Monday, November 28, 2011

A Controversial Proposal about Complementary Medicine

A controversial proposal about complementary and alternative medicine (CAM) will be the hot item today and tomorrow at the annual meeting of the College of Physicians and Surgeons of Ontario. Since the College regulates medical practice in Ontario, this isn't a Mickey Mouse discussion!

The College felt it had to create a policy because patients in Canada, like those in the U.S., were voting with their feet - and money - for CAM:
In increasing numbers, patients are looking to complementary medicine for answers to complex medical problems, strategies for improved wellness, or relief from acute medical symptoms. Patients may seek advice or treatment from Ontario physicians, or from other health care providers.
The proposed policy explicitly recognizes a patient's right to decide on the course they want to follow:
Patients are entitled to make treatment decisions and to set health care goals that accord with their own wishes, values and beliefs. This includes decisions to pursue or to refuse treatment, whether the treatment is conventional, or is CAM.
In my psychiatric practice, I heard more than once from patients that their other physicians pooh-poohed psychiatric treatment, especially psychotherapy, with terms like "magic," "witch doctor" and "rent-a-friend." From that experience, I especially liked the way the Ontario College insists that physicians conduct themselves with civility:
The College expects physicians to respect patients' treatment goals and medical decisions, even those with which physicians may disagree. In discussing these matters with patients, physicians should always state their best professional opinion about the goal or decision, but must refrain from expressing personal, non-clinical judgements or comments...about the therapeutic options, or the patient's health care goals or preferences unless those are explicitly requested by the patient.
The fact that many physicians and physician organizations complained bitterly that this standard would "muzzle" them demonstrates the need for making civility and common courtesy an ethical expectation!

The Canadian medical community was especially vehement in its criticism of the way the original draft discussed standards of evidence for CAM. In the eyes of the critics, the College was setting a lower bar of evidence for CAM compared to allopathic medicine. Here's the key passage from the original draft:
Reasonable expectations of efficacy must be supported by sound evidence. The type of evidence required will depend on the nature of the therapeutic option in question, including, the risks posed to patients, and the cost of the therapy. Those options that pose greater risks than a comparable allopathic treatment or that will impose a financial burden, based on the patient’s socio-economic status, must be supported by evidence obtained through a randomized clinical trial that has been peer-reviewed.
To my reading, this statement was entirely reasonable. It's a small percentage of medical practice that's based on rigorous randomized controlled trials. The term "sound evidence" requires explication, but it's the best we can claim for much of what we physicians do. The wording of the revised proposal being discussed in Toronto today makes it clear that the same standard of evidence should be applied to "conventional" and "complementary" medicine. But to my reading it retains an appropriately skeptical view of just how solid the evidence is for what is conventionally done:
Any CAM therapeutic option that is recommended by physicians must be informed by evidence and science, and it must:

• Have a logical connection to the diagnosis reached;
• Have a reasonable expectation of remedying or alleviating the patient's health
condition or symptoms; and
• Possess a favourable risk/benefit ratio based on: the merits of the option, the potential interactions with other treatments the patient is receiving, the conventional therapeutic options available and other considerations the physician deems relevant.

Physicians must never recommend therapeutic options that have been proven to be ineffective through scientific study.
I applied these standards to myself with regard to my treatment many years ago of a patient with trichotillomania (compulsive hair pulling). The literature recommended medication and stated that hypnosis did not work. But my patient didn't want to take medication, and liked the concept of hypnosis, despite what the literature said. We agreed that it seemed relatively risk free, and tried it.

It worked. I didn't see the patient again until 20 years later, when the symptoms recurred. A brief repeat of the hypnosis did the job again. (For a more extensive discussion of the case, see here.) I believe the Ontario College would conclude that the treatment met their standards. I had done the hypnosis, but I hadn't recommended it!

If I were in Toronto today I'd vote to approve the College's proposal. Without demeaning "conventional" medicine it implicitly recognizes the degree to which conventional practice rests on uncertainties. And without using the term "placebo effect" it allows for the provision of interventions - "conventional" and "complementary" - that may well derive their efficacy from the placebo mechanism.

(The proposal being considered by the Ontario College of Physicians and Surgeons can be found on pages 248-275 of the agenda for today's meeting. If you're especially interested in the topic, you can read the original policy statement draft here. A summary of the Canadian Medical Association's criticism of the original draft is here.)

Tuesday, November 22, 2011

Learning from Massachusetts Health Reform

The Blue Cross Blue Shield Foundation of Massachusetts has just published a report on the first five years of Massachusetts health reform. The report provides valuable lessons about how U.S. society can learn to improve access and set limits on costs. It's crucial for us to understanding the learning curve for health reform. Reforming the health system isn't primarily an intellectual challenge. The difficulties are mainly in our own psyches, and among the different players on the health care chess board.

As I see it, the key aspect of Massachusetts health reform is the process by which it came about. Prior to passage of the 2006 law, there were several years of discussions, reports, conferences, committee meetings, and more. From this combination of education, argument and deliberation, what emerged was a consensus that government, employers, and individuals had to share responsibility for making things better. And, at least as important, all that interaction created some trust among the key parties and a culture of civility that is all-too-lacking in the pathetic national non-dialogue on federal reform. The term "Obamacare" is a symptom of the lack of dialogue and civility.

In terms of shared sacrifice: individuals accepted a mandate that we be insured; employers accepted a requirement that they provide insurance or pay into a state pool; and the state accepted responsibility for subsidizing low income folks and for creating a mechanism - the Connector - to administer the new forms of insurance that were made available.

Massachusetts has reduced its uninsured population to 1.9%, compared to the shameful national average of 16.3%. The cost of the subsidized insurance has gone up 3% per year, significantly lower than the national average. Approval of the 2006 law has remained steady at two thirds of the adult population.

Massachusetts explicitly chose to tackle coverage before squaring off with cost. The five year report documents that coverage is relatively "solved." Now the state is turning its attention to cost.

It looks to me as if we're approaching the cost problem the way we approached coverage - with LOTS of talk. We've had multiple reports, all of which say much the same thing - that providers with market clout get paid high prices without delivering comparably superior outcomes, that the entire system has a great deal of waste, and that cost escalation is strangling the businesses, public agencies, and individuals, who pay for care. As I wrote back in March, Massachusetts is the jawboning capital of the western world (see here).

Wise psychotherapists understand that dealing with the resistance to change is the hard part of the work. Once resistances have been dealt with, things get easier. And the late management guru Tony Athos described Japanese management style in the same way - LOTS of process to bring about consensus and then much smoother implementation than we see with our "process-lite" U.S. approach.

I believe, and hope, that what we're seeing in Massachusetts now with with regard to health care costs is creating the human and social infrastructure we need to get a grip on costs. The next report, five years from now, will reveal whether this is true or not.

(The five year report, written by my former colleague Alan Raymond, is very readable. If you're interested in learning more about Massachusetts health reform, take a look.)

Sunday, November 20, 2011

Zeke Emanuel on Health Reform

Zeke Emanuel provides an excellent piece of public education about the potential for improved quality of care and cost savings in a recent New York Times blog post. The piece will be especially informative for folks who don't understand how fragmented the U.S. care system has become and how fee-for-service reimbursement promotes the fragmentation. Emanuel concludes, correctly, that there's substantial potential for improving care for patients with chronic illness, and that these improvements can achieve savings for the health system.

But I think Emanuel makes two mistakes in the piece. Both come from misinterpreting the psychological underpinnings of health reform.

First, after describing very lucidly how bundled payments provide financial support for coordination among caretakers, he explains that "the idea is to force all of a patient's care providers to work together." But "force" is the wrong verb here, and it reflects a mistake medical managers make all too often.

Collaborating with colleagues actually makes practice more enjoyable as well as more effective. Working together in ways that help our patients is intrinsically satisfying. When those in charge assume we clinicians have to be "forced" to do something, we buck them. When they facilitate what good clinicians want to do, we do it with pleasure. The idea of global payments is to "allow" and "support" collaboration, not to "force" it!

Second, Emanuel correctly notes that improved care coordination can produce much more savings than malpractice reform. But apart from the question of how much savings a reduction in defensive medicine might produce, the climate of litigation has a corrosive impact on the psychology of medical care and the doctor-patient relationship. In ethics discussions with medical students, residents, and practicing physicians, the first question is typically - "what does the law say - what happens if I'm sued?"

The spectre of malpractice litigation creates a sense that patients and society are potential enemies. Health reform requires collaboration between doctors, patients, and the wider public. Malpractice reform is crucial not just for whatever money it might save for the health system, but for the potential that reform will reduce the degree to which physicians feel under attack.

Wednesday, November 16, 2011

Public Altruism about Health Care is Alive and Well

Four days ago I discussed Medicare beneficiaries who think about Medicare in terms of future generations and the common good, not just in terms of their own care. That post was triggered by my reaction to hearing this aphorism:
The true meaning of life is to plant trees under whose shade you do not expect to sit.
This morning's Boston Globe included an obituary that made the same point. It told about Paul White, who died at 61 of kidney cancer, after eight years of illness. Here's the relevant passage:
In a life curtailed by cancer there was much to curse, but Mr. White was more apt to speak optimistically about how chemotherapy gave him more time with his five granddaughters and how experimental treatments would provide a foundation for patients he would never meet.

"He just felt he was doing his part," his daughter said. "He kept talking about, 'I'm doing this for the next generation.' I can hear him saying that: 'I'm the guinea pig for the next generation.'"
I've been looking to see if any surveys of Medicare beneficiaries suggest what proportion is moved by concerns about the commons. I haven't yet found what I'm looking for, but I'd predict that it's a substantial number.

The Globe also included this letter to the editor:
Five ways to cut spending on Medicare - from a beneficiary

WHEN SPENDING less on Medicare is suggested, it seems that many people, especially Democrats and those over 65, protest loudly. However, there are ways that Medicare could spend significantly less money without denying anyone medical care that is of value. As a Medicare beneficiary myself, I offer five concrete proposals.

1) Make generic drugs the default for covered prescriptions.

2) Let Medicare negotiate with drug companies on the cost of drugs.

3) Let the Medicare Independent Payment Advisory Board identify medical services that provide little or no benefit, and let Medicare refuse to pay for them, or require significant copayments.

4) For surgery or other major interventions for which there are medically reasonable alternatives, do not pay for those interventions unless patients are fully informed about their alternatives, including no intervention at all.

5) Give providers significant protection from malpractice claims if they can document that patients were well informed before a treatment decision was made.

Congress has made if difficult or impossible for Medicare leadership to take any of these reasonable steps to control Medicare costs. Enacting these reforms could significantly cut Medicare costs with no downside for patients or their doctors.

Jack Fowler


The writer is senior scientific adviser for the Foundation for Informed Medical Decision Making. His views here are his own.
Voices like Paul White and Jack Fowler can make an important contribution to our national political dialogue. There's no way to deal with the country's long-term economic health without dealing with Medicare. If enough Americans speak as Paul White and Jack Fowler did it will become harder to argue for the politics of selfishness that our anti-tax zealots are so eager to promote.

Monday, November 14, 2011

Mitt Romney on the Veterans Health System

By temperament I'm an optimist, but Republican pronouncements on health care, like Mitt Romney's proposal for privatizing the Veterans Health system, challenge that stance. Paul Krugman has a powerful op ed on this latest piece of Republican disinformation in today's New York Times.

The Veterans' care system was radically reengineered in the 1990s. It now consistently outperforms the private sector on measures of quality and cost. As Krugman points out, that violates Republican theology. When facts and faith collide, something has to give. Romney isn't dumb, so the differential diagnosis is (1) faith in markets that is so strong he'll deny facts or (2) garden variety political duplicity - (i.e., expeditious lying).

(See this piece in yesterday's Daily Kos for details about the VA program and the Republican knee-jerk assault on public programs.)

Saturday, November 12, 2011

Do Medicare Beneficiaries Only Think About Themselves?

This week I spoke with a friend about my conviction that U.S. political process needs a voice from Medicare beneficiaries advocating for a progressive and sustainable approach to Medicare. I told him that although I don't have survey data to draw on, I believe that many of us folks in the Medicare generation are worried about the impact of runaway Medicare costs on future generations. We're not all like the belligerent elders in the AARP advertisement who warn politicians - if you want my vote, don't touch my Medicare.

My friend responded with an aphorism I'd never heard before:
The true meaning of life is to plant trees under whose shade you do not expect to sit.
I do a lot of walking in the woods and love trees, so the aphorism moved me.

I went back to Erik Erickson, to review his interpretation of the stages of life. I discovered that I misremembered his schema. I mistakenly thought Erickson named the healthy approach to aging "generativity." Erickson actually posits that as the virtue for adulthood. "Wisdom" is what he ascribes to the successful 65+ folks. It's opposite is despair.

Erickson may have been on target when he formulated his views 50 years ago, but I think he's wrong for the present. "Wisdom" as he conceptualizes it involves reflecting on the meaning of one's life. That sounds passive and somewhat narcissistic. What I see, and experience, in the Medicare set, is much better described as a quest for "generativity." The question many pose for themselves is - what can I contribute to the world at this phase of life?

Current political dialogue offers two choices for Medicare policy - "don't touch Medicare" or "tinker with the mechanics - raise the age of eligibility or replace Medicare with a voucher to buy insurance."

No one is talking about a cooperative enterprise in which Medicare moves to sustainability via patients and clinicians cooperating to create a more caring, less technological, approach within an overall budget that doesn't saddle the next generations with crushing debt.

There's more than enough money in our current expenditure to provide excellent care for beneficiaries. The way I make the point to knowledgeable friends is to ask - imagine what Medicare would be like if it was guided by the best clinicians from a population-oriented program like Kaiser Permanente!

(The aphorism comes from the title of a book Wes Henderson (1928-2003), a third generation Canadian, wrote about his father Nelson. It's the advice Nelson gave Wes when Wes graduated from high school.)

Monday, November 7, 2011

Sister Margaret McBride Speaks Out

Fundamentalist certainty is an understandable, but dangerous, stance in a world that William James famously described as a "one great blooming, buzzing confusion." Believing that our "truths" are true for all, and that disagreement is iniquity, is simpler than dealing with the diverse views of seven billion fellow humans.

Last year Sister Margaret McBride was excommunicated for her role at St. Joseph's Hospital in Phoenix in allowing an abortion to be done to save a pregnant woman's life. In her first public comments since Bishop Olmsted pronounced her excommunication, she told the Arizona Republic (by email):
"My journey over the past year has led me in many directions, but ultimately to a new understanding of forgiveness and mercy...Whether we are talking about my situation, the state of the church or society in general, I believe that forgiveness and mercy are extremely important for each of us...

Our important mission to our community has not changed. This is an extraordinary place with people from every religious background doing the impossible every day. At the heart of St. Joseph's is still our commitment to caring for the poor and ill in our community. Each employee is an inspiration to me every day in carrying out the mission of the Sisters of Mercy," (McBride's religious order, which is active in education, health care and social service worldwide).
According to the article, "sources" report that Sister Margaret has "resolved" her excommunication by going to confession.

Here's my guess about what "resolved" means.

When I did my psychiatry training in Boston, we learned which priests were likely to absolve depressed patients for "sins" like masturbation and which were likely to reinforce what we saw as pathological guilt.

I hope that Sister Margaret has been absolved and recognized as a good Catholic by a wise priest!

(For previous posts on St. Joseph's Hospital and Sister Margaret McBride, see here, here, here, here, and here.)

Friday, November 4, 2011

Union Health Plans and Health System Ethics

On November 1 I blogged about how much I looked forward to meeting the next day with union leaders responsible for overseeing union health plans.

As I'd anticipated, the union leaders evinced a strong sense of solidarity with the insured population and, at the same time, a strong sense of the economic realities of the insurance fund. I presented a diagram I've often used to convey my view of the ethical framework that - ideally - patients, clinicians, purchasers and other stakeholders would use in their dealings with the health system:The idea that we should approach the health system committed to both fidelity to the needs of the individual and stewardship of the resources available for the care of the group was intuitively obvious to the group, as did the metaphor of numerator and denominator that I also like to use::Bringing about a health "system" that is more effective, equitable and efficient in a nation of more than 300 million and a bitterly divided national political process requires won't happen without multiple local initiatives. Oregon, Massachusetts and Vermont show what individual states can do.

The union leaders taught me that union health plans can make important contributions to the national learning curve. Unions are about solidarity on behalf of shared interests. As a population we should be solidly unified on behalf of achieving the best health we're capable of. Sadly, we're not. Union health plans provide a venue in which substantial components of our population are committed to the well-being of each person and, at the same time, to being realistic about how much resource can be devoted to health care. What they learn and demonstrate can help us all.

Tuesday, November 1, 2011

Can We Afford High Cost Pharmaceuticals?

I'm in New Orleans, to meet tomorrow with a group of union leaders who oversee union health plans. They will have read, or at least - I hope - glanced at "Setting Limits Fairly," the book in which Norman Daniels and I presented the "accountability for reasonableness" framework for curbing unsustainable health care costs.

I'm excited at the prospect of working with union leaders. For them the constituency in the health plans they oversee are fellow union members, not impersonal "covered lives," the unfortunate insurance jargon term for you and me. And they know where the health plan funds come from - their own contributions and, perhaps, contributions from their employers, which could otherwise go into wages.

In advance I proposed four premises for the discussion:
  1. Resources are finite.

  2. There are more potentially valuable things that health care can offer than we can pay for.

  3. Organizations like unions that provide health insurance will have to learn to work with questions like "how much is life worth?" in a thoughtful and constructive manner.

  4. High cost pharmacy is a prime area where tough decisions will have to be made.
We'll use two drugs as examples that ultimately require us to acknowledge "how much is life worth?" as a real question. Provenge is a new immunotherapy for minimally symptomatic metastatic prostate cancer not responsive to hormone therapy. It extends median survival for 4.1 months at a cost of $93K. Cerezume is a biologically engineered form of the deficient enzyme in Gaucher's disease. It can produce significant improvements in quality of life for $150K - $250K per year.

In emotional terms, life is priceless. But in economic terms, it isn't.

I'll make the point that avoiding questions about the value of health interventions is a major reason we're in the mess we're in now. We won't solve the cost dilemma until we learn to think in terms of both numerator (my needs and desires) and denominator (the insured population's needs and desires). I'll make the further point that this kind of learning is more emotional than cognitive. And it takes time, so a long term strategy is necessary.

Union health plans, which are likely to have a high degree of solidarity among the insured population, are a promising venue for thinking this way. I hope we'll be able to probe health care costs as "our problem" rather than as something "they" are forcing on us.

I'll write more after I meet with the union leaders.