Wednesday, September 28, 2011

Health Care Cost Insanity Continues

The invaluable Kaiser Family Foundation released its 2011 Employer Health Benefits report yesterday. The findings are ugly.

150 million Americans get their coverage through employer-based programs. Last year, apart from the tragedy of increased unemployment, wages increased by 2% but premiums went up by 9%. The average cost for family coverage was $15,073.

From the perspective of workers, health care costs strangle wages and job creation. From a U.S. perspective, health care costs strangle other investments that could create more human value. And from a global perspective, it's disgraceful that we spend so much on health care without commensurate benefits while people in poor countries die from readily preventable causes.

A quote in a New York Times article about the report partly explains the mess we're in:
“We’re at a watershed moment,” said Elisabeth Benjamin, who represents Health Care for All New York, a group of 100 organizations advocating affordable care. “The Cuomo administration has to decide, will the Department of Insurance stand up for the little guy, John Q. Public, or let the insurance companies get away with this nonsense?”
John Q. Public is indeed getting shafted, but pointing at insurance company "nonsense" won't get us anywhere. Insurers will blame providers for raising prices. Providers will blame (a) their own costs, (b) Medicare and Medicaid payments, and (c) demand from the John Q. Public, whose advocates blame the insurers.

This circle of unproductive blame allows the inexorable cost escalation process to continue. Each stone the blamers cast has truth in it. But the stone casters are reluctant to acknowledge their own sins. We'll only get a grasp on our pattern of cancerous cost escalation through coordinated action among the currently warring stakeholders. That ultimately requires political leadership. We're not likely to get that leadership until we have an overall budget for health care, whether through a single payer system or through a system of not for profit health insurers as envisioned by Zeke Emanuel in Healthcare, Guaranteed.

In our current political discourse, the R word ("rationing") paralyses serious consideration of establishing an overall health budget. Budgets create limits, and limits lead to the accusation of rationing.

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

If a political clod like me could develop a communication strategy for detoxifying talk about health care costs and rationing, the political pros could show us the way if they put their minds to it!

Tuesday, September 27, 2011

The Dignity of Risk

I often write posts about an article in the morning newspaper or a just published medical journal.

This post is about an article written in 1972 - "The Dignity of Risk and the Mentally Retarded."

I have the privilege of serving on the ethics committee of the Commonwealth Care Alliance (CCA), a consumer governed, not for profit health system that cares for people with complex medical and psychological needs who are covered by Medicaid or "dually eligible" (for both Medicare and Medicaid). CCA tries to help its patients live in accord with their values, which often means helping people with significant impairments live in the community.

This can involve risk. A frail elder who lives alone may fall. A young adult with developmental disability and spasticity may aspirate and choke. If the elder loves her apartment, and the young adult takes great pleasure in his meals, clinicians and family members have to ask - how much risk is acceptable?

Bob Master, an internist who has been caring for vulnerable and neglected populations for decades and co-founder of CCA introduced me to the concept of "dignity of risk." Like all really good ideas, it seems obvious.

Robert Perske introduced the concept in his 1972 article. (The article is available on his website.) At the time he was Executive Director of the Greater Omaha Association for Retarded Children. After visiting programs in Denmark and Sweden, Perske wrote about the potentially negative impact of the natural wish to protect those with retardation:
...overprotection endangers the retarded person's human dignity and tends to keep him from experiencing the normal taking of risks in life which is necessary for normal human growth and development.

The world in which we live is not always safe, secure, and predictable. It does not always say “please” or “excuse me.” Everyday there is a possibility of being thrown up against a situation where we may have to risk everything, even our lives. This is the real world. We must work to develop every human resource within us in order to prepare for these days. To deny any retarded person his fair share of risk experiences is to further cripple him for healthy living. Mentally retarded persons may, can, will, and should respond to risk with full human dignity and courage.

It is the author's firm belief that we now need to insure this dimension of human dignity for the mentally retarded and prepare them for facing real risk in a real world. Where many of us have worked overtime in past years to find clever ways of building the avoidance or risk into the lives of the mentally retarded, now we should work equally hard to help find the proper amount of normal risk for every retarded person. It is hoped that this paper has helped to illustrate that there can be such a thing as human dignity in risk, and there can be a dehumanizing indignity in safety!
In retrospect I realized that I'd applied the dignity of risk concept throughout my psychiatric career, though not by that name. As an example, meeting with a patient with schizophrenia and his family, if the patient had behaved in a rude or inconsiderate manner, I might say "Just because Joe has schizophrenia doesn't mean that he won't sometimes act like a complete jerk the way the rest of us do." The Joes of the world generally preferred being criticized for acting like a jerk rather than being indulged as an impaired person who couldn't be expected to do better.

Suicidality posed a tougher challenge. A patient with acute suicidal intent accompanied by a plan, available means, clinical depression, and a history of suicidal acts obviously requires hospitalization. But some people with chronic depression are chronically suicidal. The goal - curing the depression - can't always be achieved. What then? The situation required assessing with the patients and their families what their goals for life were and how much risk they were prepared to tolerate. Sometimes living with a recognized risk seemed better than making elimintion of risk the primary goal.

Doctors and nurses in the CCA program deal with trade offs between risk and quality of life on a daily basis. The Hippocratic precept - first, do no harm would seem to imply a very cautious approach, but only until we consider Perske's comments about the potential for human dignity in risk and the risk of dehumanizing indignity in safety!

Sunday, September 18, 2011

The Ethics of Palliative Psychotherapy

Michael Kahn, a psychiatrist at the Beth Israel Deaconess Medical Center in Boston, has an excellent short article on "Palliative Psychotherapy" in the September American Journal of Psychiatry.

Here's how the article starts:
After hearing my doubts about whether I had done anything to help a middle-aged, talented, but characterologically difficult patient lead even a marginally better life, a trusted colleague said, "I think you made his existence a little less lonely and painful."
The conversation with his colleague led Dr. Kahn to these reflections: treatment could be thought of as palliative psychotherapy. After all, I had provided comfort, if not cure. I had avoided inflicting harm. I had provided some humor and perspective for a life chronically lacking in both. I had helped a habitually poor problem solver to solve many basic problems. I had even met with several of his family members. What if fundamentally altering his many decades' worth of maladaptive coping was beyond my skills, and perhaps anyone's?
Dr. Kahn is on to something important!

Palliative care - which focuses on improving quality of life for people with serious ailments - is increasingly recognized in circumstances like heart failure, cancer, and other chronic conditions. But it's a newer concept for psychiatry.

Dr. Kahn identifies the major objection to applying the concept of palliation to his patient's treatment - "it [may] represent a fancy way of defining expectations downward and rationalizing failure."

This definitely happens, often in the form of blaming the patient for resistance to making changes rather than blaming ourselves for conducting an ineffective treatment.

I learned a valuable lesson about palliative care early in my practice. I was seeing a man in late middle age who had suffered from a major psychiatric ailment for all of his adult life. His wife often joined the meetings. I cast about for ways of making things better, but was feeling guilty for not being helpful.

At that point I wrote for tickets to a cultural event. (This was in the pre web era.) The tickets came with this letter:
Dear Dr. Sabin

This event was sold out. But when I saw who the request was from I managed to find two tickets. You've been such a wonderful doctor for my parents that I wanted to say "thank you."
Without knowing it I was doing palliative psychotherapy, but I was asking myself to bring about a definitive "cure." My patient and his wife knew that this, alas, was not in the cards. They responded to the fact that I liked and respected them, and took the issue of their happiness in life seriously.

In my eyes I was a flop. In their adult child's eyes I was doing a great job.

As Dr. Kahn points out, making a differential diagnosis between which aspects of our psyches are susceptible to change and which appear to be "hard wired" is difficult. An error in either direction can be harmful. Unwarranted pessimism can deprive our patients of potential improvement. But unwarranted optimism about the capacity for change can also cause harm.

I learned this lesson vividly with another patient. We began the treatment with great optimism about "cure." It took us both several years to recognize that what had looked like a problem of adolescent development actually represented a very serious psychiatric condition. My effort to "cure" the condition via psychoanalytic psychotherapy actually made things worse. When this finally became clear I said - "I won't be your therapist any more, but I'm happy to counsel you on how to manage your ailment. If you had diabetes we wouldn't expect psychoanalytic psychotherapy to make it go away, and the same applies to the condition we're dealing with." I haven't seen this patient for years, but we still exchange letters in which I offer coaching and support.

Given the need to constrain health care costs, how should insurance deal with palliative psychotherapy? In my view, the health system gets this question wrong in both directions.

Often insurance coverage for mental health services requires an expectation of substantial improvement within a limited time period. As a criterion, that's too rigid.

Here, for example, are excerpts from the CIGNA guidelines for outpatient therapy:
The treatment plan should include clearly defined, realistic, and achievable goals and discharge criteria, with specific timelines for expected completion.

Treatment is [not] primarily supportive in nature.
For patients like the person Dr. Kahn describes, it would be easy for the insurer to conclude that the treatment is "primarily supportive" and lacks "achievable goals" with "specific timelines."

But as occurs so hilariously in Woody Allen films, it's possible for therapy to degenerate into an unending process that is sometimes disparaged as "rent-a-friend." This form of pseudo therapy should not be paid for by insurance funds.

In my experience, monitoring the value of therapy is best done by a collegial group that cares for a population within a budget. Rather than depending on a third party to judge the value of the therapeutic process via telephone review, clinicians manage themselves within the limits set by a budget. This is the framework Kevin Grumbach and Tom Bodenheimer argued for in their brilliant 1990 article "Reins or Fences: A Physician's View of Cost Containment."

I experienced what Grumbach and Bodenheimer described in my years of practice with the not for profit Harvard Community Health Plan HMO. We had a population of patients to care for and a budget that came from the premiums we received for them. In the mental health department we set expectations for how many new patients we would take on, but were free to manage our own practices. With patients whose needs were palliative we would seek the most efficient ways of meeting their needs, as by using groups and referral to community supports.

Between (a) the "fence" created by an overall budget, (b) ethical commitment to our patients' welfare, and (c) the freedom to innovate created by a payment system not based on counting widgets, (d) palliation could be part of what we offered without breaking the bank.

These are the values the much beleaguered health reform law is trying to advance. Too bad it's in the cross hairs of a political system currently run amok!

Thursday, September 15, 2011

Altruism in Japan - Seniors Volunteer for Nuclear Cleanup

My friend and colleague Steve Moffic, who, like me, thinks of health care in the light of ethics and the religious impulse, told me about a remarkable movement among the elderly in Japan.

500 retirees have created the "Skilled Veterans Corps for Fukushima" and volunteered their services for work that doesn't require youthful muscles at the devastated Fukushima nuclear plant. Radiation levels make the work dangerous.

Here's how Kazuko Sasaki, a 72-year-old grandmother, explains her thinking: "My generation built these nuclear plants. So we have to take responsibility for them. We can't dump this on the next generation."

Yasuteru Yamada, also 72, initiated the project, because it "would be better to send men and women who have finished raising families and are in the sunset of their lives, rather than younger workers whose lives could be cut short by extreme radiation exposure." And Yamada, a third 72 year old, reported "I want to make the most of the time I have left."

Although Japanese culture is known for stronger communitarian values than we in the US live by, over the years my elderly patients often expressed sentiments that come from the same psychological and spiritual space. But contemporary medical ethics typically asks us to be suspicious of the altruistic stance. When our elderly patients say "I don't want to be a burden to my family" or "pay attention to the youngsters - I've lived my life," we interpret these sentiments as signs of depression and low self esteem. Sometimes that's what it is, but sometimes it represents the moral perspective that Yasuteru Yamada presented in his matter of fact way.

I'm working on ways to tap the altruism that is part of the aging process for many seniors. Working on behalf of making Medicare more efficient so that the next generation has a better shot at a good life isn't as dramatic as volunteering to work at Fukushima. But many seniors, myself included, agree with Kazuko Sasaki that our generation made the mess we're in and we can't in good conscience dump it on the next generation.

(See here for the NPR story about the Fukushima volunteers.)

Wednesday, September 14, 2011

Obama on Medicare - Good Clinical Ethics/Poor Partisan Politics

I was torn by Robert Pear's report in today's New York Times that Democrats are distressed about President Obama's proposal for a $300 - $500 billion reduction in Medicare and Medicaid spending over the next ten years.

I hate to see anything that will help mad dog Republicans. But clinical ethics support President Obama's stance.

Representative Emanuel Cleaver II, Democrat of Missouri and chairman of the Congressional Black Caucus, explained Democrat fears - offering such proposals “cancels out any bludgeoning that Democrats might give the Republicans over Medicare and Medicaid.”

"They [fill in the blank with your favorite opponent] will destroy Medicare" is a superb political bludgeon. It worked for Republicans in 2010 and for Democrats in 2011. For winning elections, stonewalling on Medicare cuts is the best policy.

But apart from the obvious need to constrain Medicare costs for the sake of a healthier federal budget, the right kind of cost constraints will be good for the health of Medicare beneficiaries!

Increasing the retirement age is exactly the wrong kind of "cut." It would transfer costs to others and harm all of those who became uninsured when they lost employer insurance before they became Medicare eligible. Increasing premiums, cost sharing, or both, especially for lower income beneficiaries, is almost as bad - it would lead to avoidance of needed treatment and worse health.

The sweet spot for Medicare cost containment is in overtreatment and defensive medicine. Anyone close to health care provision, whether as a clinician, administrator, or family member, knows just how common it is for beneficiaries to receive unneeded diagnostic, therapeutic, and even preventive, interventions. Apart from wasting beneficiary and taxpayer money, unneeded interventions cause all kinds of harm, through their own side effects or harms caused by other interventions done in follow up.

Economists say that malpractice reform can't be looked to for significant savings, but I don't think they understand just how toxic fear of litigation is for physicians. In addition to leading to defensive medicine practices like unneeded MRIs, concern about litigation synergizes with our cultural tilt towards the false belief that more is always better. It's time for Democrats to get on board with tort reform.

Twenty five years ago, my friends David Himmelstein and Steffie Woolhandler wrote about US administrative practices as "Cost without Benefit." I'm convinced that within the sphere of clinical care we have more than 5% of cost-without-benefit-and-often-with-harm. Reducing that segment of Medicare costs is the right thing to do - for beneficiaries as well as for the budget!

The fact that good clinical ethics could be bad politics is a symptom of pathology in our political process.

Sunday, September 11, 2011

Grady Hospital Dialysis Patients Have a Home - For Now

Last week I wrote about the ping pong match being played between Grady Hospital and Fresenius. Unfortunately, the ping pong balls were patients with advanced kidney failure.

Grady's contract with Fresenius for the remaining patients who had been under the care of Grady's dialysis program when it closed in 2009 had ended on August 31. Grady said it could not pay the price being asked for by Fresenius. Fresenius refused to care for patients without being paid.

Fresenius said these were Grady's patients and Grady's responsibility. Grady said Fresenius had been treating them for two years and they were Fresenius's responsibility.

On Friday September 9, Grady and Fresenius reached an agreement. Fresenius will care for the patients at no cost to the patients for three years. Grady will pay $15,500 per year, approximately half of what they had been paying.

If this were an ordinary business or labor management negotiation, it would be ho-hum ordinary. It's typical to go to the brink, to point accusatory fingers, and then to settle.

But between the expiration of the contract on August 31 and the deal reached on September 9, patients had to go to the emergency room to be evaluated for emergency dialysis. Some were turned away as "not sick enough." One patient who was turned away on Saturday and then admitted briefly on Sunday returned to Honduras just before the deal was signed. Her family scraped together enough money to pay for two weeks of dialysis at home, but her fate after that, her sister said, is "in God's hands."

The deal between Grady and Fresenius settles the crisis by providing dialysis care for three years - except for the patient in Honduras, who may be on her own in two weeks. The deal is a small victory for people in need.

But given that the Grady problem will continue to occur for undocumented patients all around the country unless we craft a national solution, it's also a form of "enabling." The crisis is off the front page and the evening news, so we can go about our business until the next crisis occurs.

(For Kevin Sack's New York Times report on the Grady-Fresenius deal, see here. For an excellent policy brief from the American College of Physicians that argues in detail for the "federalization" of local problems like Atlanta that I've been advocating for, see here.)

Friday, September 9, 2011

Stanford Medical Records Posted Online

The New York Times reported today that a spreadsheet with the names, diagnosis codes, admission and discharge dates, and billing charges for 20,000 patients seen at the Stanford emergency room during a six-month period in 2009 had been posted online for almost a year before it was detected!

The spread sheet had been posted on September 9, 2010, to a website called Student of Fortune a site where students can buy help with their homework. (More about it below.) It stayed posted until August 22, 2011, when a patient discovered it and reported the breach to Stanford.

The spreadsheet came from Multi-Specialty Collection Services, a vendor to Stanford, hired to do payment and billing analysis. It was posted as part of a response to a student asking about how to convert data to bar graph form. The identity and motives of the person who posted the spread sheet is unknown.

A spokesman for Stanford correctly stated that "there is no employee from Stanford Hospital who has done anything impermissible." This is true. But that's the problem!

As health care becomes more complex and more digital, information can easily be moved around. Hospitals, medical groups, health plans, and others, use vendors with specialized skills. Sophisticated analysis of population data is crucial for improving quality and constraining costs. But it creates vulnerability to data breaches, as happened at Stanford.

The article mentions other prominent institutions that have experienced major breaches. Apart from hacking incidents and erroneously addressed faxes and emails, an employee at the Lucile Packard Children's hospital stole a computer with the records of 532 patients. And an employee of the Massachusetts General Hospital left paper records on the subway while commuting to work.

Bryan Cline, a spokesperson for the Health Information Trust Alliance, a nonprofit devoted to "the belief that information security should be a core pillar of, rather than an obstacle to, the broad adoption of health information systems and exchanges," said that 20 percent of breaches involve contractors. Cline noted that providers depend on legal contracts with vendors to protect privacy, but as the Stanford case shows, contracts aren't guarantees!

The more interconnected we are, the more our own integrity depends on the integrity of those we're connected to. I practiced for more than 30 years with a large medical group. When patients described bad behavior of clinical colleagues, administrators, or support staff, I apologized. Typically my patients said "you didn't have anything to do with it." I replied with some version of "but we served you poorly, and I'm very sorry about that."

Interconnection creates great opportunities and great risks. Lapses of the kind that occurred at Stanford undermine public trust and could lead to crippling restrictions on the use of digital data. This would be a public health tragedy.

To my reading, Student of Fortune, the homework-help website where the spreadsheet was posted, smacks of the corruption of the educational process. Educators report a vast increase in plagiarism and other forms of pseudo-student work and pseudo-learning. Here's how the enterprise describes how its "tutors," which includes the person who posted the spreadsheet, are paid:
1.Users post questions to our site, seeking help with an academic or technical subject. They offer a bounty for what they're willing to pay for a tutorial that teaches them how to solve their problem.

2.You find their question by searching or browsing for questions, or by opting-in to email alerts in your areas of expertise.

3.Write up a great tutorial for their question on Student of Fortune along with how much you'd like to get paid for it. We'll pick a random 20% of your tutorial as a preview and post it for everyone to see. Don't worry... you'll a say in what 20% we're sending, and we never send the end of your tutorial (where we expect you'll put the conclusion).

4.When the other user buys your solution, we'll send you the tutorial (less 18% to cover the bare-minimum cost of processing your transaction).

5.We keep your tutorial around forever, so if it's a commonly-asked question, you could be making money off it for a long time to come! Some of our users have made over $1,000 off of a single tutorial! In these cases, we'll take 40% to help cover the cost of advertising your tutorial.
When I search online under "organizational ethics," in addition to links to this blog I find many advertisements for essays business students taking courses on the topic can purchase.

How's that for an ethics lesson to our budding organizational leaders!

Friday, September 2, 2011

Playing Ping Pong with Desperately Ill Undocumented

22 patients with kidney failure, most of them undocumented immigrants, are being ping ponged between Grady Hospital, a huge safety net facility in Atlanta, and Fresenius, the world's largest provider of private dialysis services.

Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year, but it has been in teetering on the edge of bankruptcy for many years.

In October, 2009, Grady closed its dialysis clinic, which was losing $2.5 million each year. The undocumented, who were a majority, are not eligible for Medicare. Grady was able to make other arrangements for some, and a small number agreed to return to their country of origin, with Grady providing time-limited support for continued dialysis.

For the remaining patients, Grady contracted with Fresenius for a one-year extension of dialysis services. In August 2010 the contract was extended for another year. That contract ended on August 31. Grady is facing a $20 million shortfall, and the parties haven't been able to agree on another extension. Fresenius has turned them away. Grady is trying to send them back. The patients are in limbo, and for the moment will have to wait until their condition deteriorates enough to require emergency dialysis. (See here for a discussion of how the emergency dialysis issue plays out in Texas.)

Grady and Fresenius are pointing fingers at each other:
"They are Grady patients,” [Fresenius] said. "While we are very concerned by the situation this places the patients in, the patients must seek treatment from Grady." Fresenius anticipates worldwide net income of more than $1 billion this year.

[Grady] responded indignantly. "There cannot be a debate about one thing. This group of patients has been under the care of Fresenius and their doctors for two years. If Fresenius decided to discharge a patient because they are unable to pay, that is Fresenius’s decision, having nothing to do with Grady."
Continuing to cover continued dialysis wouldn't be a big deal for Fresenius. But it would turn Fresenius into a safety net organization, and private providers would avoid contracting with public facilities in the future, for fear of being left with patients the Gradys of the world would stop paying for.

The problem is global, not local. It needs to be kicked up to the federal level. We should convene a working group to scope out the dimensions of the problem and identify options for action. The ideal convener would be the Secretary of Health and Human Services (or her designate - perhaps the Assistant Secretary for Health). The Medicare End Stage Renal Disease Center would be a key participant, as would the National Association of State Medicaid Directors and safety net providers, perhaps via the National Association of Public Hospitals & Health Systems. Because a substantial portion of the patients who are put at risk by program closure are immigrants, the Office of Citizenship and Immigration Services should be represented. And, because programs sometimes try to send immigrants back to their countries of origin, largely in Mexico and Central America, the Bureau of Western Hemisphere Affairs in the State Department should have a voice.

This may seem like overkill for a problem that involves a relatively small number of people. But the values at stake are central to who we are as a country and to the way others see us. Abu Ghraib involved very few people, but for millions, at home and abroad, it is, and should be, a source of shame. It won't take many stories, photos and videos of dying people "dumped" back to their villages, to do the same.

(Kevin Sack of the New York Times has tracked this story since 2009. See here for his latest report.)