately 17 percent of the United States economy.
I wish I could read the minds of the Oxendines of politics and talk radio to fathom how much they believe the talking points they repeat in zombie-like fashion and how much they are choosing to manipulate our longstanding and not unwarranted preference for individual responsibility and local initiative rather than large federal programs. My hunch is that the leaders are cynical manipulators and the tea party participants are, in large measure, well intentioned people who've been played upon by demagogues.

I'm in the middle of teaching the required Harvard Medical School medical ethics course. Like the U.S. population itself the students array themselves along the political spectrum. But all of them share a strong moral conviction that every American should have access to decent health care. I'm sure the same is true for medical students in Georgia as well. The near total absence in Republican rhetoric of any acknowledgment of our societal responsibility to ensure decent care for all may be effective demagoguery, but it's a deep disservice to the idealistic spirit we need and want in the next generation of caretakers.

Tuesday, April 13, 2010

Massachusetts Health Plans - Damned if You Do and Damned if you Don't!

Yesterday Superior Court Judge Stephen Neel denied the request from six not-for-profit Massachusetts health plans to be allowed to go forward with the rates they proposed on April 1 for the small group market. The insurance commissioner had rejected 235 of 274 rate proposals.

Massachusetts insurers dominate the U.S. News & World Report ranking of commercial health plans: Harvard Pilgrim is first, Tufts Health Plan is third, Fallon Health Plan is seventh, Health New England is eighth, Blue Cross/Blue Shield is number twelve,and Neighborhood Health Plan is 50th (out of 239 that were ranked). All typically earn small margins, and last year four were in the red. Now they're being pilloried for gouging the public. No good deed goes unpunished!

Many years ago I participated in a workshop led by Barry Oshry that divided a management group into tops, middles and bottoms. Middle managers were caught between the suspicious and resentful bottoms, the demanding and bossy tops, and the expectations of external constituents. Middles felt disempowered, unappreciated, and jerked around by forces they couldn't control.

Oshry's exercise focused on internal organizational function. But the findings apply to the external world as well, where health plans are caught between (1) providers whose services they pay for, (2) employers whose insurance premiums they are entrusted with, (3) enrollees who want access to the doctors and hospitals they prefer, and (4) regulators who oversee the health sector.

Here's my six step explanation of what's happening:
  1. No one wants to acknowledge the need to manage health care, because doing so requires acknowledging how much we physicians don't know and how ultimately vulnerable we mortal beings are.

  2. In the 1990s, when public policy asked insurers to take on the nasty business of managing care, some insurers - especially among the for-profits - seized the opportunity to rip revenues out of the system, without much worry about the impact on patients. But some, like the not-for-profit plans in Massachusetts, did the job well, as judged by clinical and ethical criteria.

  3. Providers turned against the concept of managed care itself, not just badly managed care. Public opinion and politicians followed them, creating an unstoppable backlash.

  4. Insurers were then told not to manage care.

  5. Between the backlash against managed care and the consolidation of providers into larger groups with power to demand ever higher payment, costs have soared into the economic stratosphere.

  6. Now, with Massachusetts in the vanguard, insurers are pilloried for the how much care is costing.
To show how fast the social learning curve is evolving, consider the following statements:

William Van Faasen, CEO: "I won’t invest any energy of mine, and I don’t want the company to invest any, in arguing that the current rate of increase in health care costs is appropriate."

Jay McQuaide, vice president: "We’re confident in the final outcome of the case. We’ll be playing the process out. We look forward to having an opportunity to demonstrate that the costs we filed are appropriate and reflect the expected medical costs of insuring these customers."

What's interesting about the quotes is that they're both from today's paper and they both come from the same company, Blue Cross and Blue Shield of Massachusetts.

From a narrow actuarial perspective, McQuaide is correct. The rates reflect the bills the insurers are paying for the enrollees' care. From a societal perspective, however, Van Faasen is correct. It would hardly be possible to design a health system better designed for profligate expenditure and poor value for money than we've done in the U.S.

Tomorrow Massachusetts Senate President Therese Murray is expected to propose an approach to resolving the standoff by bringing the key stakeholders together, presumably under the wing of the state government, which would allow competitors to cooperate without a threat of prosecution for anti-competitive practice.

The wild rumpus has moved from Washington DC to Massachusetts!

Sunday, April 11, 2010

Health Reform from the Ground Up - National Alliance on Mental Illness

For the past year "health reform" has meant activities on Mount Olympus (Washington DC) and the foothills (state capitals). But true reform typically arises from more humble origins.

On March 30, Harriet Shetler died in Madison, Wisconsin, at 92. In 1977 Ms. Shetler was anxious and preoccupied about her son Charles, who had been diagnosed with schizophrenia. A friend at the Congregational Church she attended suggested that she talk with Beverly Young, another church member whose son also had schizophrenia.

Harriet and Beverly met for lunch at the Cuba Club in Madison. In addition to having children with schizophrenia, both women were active in church and other civic activities, and they felt an immediate rapport. Harriet's daughter Jane Ross described them as "two women grieving over their personal associations with their sons, and they decided to get together, to pull together a meeting of [others] with similar interests in Wisconsin."

In April 1977 Harriet and Beverly convened 13 people at a night club in Madison. Harriet suggested that they call themselves "Alliance for the Mentally Ill," partly because the acronym, AMI, meant "friend" in French. Within 6 months they had 75 members.

In 1979 the Wisconsin group came upon a newsletter from a similar group in California. Harriet Shetler and Beverly Young organized a national conference. They expected 35 attendees, but 250 came, including Dr. Herb Pardes, then director of the National Institute of Mental Health. The attendees created and launched the National Alliance for the Mentally Ill, NAMI. (The organization has tweaked it's name but retains "NAMI," which is known to every mental health professional.)

Here's how Harriet Shetler explained NAMI's mission in a letter to the editor in 1993: "We are trying to change, one person at a time, society's attitudes toward mental illness. We are trying to level the playing field to improve job opportunities, access to housing and the chance to live in the community instead of being warehoused in an institution."

Over the years I referred many families to NAMI's family-to-family program, a twelve session course taught by trained family members. NAMI has been a super-strong lobbying force on behalf of services for people with severe mental illness.

At NAMI's 25th anniversary in 2004 Harriet said: "For 25 years we laughed when we could and we cried over the too-early deaths of our children, and we waited for the light. [Moving forward] let’s pull up our socks, and never, ever lose heart, my co-conspirators on this journey."

Harriet Shetler knew what real health reform meant!

(I gathered the information for this blog from the New York Times obituary, a statement by Michael Fitzpartick, executive director of NAMI; and an article in the Wisconsin State Journal.)

Friday, April 9, 2010

Can Massachusetts Control the Cost of Health Reform?

In the course of 20 years of studying and writing about health system ethics and health reform I've gotten progressively more humble about the impact of academic analysis and progressively more interested in understanding how democratic systems actually learn and change. Massachusetts gives a window on this process.

As I've discussed in my last two posts (here and here), Governor Deval Patrick has applied a two by four to the health system by rejecting the rate increases proposed by Massachusetts insurers. The insurers are suing the state. The Governor's flagging reelection campaign has perked up - attacking insurers is a good tactic, especially if your strongest rival is a former insurance company CEO!

Yesterday's Boston Globe editorial points to how the Governor's electioneering move could potentially catalyze social learning. I've copied the editorial below, interspersed with my comments in italics:
After Health-insurance companies covering individuals and small businesses demanded rate hikes of up to 32 percent earlier this year, the state stepped in and rejected the great majority of them. Today, six big insurers are going to court to block the state action. The judge should let the rejections stand — and the state’s action could finally compel all involved in the unsustainable inflation of health costs to slow it down.

The Globe understands that the cost of health insurance reflects the bills they pay to hospitals, physicians, and other providers. But they endorse the Governor's actions anyway - not as wise economic policy (it isn't) but as a political brickbat that might drive all the key players to the negotiating table.

The insurers point to data from a recent report by the attorney general showing that prime drivers of premium increases are not their own costs but the increasing rates for hospital stays and doctors’ visits, and a tendency among patients to seek treatment at higher-cost facilities.

Fear of price controls could motivate providers to join with insurers to take hold of the cost trend in new ways rather than choosing to point fingers at each other.

The same data also show, however, that insurers have agreed to pay higher reimbursements to hospitals based on their geographic location or market clout as big teaching hospitals. The Patrick administration is right to fault insurers for not doing a better job of using their own clout to demand lower rates from such providers. If anything, the possibility that the state might reject excessive rate increases gives insurers more leverage in negotiations with hospitals.

This is complicated. The backlash against managed care - orchestrated in large part by providers - led insurers to back off from aggressive efforts to contain costs. Having the rate increases rejected does give insurers more leverage. But in Massachusetts, whose not-for-profit insurance companies are nationally recognized as the best in the country, it would be possible in principle for the Governor say: "We in Massachusetts are lucky. Our Massachusetts-based health insurers are not owned by out-of-staters! They're well managed, ethically guided, not-for-profits. On behalf of the citizens of Massachusetts I'm asking them to join with our superb doctors and hospitals to find ways to bring down our costs. This will involve sacrifices for everyone, but that's what let us launch the reform process four years ago. This is a Massachusetts process - not a Republican or Democratic one. Governor Romney [a Republican] got us off to a good start and I [a Democrat] want to build on the foundation he and the legislature created."

Still, insurers can’t carry the entire burden of containing medical costs. The crisis brought on by the state’s rejection of the premium hikes for small businesses should spur the Legislature to give the governor and insurers new tools to control costs. Governor Patrick is seeking the power to regulate not just insurers’ rates but the reimbursements that providers get — a reasonable proposal. The insurers want to limit the freedom of individuals to jump into the market when they need a costly procedure and then opt out again once the insurer has paid for it — a justifiable request.

With those new tools, the state and insurers can work together to ensure that doctors and hospitals get paid reasonable, but not excessive, rates, and that small businesses aren’t throttled by unbearably large premium hikes.

These are reasonable ideas, but guess who's still not being talked about? It's us, the public, "consumers" of health care. As patients we have to ask our doctors and hospitals to take care of us in an efficient, frugal manner. As employees we have to ask our employers to make sure the insurers they contract with for us manage care actively - directly or via provider groups that accept financial risk.

This spring is crunch time for Massachusetts health reform. If the brickbat the Governor has launched leads to innovative action by insurers and providers, and new learning for the public, the other 49 states will be able to learn from us. If we regress into finger pointing and sloganeering, our promising health reform process will go down the tubes.

Tuesday, April 6, 2010

Massachusetts Health Insurers Sue the State

The health reform pot is boiling over in Massachusetts!

In a post three days ago I described how the Governor rejected 235 of the 274 insurance rate proposals for individuals and small businesses that were to have gone into effect on April 1. Yesterday Blue Cross and Blue Shield of Massachusetts, Harvard Pilgrim Health Care (where I direct the ethics program), Tufts Health Plan, Fallon Community Health Plan, Health New England, and Neighborhood Health Plan filed a suit against the state to reverse the decision. Here's the statement made by the Health Plan Association:
Last week’s decision by the Division of Insurance to set an artificial cap will do nothing to fix the real problem of rising health care costs. The Division’s effort to artificially cap rates is a reckless decision that is based in politics and will wreak havoc on the entire health care system. It ignores recent reports from the Attorney General and the Patrick Administration, including the Division, that have pointed to a number of factors for rising premiums, most notably the market clout of providers and provider rate increases.

This unprecedented move by the Division is likely to cause greater costs and confusion in the marketplace and will have the effect of splintering the coalition of groups that worked in 2006 to pass the state's landmark Health Care Reform Law.

Four of the five major health plans experienced operating losses last year. The rates that the health plans filed for April 2010 are actuarially sound, which is the basis upon which the Division’s decision should have been made. The Division’s decision has capped rates at levels it knows are insufficient to cover the cost of medical services and will result in collective losses to the state’s not-for-profit health plans that will exceed well over $100 million in 2010.

Massachusetts is home to the country’s best health plans, which are consistently rated tops in terms of quality and member satisfaction according to independent national accrediting organizations, including the National Committee for Quality Assurance. We will continue to work with the Legislature on meaningful reforms to help address the underlying factors driving health care costs to provide real, long-term and substantial relief to small businesses this year.
The insurers suing the state are all non-profit organizations. 90% of the premiums they receive are used to pay for medical services. One observer compared trying to control health costs by capping insurance premiums to trying to stop the incoming tide with a line in the sand! I speculated that the Governor understands this, and that in addition to playing politics by attacking insurers, he might by trying to shake the system by applying a two by four to a vulnerable (and politically advantageous) point - the insurance industry.

Trying to control health care costs by (a) capping insurance premiums while (b) ignoring increases in the 90% that comes from provider charges in (c) a political context that vilifies insurers as "villains" is (d) not a promising approach!

Ten years ago Tufts Health Plan tried to reject the price increases Massachusetts General Hospital and the other Partners HealthCare members were demanding. Partners withdrew from the Tufts system. Tufts subscribers raised a ruckus. After nine days, Tufts backed down. The Boston Business Journal summed up the situation this way (see here):
Until about a year ago, insurers were in the driver’s seat. Now, the big hospital networks, especially Partners, have been calling the shots. The likely outcome, say experts: significantly higher premiums for Bay State employers.
Blaming one cog in the health system wheel may be good short term politics. Having applied a two by four to the state health system, the Governor should now convene insurers, providers, employers, and public leaders to work together with the state to bring down health costs. That would be real leadership.

Saturday, April 3, 2010

Pogo Possum in Massachusetts

'sWhere is the matchless political philosopher Pogo Possum? We need him in Massachusetts!

On Thursday Massachusetts Insurance Commissioner Joseph Murphy rejected 235 of the 274 rate increases proposed by insurers for plans covering individuals and small businesses.

For several years Massachusetts law has allowed the commissioner to turn down health plan premium increases:
The subscriber contracts, rates and evidence of coverage shall be subject to the disapproval of the commissioner. No such contracts shall be approved if the benefits provided therein are unreasonable in relation to the rate charged, nor if the rates are excessive, inadequate or unfairly discriminatory. Classifications shall be fair and reasonable.
Thursday, however, is the first time this power has been exercised.

It didn't take long for Governor Deval Patrick's likely opponents in the November election to interpret the action as a salvo in the campaign (for example, see this article in the Boston Globe). Charlie Baker, the likely Republican nominee, was CEO of Harvard Pilgrim Health Care for ten years, and took the company from receivership to solvency and rating as the top commercial health health plan five years in a row. President Obama has led the way in attacking the health insurance industry. Pundits speculated that the Governor wants to tarnish Baker's credentials before the election.

If Pogo Possum were with us he would start by asking what makes health insurance so expensive. He'd be told - "90% goes for medical services." Then Pogo would ask why medical services cost so much more than anywhere else in the world. The answer - "our prices are higher and our doctors do a lot of things that aren't needed." Pogo would be puzzled - how come Americans let this happen? "When insurance companies tried to manage care in the 1990s politicians and the public raised hell."

Pogo's conclusion: "We have met the enemy...and he is us." He'd tell us that trying to control insurance costs by (a) capping premium increases while (b) ignoring increases in the 90% that comes from provider charges and (c) vilifying insurers when they try to modify the cost trend is (d) folly.

Insurance Commissioner Murphy was totally correct in concluding that insurance costs are "unreasonable relative to the benefits provided," but his conclusion applies to the entire U.S. health system. We spend vastly more than other developed countries, have poorer health status and lower satisfaction with the system itself. "Unreasonable" is a mild term to apply to the U.S. system.

Here's what I think Pogo would advise:
"You folks in Massachusetts have all kinds of professors and analysts telling you why health care costs so much. All that wisdom hasn't done anything for you. Don't you know about the farmer and the mule? He asked the mule politely to plow the field but the mule just stood there. He reasoned with the mule but got nowhere. He complained to the neighbor who'd sold him the mule. The neighbor took a two by for and walloped the mule on the head. Then he whispered - 'it's time to plow the field' in the mule's ear. The mule went to work right away. The neighbor explained - 'I told you to be polite with him, but you have to get his attention first!' You folks in Massachusetts are like the farmer - you keep talking politely and reasonably, but the public isn't paying attention"
In addition to whatever political campaign motives the Governor has, there's a chance that he's following Pogo's advice. Here's what the Governor said:
"We’re seeking to try to give some relief to working families and to small businesses. For a long time, policy makers have been defeated by the complexity of it, so what we’re trying to do is pierce through."
As a "solution" to the health care cost spiral, capping insurance premiums is absurd. But as a two by four applied to the head of the body politic it just might "pierce through"!

I'm one of the many Massachusetts folks who've contributed thoughtful, polite analyses of the health system to our public discussion. Perhaps I should have gone to the lumber yard instead!

Thursday, April 1, 2010

Google, Facebook, and a Suicidal Patient

A recent Washington Post article posed a fascinating ethical question about psychotherapists and the web:
As his patient lay unconscious in an emergency room from an overdose of sedatives, psychiatrist Damir Huremovic was faced with a moral dilemma: A friend of the patient had forwarded to Huremovic a suicidal e-mail from the patient that included a link to a Web site and blog he wrote. Should Huremovic go online and check it out, even without his patient's consent?

Huremovic decided yes; after all, the Web site was in the public domain and it might contain some potentially important information for treatment. When Huremovic clicked on the blog, he found quotations such as this: "Death makes angels of us all and gives us wings." A final blog post read: "I wish I didn't wake up." Yet as Huremovic continued scanning the patient's personal photographs and writings, he began to feel uncomfortable, that perhaps he'd crossed some line he shouldn't have.

Across the country, therapists are facing similar situations and conflicted feelings. When Huremovic, director of psychosomatic medicine services at Nassau University Medical Center in New York, recounted his vignette last year at an American Psychiatric Association meeting and asked whether others would have read the suicidal man's blog, his audience responded with resounding calls -- of both "yes!" and "no!" One thing was clear: How and when a therapist should use the Internet -- and even whether he or she should -- are questions subject to vigorous debate.
In my view, Dr. Huremovic got the ethical challenge exactly right. With his patient in the midst of treatment for an overdose, the information might have life and death implications. Perhaps his patient wrote about what substances he intended to ingest. That could be important for the emergency medical treatment itself. Or perhaps the blog would suggest a stronger suicidal drive than Dr. Huremovic was aware of. That could guide psychiatric treatment after recovery from the overdose.

But what about confidentiality?

From the perspective of the patient, the clinician's responsibility to do what he can to save his patient's life and health clearly trumps confidentiality concerns. The patient had been speaking to the public through his blog. The patient's friend knew about the blog and about the treatment with Dr. Huremovic. If, in the future, the patient accused Dr. Huremovic of "violating my privacy - you went to my website without my permission," Dr. Huremovic would rightly respond - "I'd rather risk disturbing your concern with privacy than attending your otherwise avoidable funeral!"

If the patient was a philosopher familiar with rule utilitarianism he might respond - "the issue isn't just the impact on me - your actions will reduce overall trust in the future patients who are suicidal may avoid therapy out of privacy concerns...what you did increased the risk that people will die from suicide!" Here Dr. Huremovic could make a two part response. First, he might challenge the empirical claim - "I think it's just the opposite - how could potential patients trust therapists who would let theoretical concerns outweigh commitment to their patient's lives?" But beyond the competing hypotheticals Dr. Huremovic could say "In theory you could be right about the impact on others - but given the uncertainty, combined with the emergency, I felt - and continue to feel - that my primary duty was to your safety."

In the course of looking to see whether therapists have expressed opinions about situations like this I came upon Dr. Keely Kolmes' social media policy (see here):
It is NOT a regular part of my practice to search for clients on Google or Facebook or other search engines. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet.
I sent Dr. Kolmes a fan letter for this model of ethical analysis and clear communication with patients.

The web continues to pose new, important and fascinating ethical questions. It's heartening to see colleagues like Drs. Huremovic and Kolmes identifying the issues and dealing with them so thoughtfully!