A Personal View of the Medical Home concept

Into my mid 70s I felt remarkably fit. I was still playing tennis and taking my favorite hikes during the summer in Vermont. That changed when a mysterious problem I've written about in a couple of posts (here & here) set in.

As a result of the problem that developed, I've had more medical appointments in the last six months than in the previous 25 years. As someone with an interest in health policy & systems, my experience has sharpened my sense of what's required to make a "medical home" work. (For those who aren't familiar with the medical home concept, I've copied material from the Patient-Centered Primary Care Collaborative at the end of my post.)

Here's my patient's eye view of my experience:

1. In the fall of 2016 I was floundering as to what to do about the problem, Whatever was causing pain and discoloration of my left foot/ankle/lower leg was still a mystery. My primary care physician (PCP) suggested seeing a dermatologist, something I hadn't thought of myself.
2. The dermatologist said what she saw was unusual. She did a biopsy which, alas, came back as "non-specific changes," That meant we were still unsure. She could simply have sent me back to my PCP, but to her credit, she suggested that we get a second opinion from someone at the hospital my care group is associated with.
3. Initially the referral went to the referral coordinator and an appointment was set with a presumably thoroughly competent dermatologist, but one who did not have more experience than the one I had seen. I discussed this with my PCP. He called the chief of the department who recommended a senior colleague who he said "is especially good with complex cases."
4. I saw the recommended dermatologist who had some hypotheses about obscure possibilities and did two further biopsies which showed (a) clotting in the tiny blood vessels and (b) no inflammation. 
5. With a narrower set diagnostic possibilities, the second dermatologist wrote to my PCP, recommending that I see a hematologist and suggesting some further blood tests. My PCP agreed, and referred me to an excellent hematologist with whom I had shared patients before I retired from practice ten years ago.
6. By this time my blood count showed something new - an abnormal level of platelets, which are crucial for clotting. The hematologist prescribed a medication that acts on the bone marrow with the aim reducing the platelets. We've used the group's secure email to follow the counts and adjust the medication. We've only met in-person once, but the email communication has been very reliable.
7. As the platelets have come down, the lower leg and ankle problems have completely cleared up. But the toes have not, and in particular my left fourth toe was exquisitely painful. Last weekend I saw an ugly open sore on the toe. I didn't know what gangrene looked like, but my imagination ran away with unpleasant possibilities.
8. On Monday morning I was able to see an urgent care physician who allayed by fears and prescribed  oral and topical antibiotics. 
9. I informed the hematologist and my PCP about the situation to make sure we were all "on the same page."
10. Happily, the wound is improving, and the pain is markedly reduced. 

So what's the point of all these details?

For me it's this: in the same way that it takes a village to raise a child, it can take an "extended family" to treat a chronic condition. My experience has been one of receiving excellent continuity of care even though I've been bouncing between clinicians the way a pin ball bounces. But the clinicians were part of the same "family." They had access to the same electronic health record and communicated with each other - either directly or via my sending "FYI" updates to them. For the underlying chronic problem I've had my blood drawn at the practice's laboratory. The results get to the hematologist and to me within a few hours, and she has followed up with email advice very promptly.

My guess is that my treatment in the past few weeks has not occupied much physician time, but as a patient I have felt very attended to. When I was worried about toe pain and an open wound I was able to see a clinician promptly, and her findings went to my PCP and the hematologist I am working with.

I believe my experience shows how a "medical home" and "team care" can be more than euphemisms. Continuity of care doesn't require continuous appointments with a single physician. When a "medical home" functions the way a harmonious extended family does, it works!

Here's the material about the medical home concept for those who want to read about it in more detail:

The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system, and is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions. It is a place where patients are treated with respect, dignity, and compassion, and enable strong and trusting relationships with providers and staff. Above all, the medical home is not a final destination instead, it is a model for achieving primary care excellence so that care is received in the right place, at the right time, and in the manner that best suits a patient's needs.

In 2007, the major primary care physician associations developed and endorsed the Joint Principles of the Patient-Centered Medical Home. The model has since evolved, and today the PCPCC actively promotes the medical home as defined by the Agency for Healthcare Research and Quality (AHRQ). 

Features of the Medical Home

Adapted from the AHRQ definition, the PCPCC describes the medical home as an approach to the delivery of primary care that is:

• Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
   
• Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
   
• Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
   
• Accessible: Patients are able to access services with shorter waiting times, "after hours" care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
   
• Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health

Adding Value by Talking More

A recent article in the New England Journal of Medicine - Adding Value by Talking More - caught my eye. For me, having practiced psychiatry for 43 years, the authors' argument was preaching to the choir. But what is special about the article is the hard-nosed way it cites data that demonstrates cost savings from investing time and money in well-planned conversation.

Here's the final paragraph of the article:

As these examples illustrate, increased physician communication is time very well spent when it leads to better patient outcomes and lower total costs. Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results. Physicians now have the discretion, incentives, and accountability to use their time wisely and productively to reduce the total costs of patient care and improve the outcomes they deliver.

The otherwise excellent article omits one crucial element. Talking more with our patients also increases physician satisfaction. In conversations and CME sessions, when physicians are asked about meaningful clinical experiences, relationships with patients and moments of empathic connection predominate.

I encourage readers to go to the NEJM article. The three authors are all from the business school and the consulting world. They makes the kind of case for "talking more" that administrators will understand and be influenced by. I also encourage readers to go to the website of Avant -garde Health, a health care technology and analytics company founded by one of the authors.

Some harried physicians, unhappy in practices in which talking with their patients feels like a luxury they can't afford, choose to move into a concierge model of practice, in which they (a) limit the number of patients they care for and (b) charge an "entry fee" to be part of the practice. This solves the morale problem for the individual physician, but it weakens the health system itself by reducing the number of available primary care physicians.

The kind of work behind Adding Value by Talking More is addressed to the same problem concierge physicians are dealing with, but at the population level. As such it is a more socially responsible approach to the effort of making our health system more "patient centered."

Access to health CARE vs access to health INSURANCE

A dear friend who follows this blog sent me an email about the two posts I wrote last week about my own recent medical experiences (here & here). With my friend's permission I've copied the message s/he sent [I'm deliberately disguising gender], edited to protect confidentiality and to highlight the themes I want to emphasize:

Thank you for the very informative posts. In general, however, I think the blog doesn't describe the experience of patients who are not MDs and/or are not in an integrated group practice such as the one you belong to. In my own experience, PCPs defer to specialists and won't contradict them. Further, the placebo effect of the PCP relationship is reduced if not nullified by the patient's difficulty in contacting the PCP over the phone. I can never get an appointment on short notice with my PCP; I can only count on seeing him if the appointment is made months in advance, or if I am in an emergency ward or am admitted to a hospital as an inpatient. If I have an immediate problem that is not an emergency (e.g., burn, sprain/suspected fracture, bronchitis), I have to work through two layers on the phone (secretary, medical assistant) -- and then the outcome will be an examination by a nurse practitioner. I therefore now prefer to use the XYZ Hospital's Walk-In Clinic rather than even trying to reach my PCP's office by phone. Finally, your encomium to the email system doesn't apply to the sharing of medical records between hospitals on different systems (e.g., XYZ hospital and ABC, where I have also had care) or to practice groups that are located in one and the same hospital office building but that don't share the same medical records system.

My friend is well insured - s/he has no problem with insurance access. And the community where s/he  lives is replete with medical services.

In a follow up conversation I will ask my friend about experience with the nurse practitioner. Over the decades of my clinical practice, and in my own care, I've had terrific experiences with nurse practitioners and physician assistants. Assuming that the NP is indeed a skillful clinician, the PCP can foster trust and comfort with the NP by explaining how they collaborate and demonstrating how they work together.

My positive experiences have definitely been fostered by the fact that I'd been a clinician in the group practice from which I was getting my care. But I'm convinced that a patient who had not had a career in health care and had not been part of the group could have a comparably positive clinical experience if they had the same skills I have in managing my care experience.

I anticipate that in the future, patients will routinely have electronic access to their own medical records. That kind of access, combined with a robust secure communication system with and within the practice, would promote more secure connection to the medical home than my friend experienced.

From 1975 until I ended my clinical practice I was paid a salary. That meant I was not dependent on billing for each in-person service for my compensation. One of my patients who had significant depression and was dealing with major stressors strongly preferred the convenience of electronic interchange rather than coming to my office. After we had gotten to know each other in 5-6 in-person appointments, we switched to email, which we used for ten years. When we met to say goodbye in person when I retired from practice, we felt we knew each other very well, but neither remembered what the other looked like, which made for some amusing uncertainty in the waiting room. Being paid by salary meant that I was not "penalized" for providing care to my patient with so few in-person meetings.

It's not likely that we will have enough PCPs to ensure prompt access for all patients in the foreseeable future. To provide the kind of secure connection my friend was looking for we'll have to manage the process of team collaboration better than s/he has experienced, and make use of electronic forms of communication to augment connection between the patient and the team.

The generation moving into adulthood is schooled in making electronic connection with their peers. They will demand that kind of opportunity in their medical care.

Affordable Care in Rural India

I just returned from India, where I visited Flame University (the name is derived from "Foundation for Liberal  and Management Education") in Pune.

At a meeting with Professor D.S. Rao, Provost and Dean of the Flame School of Business, I learned about Yeshasvini, a cooperative health insurance venture for farmers in the state of Karnataka. At the depressing moment where the new U.S. administration  is preparing to tear down President Obama's extension of health insurance to a wider population, it was heartening to learn about a program working to advance Obama's ideals by insuring the poorest of the Indian poor.

India does not have a tradition of paying for health care through insurance. The majority of health care is still paid for on an out-of-pocket basis. Even though costs are much lower than in the U.S., for the large population of rural poor, modern health care is unaffordable.

Yeshavini, started in 2003, offers a limited insurance package to members of rural farm cooperatives on a prepaid basis for less than $5 per year per insured person! The state of Karnataka matches some or all of the farmers' payments. Karnataka, approximately the size of Nebraska, has a population of 64 million. As of 2014-2015, 3.8 million were enrolledin Yeshasvini.

Yeshavini's mission is noble:

"To bring health care of International Standards within the reach of every cooperative farmer of Karnataka. We are committed to the achievement & maintenance of excellence in health care for the benefit of farmer cooperator."

Even in India, $10/ year cannot provide "health care of International Standards." The package is largely for surgical services at 550 participating hospitals. Non-surgical treatment for cancer and diabetes is  not covered. But hazards faced by farmers like snake bites. goring by bulls, and accidents involving agricultural machinery are.

From a U.S. perspective, Yeshasvini is best thought about as a "proof of concept." In 1969 when I first encountered the concept of prepaid health care delivered by the not-for-profit Harvard Community Health Plan to a defined population on a prepaid basis, I thought this was the right way to provide modern health care. I still do. I joined the group in 1975, and while I ended my practice in 2008, I still get my own  care from the group and I work with it on establishing its new ethics program.

Somewhere between the pared-down Yeshasvini program in Karnataka that is affordable to poor farmers but covers too little and the super-comprehensive U.S. programs that cover too much and are a stretch for all but the wealthiest, is the golden mean of health care. But Yeshasvini supports the view that health care should be (a) population oriented, (b) prepaid, and (c) not-for-profit.

That's a perspective likely to come under attack from the newly installed Republican administration!

When is Rationing Ethically Accptable?

If I prefer a medicine that produces fewer side effects or marginally better outcomes, how much should you be expected to pay for my preference?

That's a question we in the US run away from. We'd rather say - "rationing is unethical! Period."

In truth, rationing happens all the time. The trend towards requiring us to pay a larger portion of our health care expenses out of pocket aims at making us responsible for our own rationing choices. If my physician recommends a CT scan "so we can be sure..." and I decide it's not worth the cost to me - that's self-imposed rationing. In our personal lives we make rationing decisions based on informal cost-effectiveness decisions every day.

But at the level of policy, acknowledging the need for ethically-grounded rationing is a third rail.

That's why the publication of Cost-Effectiveness of Long-Acting Injectable Paliperidone Palmitate Versus Haloperidol Decanoate in Maintenance Treatment of Schizophrenia is so important. for my field - psychiatry. In addition to providing valuable clinical information, the authors are admirably honest in presenting the rationale for potential rationing decisions.

Here's what the article is about:

Some patients with schizophrenia who benefit from antipsychotic medications follow their regimen reliably. But some don't, and for them a long-acting injectable antipsychotic medication can literally be a life-saver. I remember well a patient of mine who wouldn't take pills and wasn't keen on seeing a "shrink," but who accepted a monthly injection of haldol from his primary care physician. I made a serious joke with my colleague - "I may accomplish some useful things, but you are 'curing' schizophrenia in five minute appointments!" My patient and his family were enormously grateful that he functioned better and was happier than he'd been for a decade.

Paliperidone palmitate is still on patent and theoretically had some advantages over haldol decanoate, a much less costly generic medication. In a well-controlled randomized comparative effectiveness study, the authors compared the two medications, quantifying the differences between them in terms of quality adjusted life years (QALYs). Paliperidone had a slight advantage in terms of side effects, but at a cost of $500,000 per QALY, well-above what virtually every explicit discussion of QALYs has seen as an acceptable cost. Here's part of the author's conclusions:

The results of this study should encourage consideration of older, less expensive drugs, such as HD. Used at moderate dosages in this study, HD’s overall effectiveness and tolerability were only slightly worse...than those of PP, and it had clear advantages in cost-effectiveness...A rational policy for treatment of chronic schizophrenia might limit use of the more expensive [PP] to patients who do not benefit from or cannot tolerate HD. 

My colleague and friend Norman Daniels and I have written extensively about the overall ethics of rationing. I'm proud of the work we've done and believe it's useful. But progress in coming to grips with the need to ration care in a clinically grounded, ethically admirable manner will have to be done specialty by specialty in medicine, in concert with concerned members of the public.

The comparative effectiveness study of paliperidone and haldol illustrates four crucial steps that need to be taken for us as a nation to learn to set limits fairly:

1. Develop clinically and humanly meaningful evidence about key treatment choices.
2. Acknowledge the findings in an explicit, east to understand manner.
3. Do economic analysis to define the costs involved with the choice.
4. Decide whether the differences between the choices are worth the costs entailed.

The fifth and most difficult step is making use of these findings in the real world. In a health system based on competing health plans, health plan A would be reluctant to apply findings like these in its policies before health plan B does the same. If they did, word on the street would be "health plan A RATIONS CARE! How can we tolerate money grubbers like that in our health system?"

Learning to set limits fairly is more of a challenge to the heart than the head. At an intellectual level it's easy to see that limits are necessary. But thus far in the US, health system leaders, health care organizations, and the public have preferred to act as if rationing is evil and can be avoided.

That may have been true in the Garden of Eden. But, alas, that paradise vanished long ago.

Who Should be Seen as a "Healthcare Executive" and Why Does it Matter?

The American College of Healthcare Executives (ACHE) has as its vision "To be the premier professional society for healthcare executives dedicated to improving healthcare delivery." ACHE's excellent 2015 statement - Creating an Ethical Culture Within the Healthcare Organization - rests on an assertion I wholeheartedly support: namely, that "all healthcare executives have a professional obligation to create an ethical culture." (I added the emphasis)

If you agree with the ACHE assertion, and I'm prepared to go to the mat for it, the first question is: what counts as a "healthcare executive"? How wide is the scope of the term?

Clearly, executives at hospitals, medical groups, and other organizations that deal directly with patients carry major moral responsibilities. After all, health care is crucial for realizing all three of the "unalienable rights" put forward in the Declaration of Independence: life (sometimes health care saves our lives), liberty (we can't exercise our freedom without health), and pursuit of happiness (we can be happy without health, but it's more difficult, and severe enough pain makes it impossible).

ACHE deliberately leaves the scope of the term vague. It defines itself an an organization for "healthcare executives who lead hospitals, healthcare systems and other healthcare organizations." From my experience as a physician, administrator, and patient, I'd cast a wide net for defining "other healthcare organizations" and setting ethical expectations for them.

In the complex U.S. health system direct care organizations aren't the only important moral agents. Health plans and pharmaceutical companies are perhaps the two most important examples of indirect moral agents.

Over the years I've tried to encourage health plans to create ethics programs the way Harvard Pilgrim Health Care, where I have directed the ethics program for sixteen years, has done. I've had zero success. This doesn't mean that other health plans are unethical, but it does suggest that ethical performance is not seen as something that requires the kind of concerted leadership the ACHE statement on responsibility for creating an ethical culture calls for. (For a previous post about my quixotic efforts, see here.)

Executives in the pharmaceutical industry face especially difficult challenges in relation to the kinds of expectations the ACHE standards articulate. They're clearly crucial participants in  the sacred calling of health care. At the same time, they're embedded in a highly competitive industry with strong profit demands. Pharmaceutical executives work in the jaws of a severe dual agency challenge: sacred calling vs the invisible hand of the market.

More than forty years ago, Arnold Relman warned of the potentially disruptive moral impact of what he called "The New Medical-Industrial Complex." Since his prescient warning there have been efforts to establish a shared moral code for all participants in the world of health care. A distinguished U.S. and U.K. group articulated the "Tavistock Principles," but these, alas, seem to have been dead on arrival, and have not been heard from for fifteen years. And for a number of years the American Medical Association sponsored an "Ethical Force" program that sought to establish measurable ethical standards for the major players in the health sector. I had the privilege of being on the advisory panel on health benefits determination. The project produced some excellent materials and a book, but as with the Tavistock principles, the effort was relatively short-lived.

When I mulled over how to end this post I realized that I don't have a tidy upbeat ending. The image that came to mind was of Sisyphus, eternally pushing a rock up the hill. It seems to me that Arnold Relman's call to action points to an ongoing task captured in this cartoon:

I'll do more rock pushing in future posts!

Retail Clinics, Health Care Costs, and Medical Ethics

The March issue of Health Affairs includes an report by Ateev Mehrotra and colleagues about the impact of retail clinics on health care utilization and cost. His team used insurance claims from Aetna to study the question of the degree to which retail clinic visits replace physician office and emergency room visits or represent additional utilization.

In-store clinics like the 1,100 CVS Minute Clinics offer prompt attention for minor ailments and preventive care. They're convenient and cost less than physician office visits and vastly less than an emergency room visit. Health policy gurus have hoped that they would improve access and reduce costs.

It looks as if the hopes are half fulfilled. The clinics do improve access for minor conditions and as such are a welcome service. According to the Convenient Care Association - the trade association for retail clinics - to date consumers have made 35 million visits to these entities. But Mehrotra and colleagues found that 58 percent of the visits appeared to represent new utilization, with the result that covering retail clinic visits cost Aetna $14 more per patient per year.

The medical group where I and my family have gotten our care for decades operates its own internal version of retail clinics. During daytime hours it's possible to be seen for same day appointments and advance practice nurses are available 24/7 by telephone. When I've used the service my primary care physician has received immediate feedback via the electronic medical record. In one instance I would have gone to an emergency room if urgent care had not been available. And my impression from what I've read from Kaiser Permanente is that in the setting of an integrated group practice, walk-in capacity is cost effective as well as popular with patients.

So what's the big lesson from the Health Affairs report?

For me the study implies that our recurrent hope for a magic bullet that will reduce cost without integrating the care system and creating a budget for it is a pipe dream. Retail clinics have a lot to offer, but they won't solve our cost problem. Telemedicine also has a lot to offer, but it won't do the cost containment job for us either.

Instead of imagining that a magic bullet will solve the cost trend without our making hard choices, we instead need to bite the bullet and create budgeted care systems like the much maligned not-for-profit HMOs from past years. 

Accountable Health Communities and Primary Care

Last month CMS announced an "Accountable Health Communities" initiative:

The Accountable Health Communities (AHC) model addresses a critical gap between clinical care and community services in the current health care delivery system by testing whether systematically identifying and addressing the health-related social needs of beneficiaries’ impacts total health care costs, improves health, and quality of care. In taking this approach, the Accountable Health Communities model supports the Center for Medicare & Medicaid Service’s (CMS) “better care, smarter spending, and healthier people” approach to improving health care delivery.

I think the initiative is a very big deal!

The US health system is badly out of whack. 95% of the trillion dollars we spend on health care each year goes for acute medical treatment, but 60% or the preventable deaths are caused by "social" factors. In the brief appointments that are too characteristic of medical practice, it's difficult for physicians to learn about a patient's social circumstances. And I know from the brilliant and idealistic primary care residents I teach that they feel their training has not prepared them to know what to do in response to the stories they hear from their patients.

I believe the disconnect between what typical medical care involves and the existential circumstances of our patients' lives is a major contributor to the high rate of "burnout" and "demoralization" among physicians. When physicians and patients feel deeply connected, medical interventions are more effective and both parties experience intrinsic satisfaction. Sadly for all, this connection often does not occur.

Dr. Heidi Behforouz, a colleague at Harvard Medical School, has written usefully about "rethinking the social history." Here's her diagnosis of the problem young physicians like those I have the privilege of working with encounter:

Physicians often see patients with complex social situations as a burden — requiring extra work that is neither reimbursable nor central to our core clinical expertise. Unfortunately, we inculcate these attitudes in trainees, implicitly and explicitly, perhaps because  of our discomfort with hearing difficult stories or our sense of powerlessness or incompetence in addressing these root problems. Whereas biologic pathology may present specific targets for intervention, social or structural pathology is difficult to treat.

 The CMS "Accountable Health Communities" initiative is designed to explore organizational models that foster a stronger connection between the "medical" and "social" aspects of our patients' lives. Strong links to community resources, new skills for understanding social contexts, and improved tools for recording social information in a useful form, will all be required.

When health organizations move from being strictly "medical" to becoming "health communities," we'll have created settings in which medical, nursing, and other health professional students can learn how to do what William Osler urged a century ago: "the good physician treats the disease; the great physician treats the patient who has the disease."

Vietnam, Iraq, and Health Care Organizational Ethics

Vietnam was the shaping experience for my generation. In the later 1960s, all male physicians who were not conscientious objectors did some form of military service. I opposed the war in Vietnam and was active in anti-war demonstrations, but the law did not allow selective conscientious objection. To claim CO status one had to oppose all war, and the memory of World War II - which I regarded as a "just war" - was still fresh.

When I completed psychiatry training in 1968, I had the good luck of being an officer in the Public Health Service for two years at the National Institute of Mental Health. The "real" military who were stationed in the area dismissed us as "yellow berets." But notwithstanding the insult, I was proud of being an Public Health officer.

This past winter, when my wife and I were part of the faculty in the Semester at Sea program, we visited Vietnam for 6 days. That powerful experience led me to read six excellent books about our wars there and in Iraq:

• The Things They Carried (Tim O'Brien)
• Matterhorn and What it is Like to Go to War (Karl Marlantes)
• A Rumor of War (Philip Caputo)
• The Good Soldiers and Thank You for Your Service (David Finkel)

All six books were terrific. I recommend any and all to readers who want to know more about what the war experience was like for our military. But for this blog, I want to describe three "lessons" I took from the books about the ethics of health care organizations:

1. The culture of the unit (squad, platoon & company) has enormous influence on the ethics of the unit's behavior. The military has a deeply held commitment to taking care of its wounded and dead. Soldiers risked their lives to act on this value. And, in the opposite direction, Philip Caputo described a massacre-like event carried out by the unit he was leading when he, and his men, were engulfed by hatred for the opposing soldiers. Unit culture could lead ordinary men to become heroes or monsters.
   
   In health care organizations we should recruit staff who - whatever other skills and talents they have - are caring people. But we need to pay careful attention to building and sustaining a culture of care. Good people can do bad things when the culture they are in points in the wrong direction.
   
2. In all of the books it was strikingly clear that the behavior of leaders had a profound influence on the ethical performance of the individuals in the unit. When the leaders were models of admirable conduct, the soldiers were more ethically admirable in their own front-line conduct. When the leaders elicited cynicism, bad things ensued. In Matterhorn there's a scary incident in which a soldier actually tries to kill the commander.
   
3. Being in a war shapes soldiers, both for better and worse. Retired General Peter Chiarelli (described in David Finkel's books) was so moved by what he learned about traumatic brain injury, post-traumatic stress, and suicide among veterans, that in his retirement from the military he is devoting himself to suicide prevention. In health care we're not literally in combat, but there are "war-like" experiences in fighting for the health of individual patients. More of us need to emulate General Chiarelli and move from immersive front-line experience to advocacy for social justice and societal benefit. (See here and here for stories about General Chiarelli.)

I've been critical of the ubiquitous use of war metaphors as seen in obituaries that describe the deceased person's "heroic fight with cancer/heart disease...." When physicians feel that death is their mortal enemy they are at risk for overtreating patients. Over the years I've heard students use the term "flogging," as in "the oncologists are flogging the patient again with another treatment that will just make him sicker..." But there are other aspects of war that model what we should strive for in health care: ethical leadership, a culture of caring, and experience-based advocacy.

Professional Societies and Stewardship in Health Care

Three imaging specialists from Johns Hopkins published a short but VERY important article - "Medical-Imaging Stewardship in the Accountable Care Era" - in the October 29 issue of the New England Journal of Medicine. (Unfortunately, the article is available free only to subscribers.)

The authors are leaders in imaging at Johns Hopkins. In their eminently practical article, they recommend that hospitals and medical groups designate internal experts to set standards for "appropriate" use of imaging studies. CT, MRI and other technologies are, arguably, the most important diagnostic advances in the last 25 years. When used "appropriately" they are the source of enormous benefit. When used "inappropriately" they are the source of high costs without concomitant benefit, and sometimes cause harm when incidental findings lead to unneeded biopsies or other interventions.

I put the word "appropriate" into quotes because in health management jargon it's used as if it's a statement of fact. In reality, it's a contestable judgment about value. The term, like its cousin "medical necessity," allows the health system and political leaders to pretend that we're just dealing with science, and not making value judgments about interventions and resource allocation.

Many health insurers have turned to radiology benefit management companies to oversee the use of imaging services. When this function is carried out well it applies evidence-based criteria to the ordering process and offers educational services to the clinicians whose orders they are reviewing. However, no matter how well the external review process is conducted, an unavoidable "us versus them" dynamic often emerges. In principle, self-management within a hospital or medical group is a preferable approach. Put simply, if it's good clinical care and "appropriate" resource allocation, we clinicians should be doing it ourselves, and not require external "disciplinarians" to enforce good practice.

What I just said is not a critique of radiology benefit management companies, but, rather, a reflection on a structural dynamic. In growing up, when we start to do the "right thing" on our own rather than depending on our parents to guide us, we're carrying out the same actions but in a more mature manner. That's what we should be doing as clinicians in our medical practices!

In "Medical-Imaging Stewardship in the Accountable Care Era," the authors are illustrating the kind of leadership professional societies and leaders within a profession can provide. Evidence based use of imaging and "appropriate" resource allocation are what we should be doing because it's the right way to provide health care. A true profession doesn't require or want health insurers to take responsibility for these core elements of professionalism.

The medical profession hated managed care when it emerged in the 1980s and 1990s. But if we had been managing ourselves in a clinically and socially responsible manner, external review would not have been needed. We left a vacuum. External entities then filled it.

Two teaching cases about unneeded MRIs

Readers who teach may find these two cases useful. But I think they'll be interesting for most thoughtful adults. 

CASE I.  Many years ago I wrote a hypothetical case for a session on rationing for medical students.

Tension Headache

You are a primary care physician at a not-for-profit health maintenance organization (HMO) that serves 500,000 members, paid for by capitation, a monthly premium paid to the HMO by the members’ employer, Medicaid, or Medicare. The premium revenues create a budget to care for the entire HMO population. 

Susan Jackson, a 28 year old office worker, consults you about headaches. For the past month she has had frequent headaches at the end of the work day. The headaches are much less frequent on the weekends. She describes the headaches as a dull, mild to moderate pain, that feels like tightness or a band around her head. She is otherwise healthy. Her neurological examination is normal. She identifies clear stressors at work.

You explain that this is a classical pattern for tension-type headaches and give practical advice on what to do. You predict that the headaches will improve as Susan learns to master the stressors and to build more relaxation into her day. Susan thanks you, but says that a friend who had headaches received an MRI, which showed a tumor that required surgery. With some urgency she says “unless you can guarantee that there is no possibility whatsoever that I have a tumor, I want an MRI. What harm can an MRI do?”

You know that the likelihood of a tumor is vanishingly low, and that established standards of care do not recommend imaging studies in a situation like Susan’s. There is no medical contraindication to getting an MRI, but you know that it would cost between $1500 - $2000, which would come out of the budget for the HMO population. You reflect on what to do, and how to explain your thinking about the MRI to Susan.

CASE II. Today I read the following case on the excellent "Costs of Care" blog:

Doc, I need an MRI

By Patricia Czapp, MD

“Doc, I need an MRI for my back.”

I recognized the voice immediately and turned to greet one of my favorite patients, Mr. P. There he was, smiling, leaning on his walker.

Mr. P visits me several times a day in my primary care office that is essentially in his living room.  The practice itself, sized fewer than 1,000 square feet, is on the first floor of a high-rise apartment building that houses disabled and low-income adults.

My team and I provide primary care to the residents of the building  (a public housing unit) and the surrounding community, a diverse population that has in common these characteristics:  social isolation, low health literacy and low general literacy, a high prevalence of behavioral health problems, and limited transportation.

We came to practice in the building because our health system, Anne Arundel Medical Center, several years ago noted a high number of ED visits from individuals of one address. We visited the address to meet the residents of the building and their landlord, the local housing authority.

We found a population of individuals who were aged beyond their years, suffering from preventable complications of chronic disease and for whom a visit to the hospital met medical as well as nonmedical needs…individuals like Mr. P.

Mr. P is a man living a marginalized existence. He thrives when people take the time to listen to him, touch him, and show him that they care. For many decades , he found this comfort in the ED. When his landlord agreed to try an experiment with us, we came to practice in his building.  Mr. P was one of our earliest patients.

We provide a low-cost alternative to meet his needs and do so with kindness, tolerance and generosity.

“What happened to your back, Mr. P?” I asked.  “Did you fall or hurt yourself”?
“No Doctor, I Just woke up, got out of bed and it hurt real bad for a while.  I could hardly stand up. ”

Rather than lecture him about the lack of medical necessity for an MRI, I accompany him to his modest apartment where we review the condition of his bed and mattress and suggest alternative ways to use pillows to support his back.   Mr. P beams, “Thank you so much.”  And then shuffles toward the Community Room.

If we had not been there to intercept Mr. P, he would have dialed 911. It shocks many to learn that individuals use the ED for nonmedical needs. But for some, this is the only way they feel human.

Our practice has been open for two years. In that time, we have experienced a significant decrease in medical 911 calls, ED visits, admissions and readmissions of residents of the apartment building. They have an alternative now to the ED, and we meet their social needs in their living room – one visit at a time, sometimes multiple times a day…
“Doc, I need a CT scan for my head.”
___________________________________________________________________
Patricia Czapp, MD was contestant of  “The Best Care, The lowest cost: one idea at a time” – a collaboration between Costs of Care, Healthcare Financial Management Association, Strata Decision Technologies, and Yale-New Haven Health.

"Tension headache" works well with medical students and residents. It ends with a resource allocation dilemma. Ms. Jackson wants a guarantee of absolute certainty, which is virtually never possible. The MRI is not required for good clinical care, but if  it cost $15-$20, not $1,500-$2,000, should it be covered because of her understandable anxiety? And, however one thinks through the dilemma, what should the primary care physician actually say to Ms. Jackson?

The second case is a beautiful example of ministering to one's patient - clinical practice as a calling. It's invites learning about "hotspotting" - meeting the real needs of people who are "overutilizing" expensive medical care. Mr. P was suffering, but ED visits were not the best pathway to relief. Dr. Czapp's remarkable practice has the potential to reduce costs even as it provides vastly better care for the population she serves.

Political candidates continue to bash their opponents by accusing them of health care rationing. Cases like these allow us to understand how cost reduction and frank rationing can be conducted in an ethically admirable, clinically sound manner.

Public Learning about ACOs

"Culture beats strategy every time" is a truism in management consultation. The Accountable Care Organization concept is excellent strategy, but it won't get anywhere if our health system culture doesn't support it.

This morning I was happy to see a front page article in the New York Times about how Advocate Health Care is developing its ACO. The article is clear and informative. But the amateur medical anthropologist in me was struck by what the language reveals about the cultural context within which ACOs will thrive or crash and burn. In what follows, snippets from the article are in italics, followed by my editorial comments. I've highlighted key phrases - all of the emphases are mine:

On a stormy evening this spring, nurses at Dr. Gary Stuck’s family practice were on the phone with patients with heart ailments, asking them not to shovel snow. The idea was to keep them out of the hospital, and that effort — combined with dozens more like it — is starting to make a difference: across the city, doctors are providing less, but not worse, health care.

In recent years I've been careful to shovel snow slowly and not to overload the shovel. If I was one of Dr. Stuck's patients I would have appreciated a call from the nurse. But note the assumption that less care is likely to be worse. As a physician who practiced for 43 years my default view is that less is better/more is worse. Many of my colleagues think the same way. ACOs won't succeed unless we can nudge the wider public into understanding that "more" does not equal "better" and "less" is often an improvement!

For most health care providers, that would be cause for alarm. But not for Advocate Health Care, based in Oak Brook, Ill., a pioneer in an approach known as “accountable care” that offers financial incentives for doctors and hospitals to cut costs rather than funnel patients through an ever-greater volume of costly medical services. Under the agreement, hospital admissions are down 6 percent. Days spent in the hospital are down nearly 9 percent. The average length of a stay has declined, and many other measures show doctors providing less care, too.

Insofar as the kind of integrated care ACOs are designed to promote is the right way to deliver care, the changed payment structure is removing a barrier to doing the right thing, not "incentivizing" us like rats in a maze. I don't think I'm alone in finding all the talk about "incentivizing physicians" to collaborate with their patients and colleagues offputting. And if I were a naive patient I'd be suspicious of care that my doctor had to be "incentivized" to provide!

“It’s hard to imagine that you could start from scratch and do this and be successful in three years," said Dr. Lee Sacks, Advocate’s chief medical officer, noting that other systems may find it far harder to flip the traditional fee-for-services system on its head. “We had a running head-start going back to 1995.”

The organizations that joined in 1995 to create Advocate have a 100 year history of faith-based health care. As a non-Christian I found the Advocate mission inspiring. I would be proud to practice with colleagues who shared the values Advocate promulgates. I wish the article had taken the following great quote from Dr. Sacks that I found on the Advocate website:

"There is just a special feeling throughout Advocate Health Care. We regularly recognize those who exemplify our values of compassion, equality, excellence, partnership and stewardship, even though many of them would say that they were just doing their job.”

A piece of cheese at the end of a maze isn't what "incentivizes" health professionals - it's the privilege of being part of a caring profession whose values go back for millennia! The admirable clinicians Dr. Sacks is talking about would be stunned to be told that their comportment reflected economic incentives, not personal mission!

In some ways, accountable care resembles earlier efforts to control medical spending, including the health maintenance organizations that proliferated in the 1980s but fell out of favor, in part because they severely limited patients’ choices. But accountable care differs by giving doctors and hospitals a direct financial stake in saving money and a reason to invest in various programs of preventive care rather than relying exclusively on the fees they would normally earn from providing services.

This snippet tip toes towards getting the culture issue right, but it still misses the crucial point. Capitated payments facilitate investment in programs (and not just for prevention) that are not paid for in our cockeyed fee-for-service/widget-rewarding payment system. But that's not what gives doctors a "reason" to invest. The reason is that it's the right thing to do in light of a mission that even many athiest clinicians regard as "sacred."

So far, Advocate has achieved a small but significant savings of about 2 percent below projected costs, Blue Cross Blue Shield said, but it is not clear whether it can continue to make progress. Already, some Advocate hospital chiefs have expressed fears over losing revenue and warned about the threat to their financial performance. Doctors fret that their incomes may suffer. “We’re doing it because it’s the right thing to do for patients,” said Dr. Stuck, the Advocate family physician. “We’re not making more money.”

Dr. Stuck's point about doing the right thing speaks for itself!

“You’re trying to overlay a payment design onto a benefit model that allows a patient to go anywhere he wants,” said Steve Hamman of Blue Cross Blue Shield, noting that patients can undermine the advantages of the new approach if they ignore the advice or insist on unnecessary tests and procedures. “We can talk all we want about provider accountability and how important that is. But there is a measure of patient accountability that is critical as well.”

For readers who aren't familiar with the ins and outs of the ACO concept, this paragraph is referring to the fact that Medicare beneficiaries who are receiving their care from an ACO aren't "locked in" to the ACO network. If Dr. Stuck's patients want to go to the Mayo Clinic they can do so. This is likely to create clinical, economic and ethical challenges for ACOs. What if the Mayo Clinic does knee replacements better than the ACO? Do we have to refer patients "out"? What are the acceptable ways for ACOs to try to keep patients "in network"? And, most important, how do we engage patients and the public in seeing stewardship of shared resources as a societal imperative they share responsibility for?

We Yanks believe in magic bullets. That's why we have so many drugs in our medicine cabinets and drones in the sky. ACOs, alas, will not magically solve our health "system's" problems of quality and cost. The ACO is a good concept, but it won't thrive without a supportive culture. The otherwise excellent article in the New York Times shows how far we have to go to develop the culture we need!

(See here, here, and here for posts that discuss related aspects of the ACO concept.)

Accountable Care Sprints Ahead

A recent report from the Oliver Wyman consulting firm - "The ACO Surprise" - argues that ACOs are on the verge of triggering a major transformation of the US health system. I hope their prediction comes true!

For all the complexity of federal ACO regulations, I see ACOs as making four core basic commitments:

1. Take responsibility for helping a population be as healthy as possible
2. Connect specialties, disciplines, and sites (hospitals, rehabilitation, nursing homes) in a coordinated manner
3. Engage patients as active partners - ideally leaders - in promoting their own health and guiding their treatment
4. Accept payment for producing valuable results for the population, not for the individual units of service rendered

Here's the Oliver Wyman view of the near term ACO landscape:

• 2.4 million current Medicare ACO patients
• 15 million non-Medicare patients of the Medicare ACOs. The report predicts that the Medicare ACOs will move towards caring for all of their patients in the "ACO manner"
• 8 - 14 million patients to be cared for in non-Medicare ACOs

If Oliver Wyman is correct, it won't be many years before 10 percent of the US population receives its care in accord with the ACO philosophy. Insofar as ACOs are successful in creating more value for patients per dollar of investment, they'll come to dominate the marketplace.

In my physician hat I see the ACO vision as embodying the fundamental values that motivate most clinicians. The reason I joined the not-for-profit Harvard Community Health Plan practice in 1975 was because it was organized around those values.

In my patient hat, I've chosen to have my own medical care from one of the "Pioneer ACOs". I want my doctors, nurses and hospitalists (if I come under their wing in the future) to collaborate in what they do with, for and to me.

Some years ago a patient of mine was in a severe state of psychiatric crisis. The long term problem was a major psychiatric ailment, but the immediate challenge was getting control of acute alcohol abuse. I made what felt like a zillion telephone calls (this was before all parties used a shared electronic medical record) to alert all those likely to be involved with my patient to the clinical situation and what I was recommending. A week or so later my patient reported - with appreciation - "I spoke with nine different people last week and they all said the same thing..." The crisis subsided.

From the perspective of clinicians and patients, care delivered in accord with the first three ACO commitments listed above feels right. The three commitments meet patient wishes and reflect the underlying ideals of the health professions. The fourth commitment is what matters to us from the economic perspective. I share CMS's belief that doing the right thing in health care will end up saving money. But that will be a happy result of ACOs, not the reason for going down that path.

Goldman Sachs, Corporate Culture, and Medical Ethics

When Greg Smith, an executive director at Goldman Sachs, and head of the firm's US equity derivatives business in Europe, the Middle East, and Africa, explained why he resigned from the company in a remarkable New York Times op ed piece two days ago, the story went viral. Here's the essence of what he had to say:

After almost 12 years at the firm...I believe I have worked here long enough to understand the trajectory of its culture, its people, and its identity. And I can honestly say the environment now is as toxic and destructive as I have ever seen it....I have always taken a lot of pride in advising my clients to do what I believe is right for them, even if it means less money for the firm. This view is becoming increasingly unpopular at Goldman Sachs...I attend derivatives sales meeting where not one single minute is spent asking questions about how we can help clients. It's purely about how we can make the most possible money off of them. If you were an alien from Mars and sat in on one of these meetings, you would believe that a client's success or progress was not part of the thought process at all.

Years ago, my friend Marc Bard, a brilliant consultant, taught me the aphorism - "culture beats strategy every time." This is perhaps especially true in health care, which is so strongly mission-driven. If the shared culture of a health organization is truly patient centered every action will express the organization's values.

I experienced how culture works especially clearly 19 years ago, when my father, near the end of his life, was a patient at the Lahey Clinic. In my distracted and distressed state, I locked my keys in my car. I went to the building services office to get help. A staff member (a) picked the car's lock with expertise, but also (b) conducted excellent common sense psychotherapy with me around how we get forgetful when we're upset, and (c) said he would pray for my father. Remembering the incident and writing about it here brought tears back to my eyes. I'm happy that I wrote to the CEO to report on the excellent care I received from his non-clinical staff and to congratulate him on the culture of the organization.

I'm lucky that the four health organizations I've been part of during my career - the Massachusetts Mental Health Center, Harvard Community Health Plan/Harvard Vanguard Medical Associates (HCHP morphed into HVMA), the Harvard Pilgrim Health Care insurance company, and the Harvard Pilgrim Health Care Institute,  have all had cultures and evinced values I've been proud to be associated with. I doubt, however, that the people at those organizations were intrinsically more ethical than the colleagues Greg Smith is writing about.

When one's colleagues and the leaders of an organization share core values they reinforce each other. Newcomers are selected for fit with the culture, and the culture (what educators call the "hidden curriculum") brings out the best in us. It's easier for a health organization than for Goldman Sachs to cultivate a positive culture because the mission of caring for people who are suffering encourages empathy. I'd like to believe that I'd leave as Greg Smith did if I found myself part of an organization with a environment that is "toxic and destructive" and was unable to influence it, but knowing the human capacity for self-delusion, I can't be smug and certain that I wouldn't follow the same playbook Greg Smith discerned at Goldman Sachs.

Aristotle conceptualized "character" as an inner state or way of being that shows itself in the patterns of our actions. "Culture" is the organizational equivalent of "character." Culture is partly formed by the characters of those who constitute it, but the influence goes both ways. In trying to understand our human natures, we need to consider "culture" and "character" along with "nature" and "nurture."

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.

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:

...my 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!

Concierge Medicine

Yesterday the Boston Globe reported that two of the most respected physicians at the Newton Wellesley Hospital, five miles from where I live, are shifting to a mode of practice called "boutique" or "concierge."

In this format physicians limit their practice to 300 - 600, a much smaller number than is typical for primary care, and charge a fee ($1,500 and up) for membership in the practice. Patients are offered prompt appointments, more time for their visits, 24/7 access to their physician, and more. Insurance doesn't pay the membership fee. Patients need insurance to cover tests, office visits, specialty consultations, hospitalization, and other insurance-covered services.

Concierge practice is small in number, but like canaries in coal mines, it's the source of important information. I only know one physician in a concierge practice - Dr. Jordan Busch, co-founder of Personal Physicians HealthCare, a four physician practice near Boston. Jordan is a superb physician with strong caretaker values. He came to feel that he was not able to care for patients in the comprehensive, personalized manner he aspired to while at the same time making a middle class income. Insurance reimbursement (private insurance, Medicare and Medicaid) for primary care pays by the visit, at a relatively low level. Meeting office expenses and earning a middle class income required a large volume practice. For Jordan (and his colleagues), Personal Physicians HealthCare is a way to practice the kind of medicine he believes in.

I've visited the website of MDVIP, a Florida-based entrepreneurial organization that provides support for approximately 225 physicians in the U.S. (16 in my own state - Jordan's practice is not affiliated with it). I wish I could say I was impressed by idealism, but I wasn't. Much of the executive team comes from Proctor & Gamble. The marketing is pitched to affluent patients. I was struck by the absence of any reference to improving the health system. It presents concierge practice as a "solution" to the frustrations of individual patients and physicians by opting out of the larger system. Although the numbers are still small, each primary care physician who moves to a boutique practice makes it harder for patients to find their own physicians and makes practice even busier for those who don't opt out.

When I trained in psychiatry in the late 1960s, many of the best and the brightest chose to become psychoanalysts. I thought of psychoanalytic theory as a source of insight, but the idea of a small panel of affluent patients didn't represent the kind of diverse, population-oriented practice that I aspired to. I can understand the frustration many primary care physicians, perhaps most, feel at present. But if I were a PCP, I'd think of concierge practice the way I thought of psychoanalysis - a failed model from the perspective of societal needs and population health.

Over time, moving to accountable care organizations and other formats that pay physicians for the populations they care for, not for the visits they provide, is a much more promising and socially responsible direction than concierge practice. Concierge practice, like dead canaries in the coal mines, is a symptom of a societal problem, not a solution!

Pain Control, Hypnosis, and Medical Ethics

Two years ago I wrote about self-directed hypnosis as a effective and ethically admirable clinical intervention. A recent New York times article - "Using Hypnosis to Gain More Control Over Your Illness" - got me back into the literature on hypnosis for pain control. Since I last dipped into it there have been impressive findings about the impact of hypnosis on procedures associated with pain and anxiety. Here are a few examples:

• A Cochrane review confirmed that women taught self-hypnosis used less pain medication during labor and were more satisfied with their pain management experience than women receiving standard care.


• A study conducted at Mt. Sinai in New York showed that hypnosis combined with cognitive behavioral therapy reduced the amount of fatigue experienced by women undergoing radiotherapy for breast cancer.


• 236 women undergoing large core needle breast biopsy were randomized to standard treatment, structured empathy, and self hypnosis. Pain and anxiety were significantly less with hypnosis, resulting in a shortening of procedure time (39 minutes compared to 46 minutes). The savings from a shortened procedure offset the incremental cost of hypnosis.


• For children undergoing a voiding cystourethrogram, a decidedly unpleasant radiological study that requires insertion of a catheter through the urethra and fluoroscopic visualization of the bladder while the child urinates. (Just thinking about the procedure gives me anxiety.) In a randomized study, children from 4 - 15 who, along with their parents, received a one hour training session in self-hypnosis, reported significantly less pain and anxiety during the procedure and showed fewer outward signs of distress, leading to a 14 minute shortening of procedure time and reduced cost.

If a new drug - I'll call it hypnotyx - was shown to have comparable effects to self-hypnosis, we would see rapid wide dissemination, a likely cost of several hundred dollars a pop, and, ultimately, hundreds of millions of dollars in sales. Parents would demand hypnotyx for their children. Adults undergoing biopsies would insist on receiving it. But self-hypnosis, a low technology, "alternative" treatment, without a glitzy name, vigorous advertising, or significant profit opportunity, has relatively few fans.

This embrace of "pharmacophilia" is a sad reflection on our national medical culture. We physicians can't simply blame the low uptake for an "alternative" treatment like self-hypnosis on our patients. If we expressed comparable enthusiasm and belief in hypnosis that would occur for hypnotyx our patients would move in the same direction. Advertising has a huge impact, but so does our offhand comments, tone of voice, facial expression, and other components of communication.

If I were again involved in managing a group practice - something I've been out of for 25 years - I'd make a systematic effort to bring techniques like self-hypnosis into areas of the practice like those the studies focused on. It's well and good for individual physicians to incorporate "alternative" methods into their standard practice, but that won't go far in changing our medical culture.

The focus of my work is on ethics, but I cringe when I'm introduced as an "ethicist." The term connotes expertise in an arcane domain, when the fact is that articulating and promoting values is a universal responsibility. With regard to promoting self-hypnosis as an effective, low risk/low cost approach to reducing pain and anxiety, the true ethics leaders will be those who succeed in implementing the robust research findings that are readily available in the literature!

(Dear friends - I've been in Hawaii for two excellent weeks of holiday and then in DC for a meeting - that accounts for the two week hiatus in posting.)

Pumping out Prescriptions

A story on the front page of today's New York Times caught my eye - "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy." For psychiatrists of my generation who've had the privilege of treating our patients in a comprehensive manner - psychotherapy when it was called for and medications when they were needed - it's a sad story.

The article describes Dr. Donald Levin, 68, who early in his career did primarily "talk therapy," with 50-60 patients in his practice who he saw for 45 minute appointments, typically weekly or twice weekly. Now he has a panel of 1,200, who he sees intermittently for 15 minutes to prescribe and manage medications. For psychotherapy they see social workers or psychologists.

Dr. Levin has done a real service with his candor. He comes across as a competent, caring person, who is trying to make a middle class living and can only do it by changing himself from a "therapist" to a "prescriber." The reporter was able to interview some of Dr. Levin's patients, who spoke warmly of him. Dr. Levin was surprised at their reactions. "The sad thing is that I’m very important to them, but I barely know them. I feel shame about that, but that’s probably because I was trained in a different era."

My professional colleagues blame the transformation of the profession on managed care. The accusation is half right.

It doesn't take a PhD in economics to recognize that fees paid to psychologists and social workers are lower than fees paid to MDs. In many areas of the country, well educated, skillful non-physician clinicians are readily available. For patients whose primary need is psychotherapy, using the insurance pool to pay a higher fee would only be justified if psychotherapy done by MDs produced better outcomes. For relatively healthy patients for whom medication isn't needed, there's no reason to see medical training as a necessary component of effectiveness. For these patients, insurers are right to pay for psychotherapy at the lower, non-MD level. Psychiatrists can do this form of psychotherapy, but won't be paid a premium for doing it.

But many patients require medication and monitoring of their physical health, combined with psychotherapy. Here, insurers have often carried over the model of split treatment in a rigid and short-sighted manner. Many years ago my psychiatrist friend Bill Goldman, then medical director of United Behavioral Health, demonstrated that integrated treatment of depressed patients with medication and psychotherapy, done by a single psychiatrist, was actually less costly than split treatment for comparable patients, with the psychiatrist handling medication and a non-MD providing psychotherapy.

In past decades, my guild made a typical guild error. We claimed that psychotherapy done by psychiatrists was better than psychotherapy done by non-MDs. For patients who needed integrated treatment, my guild's claim is true. For patients whose need was for psychotherapy alone, our claim was false.

Our defensive posture weakened our bargaining position with insurers, and the insurers' short-sightedness about the validity of integrated treatment with a subset of patients made them hard to bargain with. The result has been a large scale transformation of the profession into one where psychiatrists do intermittent "med checks," described in poignant detail by Dr. Levin in the New York Times.

In 1975 I joined the practice in a not for profit HMO, in which the insurance function and the medical group were part of a single organization. I and my psychiatrist colleagues shaped our practices so that we cared for patients for whom our medical training provided additional value. Patients who needed psychotherapy alone went to our excellent non-physician colleagues. This arrangement was (1) satisfying for patients, (2) satisfying for clinicians, and (3)an efficient use of the insurance pool. It required trust between the clinical and insurance components of the organization.

If the anticipated trend to encourage the development of accountable care organizations - medical groups that take responsibility for quality and cost - unfolds as predicted, we'll see recalibration of psychiatric practice. Psychiatrists will be paid to talk and prescribe, but only for the subset of patients who require their combined expertise. That could foster good clinical care, good professional life, and good economics!

(For more about the transformation of psychiatry, see my post "Psychiatrists should talk with patients, not just give pills.")

Can Patients Trust Accountable Care Organizations?

The 1990s version of managed care 1.0 crashed and burned because of distrust. Physicians distrusted the utilization review systems and payment schemes imposed on them by insurers. Patients feared the care they needed would be withheld for reasons of cost, and they wouldn't even be told what was going on. When Helen Hunt riffed about "bleeping HMO bastard pieces of shit" in the 1997 movie "As Good As It Gets," audiences cheered! (You can see the segment on YouTube here.)

Prior to talking with a group of physicians, insurers, and other stakeholders involved in a pilot ACO program, I reviewed literature about trust to see how managed care 2.0 could avoid the backlash that felled managed care 1.0 in the 1990s. Two empirical studies seemed especially useful: "The Effect of Physician Disclosure of Financial Incentives on Trust," by Wendy Levinson and colleagues, and "A Trial of Disclosing Physicians' Financial Incentives to Patients," by Steve Pearson and colleagues.

Dr. Levinson surveyed the reactions of almost 3,000 interviewees chosen to reflect U.S. households, on their reactions to this vignette:

Imagine you've been experiencing headaches. You visit your doctor and talk to him about your symptoms. You also tell the doctor that you've been feeling a lot of stress lately. After doing a complete examination the doctor decides that the headaches are probably due to stress. The doctor wants to work with you over the next month to reduce your stress. You want to have an MRI to make sure everything is okay. Remember that after your complete examination the doctor thinks you don't need the MRI. Then imagine that you have the following conversation with the doctor about the MRI and financial incentives.

After hearing the scenario, one of six possible strategies was played, each beginning with this patient statement: "I'd feel better if I had an MRI. I'm worried that you won't order it because it's too expensive."

Three physician communication strategies were primarily "cognitive" - giving direct information, stressing expertise, and denying that incentives had any influence. Three were primarily "affective" - addressing the patient's emotions, badmouthing managed care as a common enemy, and negotiating with the patient for a mutually acceptable plan.

The article includes many fascinating details, but the overall conclusion is simple and clear. The interviewees overwhelmingly wanted to know about the incentives. Their preference was to be told about them at the time of enrollment in their health plan. Two physician communication strategies - addressing patient emotions and negotiating for a mutually acceptable plan - worked best to convey information and preserve trust. The authors' bottom line was that "physicians should acquire the skills needed to openly discuss if, and how, they are influenced by financial constraints and cost containment programs."

Dr. Pearson conducted an experiment in two medical groups. The chief medical officers sent letters to randomly selected patients describing the compensation arrangements for physicians in the group. Neither group put physicians at risk for cost overruns or rewarded individual physicians for withholding services. Three months later the patients to whom letters had been sent and a matched control group were surveyed.

The intervention of a one-time letter significantly improved knowledge of how physicians in the group were compensated. Nearly a quarter of the patients who remembered receiving a letter reported that it had increased trust in their primary care physician. The disclosure letter did not decrease trust that PCPs would patients' interests above concern about costs. The authors' bottom line was that "regulators, policy makers, and physician groups themselves should renew their consideration of disclosure as an instrument to advance the best interests of patients and physicians."

Some policy makers anticipate that patients will be "attributed" to ACOs without being told, hoping that being part of an ACO will be invisible. This is wishful thinking. It won't take Wikileaks and Julian Assange to reveal the ACO structure. And if, as I believe, properly run ACOs represent an ideal way of providing and receiving care, lack of transparency will breed unnecessary suspicion and distrust.

It remains to be seen if we (physicians, patients, health plans, and other stakeholders) will be able to make managed care 2.0 work better than the earlier version. But unless physicians and health plans engage patients in an open, educative, and collaborative manner, 2.0 will go down the tubes just as 1.0 did.