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!

Insurance Coverage for Telemedicine

Last week the Harvard Pilgrim Ethics Advisory Group (EAG) devoted its quarterly meeting to the topic of "Developing a Framework of Ethics for Telemedicine." I chair the group and write a consultation report based on the discussion. Four of the group's recommendations are relevant for all health insurers and health plans, so I'm presenting them here:

1.  Nationally, telemedicine is evolving rapidly in a somewhat helter-skelter manner. The EAG recommended that insurers should focus coverage on areas in which telemedicine can minister to significant health needs. Fitbit and other health trackers are popular with consumers but do not reflect the kind of “need” that health insurance should cover. In contrast, services for patients who cannot access important care because of geography or limited mobility and services that maintain or improve quality while reducing costs provide real value.
2.  Patients and physicians both see continuity of care as a crucial health care value. But patients also value access and convenience, which have driven the uptake of telemedicine. Ideally, insurers will find ways to reconcile these potentially conflicting values, as by requiring telemedicine providers to foster communication with the patient’s primary care physician if the patient gives permission. The group imagined technological “fixes” that would encourage patients to be active participants in establishing continuity of care, as by having the telemedicine provider’s note go to the patient, to be shared with whomever the patient wishes to inform. 
3.  One of the questions the EAG had been asked was: "Should Harvard Pilgrim be a leader in providing telemedicine coverage or wait for well established quality information and support from the relevant professional organizations prior to offering access?" The group saw the question as too either/or. Telemedicine is at once (a) a promising innovation that is (b) energized by societal trends in use of technology in other sectors of life, but (c) uncertain in its impact on cost and quality of care. It encouraged Harvard Pilgrim to be active in the area of telemedicine, but do so in a try it/evaluate it/fix it/or drop it manner, in order to learn from experience and contribute to knowledge about the emerging trend.
4.   A Google search for "telemedicine providers" brings up a dizzying array of links. There is a lot of money to be made, and the marketplace is in a feeding frenzy. Given the certainty that consumers will be exposed to services ranging from high quality/high value enterprises to bottom feeders hoping to take the money and run, the EAG recommended that insurers only cover services from vendors who share and apply the same values with regard to improving quality, reducing overall costs, and supporting continuity of care. This revenue prediction table illustrates why the marketplace offers patients both promise and risk: 
5. 
   

   

   SKYROCKETING REVENUE PREDICTIONS FOR TELEMEDICINE!

To learn more about the Harvard Pilgrim Health Care ethics program, see previous blog posts here and here, and this article in Health Affairs

A Personal Experience with Medical Cost Containment

When I saw my primary care physician earlier this week he gave me a pep talk about scheduling the colonoscopy I'd been dawdling on doing. I decided it was time to follow his advice.

I had two reasons for being concerned about how much the colonoscopy would cost. First, from the self-centered perspective, my insurance includes a $1500 deductible, so I would be paying some or all of the cost on my own nickel. Second, from the perspective of a concerned citizen, I believe we all have a moral responsibility to (a) take care of our health (b) at the lowest cost to collective insurance funds. If the test cost more than my deductible my fellow insurees will be paying for my charges, and I should consider their financial well-being just as I consider my own.

I'd recently received notice that my self-insured employer offers a service called SaveOn, provided by Tandem Care, a five year old New Hampshire company that gives patients comparative cost information on services within their insurance network. If we're already scheduled to go to a "low cost" provider, we get a $10 reward simply for having called the SaveOn program. If we're scheduled for a high cost provider and choose to go to a lower cost provider instead, we get a reward of $25 to $75, depending on the cost of the procedure.

I receive my care from Harvard Vanguard Medical Associates, a large non-profit, multi-specialty group practice in Massachusetts. I preferred to have the colonoscopy done at the HVMA facility. Doing so would ensure the best coordination of information flow and followup. But suppose an alternative of good enough quality cost $500 less? Would coordination be worth that much additional cost to me?

I called the SaveOn service with some trepidation. The service itself was excellent. A nurse answered my call after one ring. She took my information efficiently and called me back within 15 minutes. Happily, the site I'd been referred to within the group practice was considered a "low cost provider." That spared me the challenge of (a) deciding how much additional cost continuity of care was worth to me and (b) chiding my medical team for being "high cost." The SaveOn nurse told me I'd receive a $10 check after the procedure was done.

Within the cockamamie U.S. health "system," Tandem Care/SaveOn are providing a valuable service. In our consumer role it helps us take care of ourselves at a lower cost. Even if our insurance does not include a deductible - something that is increasingly rare nowadays - the reward for choosing a lower cost provider is enough to matter to us. In our citizen role the program helps us reduce overall costs to the body politic, and, at the same time, educates us to think about costs in health care as we do in virtually every other aspect of our lives.

For decades, we in the U.S. have been searching desperately for ways to make health care less costly. None of the gimmicks we try will work unless we citizens embrace the effort. If we had a national system with a budget paid for via our taxes the way most other developed countries do we'd be invested in getting the most bang for our bucks. But in the highly fragmented "system" we have, the relationship between overall costs and the choices we make as individuals is largely invisible to us. My little experience with SaveOn shows how smart systems can help to make us less stupid about costs!

Nonprofit Regional Health Plans

As the US health system moves towards the 2014 launching of health exchanges and other components of Obamacare, regional nonprofit health plans are poised to take a distinctively important role.

An article in today's New York Times described the steps Florida Blue, which covers 4 million Floridians - 30 percent of the Florida insurance market - is taking. The  proposal for a "public option" like Medicare for all that would compete with private insurers crashed and burned in the health reform process, but regional nonprofits like Florida Blue are carrying out the function that was envisioned for the public option. Nonprofits can't function without making a margin beyond their expenses, but their structure allows them to be more mission-driven and locally connected than investor-owned plans.

For much of my clinical career I practiced at the nonprofit Harvard Community Health Plan (HCHP) HMO. My late father, who lived in Florida, know how much I respected HCHP, and asked me if he should join an HMO. At that time none of his choices were nonprofits, and I'd read about various scandals in the Florida market. If he'd been living in Massachusetts I would have encouraged him to join HCHP where I and my family got our care, but I advised him against the HMO route in Florida.

Medical care is ultimately local. It works best when clinicians and their organizations are part of the local community. This passage in the article stood out for me:

“Florida Blue has the same problems everyone else has,” said Dr. Michael A. Wasylik, an orthopedic surgeon in Tampa who works with insurers through the Florida Medical Association, but “they have a better trust relationship with doctors.” The local representatives are better able to address doctors’ concerns, he said.

Health reform won't get anywhere without enthusiastic participation from the clinical community. Insurers can facilitate reform, but they can't make it happen. Engagement with the local community, and above all the kind of trust that Dr. Wasylik refers to, are key. If the national for-profit giants can compete successfully with regional nonprofits like Florida Blue, more power to them. But if the narrow margins and need for highly collaborative relationships with the clinical community make Obamacare an undesirable business opportunity, regional nonprofits like Florida Blue will flourish.

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."

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.

Health Insurer Secrecy and Public Trust

Ten health insurers, including Aetna and United Healthcare, are suing the New York State Insurance Department to prevent publication of memos that present their rationales for rate increases. The companies argue that the memos reveal proprietary trade secrets and that making them public would cause “substantial and irreparable injury" in the competitive marketplace.

I've not seen the complaints the insurers have submitted to the court, but it's quite imaginable that the rate increase memos include company secrets that are protected by law. If this is the case, the companies may win the immediate battle. But they're sure to lose the long term war about transparency.

At the not-for-profit health plan where I direct the ethics program, rate increases reflect the cost of care delivered to members. There are no equity owners demanding dividends and improved stock prices. Approximately 90% of the health plan's revenues go out as claims payments. Among for-profit insurers the "medical loss ratio" (better thought of as the "medical care ratio," since the purpose of health insurance is to pay for medical care!) is lower - often less than 80%!

Patients and the public need to understand the drivers of health care costs. Without that knowledge we can't be part of the solution to the cost crisis. And, increasingly, consumers are demanding to know why health insurance premiums are so high compared to other countries whose health outcomes are as good or better. Transparency is inevitable, and that's a good thing.

But the kind of transparency about pricing being called for in New York and elsewhere isn't ordinarily part of the world of for-profit enterprises. Health care, however, is better thought of as a public good than as a commercial commodity. As patients, we want our doctors and hospitals to be mission-driven. Secrecy about costs isn't compatible with professionalism and public trust.

(For a New York Times article about the litigation, see here.)

Insurance Executive Compensation and Medical Ethics

The uproar in Massachusetts about the golden parachute given to the former Blue Cross Blue Shield CEO that I posted about two weeks ago refuses to go away, as evidenced by the first two paragraphs in a front page story in yesterday's Boston Globe:

The doctor was angry. Not long after Blue Cross Blue Shield of Massachusetts urged him and other health care providers to keep their costs down, the insurer this month disclosed it had agreed to an $11 million payout for its former chief executive. In a terse voicemail, the physician told Blue Cross: You have a credibility problem.

It was the kind of call Andrew Dreyfus expected. Hired as chief executive of Blue Cross last fall, Dreyfus has been championing affordability — prodding payers and providers to work together to rein in the price of medical care following years of double-digit insurance premium increases. Then came the uproar over millions of dollars collected by his predecessor, Cleve L. Killingsworth, and headlines about five-figure annual fees paid to board members. Suddenly, the talk about lowering health care costs rang hollow.

The doctor was right!

The issue isn't dollars and cents economics. By my back of the envelope calculation, if the top 50 executives at Massachusetts Blue Cross Blue Shield worked for free and received only a handshake on retiring, there would be no visible impact on the cost of insurance for members and employers.

What's at stake is the challenge of integrating the two fundamental values a health system must serve: fidelity to the needs of individual patients and stewardship of society's resources to allow access to health care for all.

When one group (clinicians) is charged with protecting fidelity, and another (insurers) is charged with protecting stewardship, human nature and group psychology inevitably leads to mutual suspicion. Clinicians can see insurers as "uncaring bean counters." Insurers can see clinicians as narcissists who feel entitled to spend other people's money in an unchecked manner. In the 1990s, these reactions ran amok, leading to the demise of managed care.

Tension between those who are directly responsible for patient care and those who are directly responsible for stewardship of collective funds isn't peculiar to the United States. I observed the same tension in England between clinicians and the National Health Service. The tension arises from a classical good v good conflict. It is good to care about patients and to seek to do everything possible for them (fidelity). And it is good to care about containing health care costs so that individuals and society have the wherewithal to address other important areas of life (stewardship). As important as health care is, individuals and societies have other interests as well!

For us to get a grip on health care costs, insurers - no matter whether they are private or public, for profit or not for profit - must be able to work collaboratively with clinicians. For this to happen, they have to be seen as understanding and caring about core clinical values. Appearance counts for a lot. An $11 million golden parachute to a departing CEO and high compensation for a board of directors will lead many clinicians and patients to see insurers as "uncaring bean counters" even if Albert Schweitzer or Mother Theresa is in charge of the organization!

Paying Health Care Executives and Board Members

Unions, employers, legislators, and the public erupted with anger at the announcement that Cleve Killingsworth, the former CEO and President of Massachusetts Blue Cross Blue Shield, received a departure payout of $8.6 million. A Boston Globe editorial fulminated about "Blue Cross at the Trough." Brian McGrory weighed in with a column blasting the four not for profit Massachusetts health insurers for paying their board members. And Derek Jackson, another Globe columnist, opined that "if Massachusetts is the model, then national health care reform is ultimately doomed."

It's an interesting issue of business and health system ethics. From one perspective, the "right" payment to a CEO or board member is the amount that results in the best "output" by the enterprise. If $8.6 million produces better results for health plan members than a lesser sum, it would seem to be the correct pay package. If $9.6 million would have produced substantially more benefit for Blue Cross members, Killingsworth was underpaid!

But real life is not so simple. Apart from the practical difficulties relating CEO and board member compensation to the level of output produced by the enterprise, the way the compensation "looks," often called the "sniff test," has to be considered. Deirdre Cummings, legislative director for the Massachusetts Public Interest Research Group, put the sniff test factor this way:

"This compensation package undermines the credibility of insurers when they say they’re serious about bringing down the cost of health care. When a CEO makes that kind of money, the public loses faith that we can solve the problem of health costs."

In my view, Cummings is on to something important here. Small businesses that provide insurance to their employees are reeling from health insurance costs. Insurees face bankruptcy from high premiums, deductibles, and other payments they must make. Primary care physicians, nurses, and many other health professionals, are struggling to stay in the middle class as their incomes dwindle. When they sniff the CEO's compensation, they find a decidedly bad aroma.

Defenders of the compensation system argue that the situation would be even worse if CEOs were not guaranteed payout of $8.6 million. But this argument is essentially faith-based. Why on earth would a small business owner, who works just as hard or harder than the health plan CEO, but earns 1/100th of the CEO's payout, believe that his health insurance premium would be higher if the CEO were paid less. Likewise for the nurse who works extra shifts to afford basic expenses or the primary care physician who works seventy hours a week for the same reason.

Income inequity has been rising steadily in the United States. The top one percent control one quarter of our wealth. Income inequity correlates with loss of social solidarity and poorer national health outcomes. And as in the recent flap in Massachusetts, an $8.6 million payout fuels distrust and rancor in a sector that requires trust and collaboration. If we had proof of the kind we look for in evidence based medicine that higher CEO compensation produced greater population health, the backlash would be substantially less. But when all we have is economic platitudes, public outrage simply increases.

(A lot has been written about income inequity. One good summary, from Slate magazine, can be found here.)

Consumer Directed Health Care Can Work!

On Thursday during a break in the cloudy/rainy weather in Vermont, I took the 3/4 mile hike up to Lake Pleiad, a mountain lake that's a favorite swimming spot. The weather was dicey and there was only one other person there, a large man with two large tattoos, who, I learned, had been a bouncer in a bar, but now now worked for a small manufacturing company.

I asked about the health insurance the company provided. Here's my reconstruction of what he said:

It's a health savings account type of thing. I have a $5,000 deductible. It's a good deal because the employer puts some money into the savings account. The deductible is a lot of money, but I'd only have to spend it all if I went into the hospital. I'd rather take that risk and have a lower monthly premium, even though a 'lower premium' is still a lot! Doctor visits and tests don't come to all that much. I don't just take a doctor's word about things - I ask a lot of questions. 'What could this test show? Would the results make us do anything different? How important is it?' Sometimes they give me a good answer, and I'm satisfied, but sometime it seems like they didn't really have a good reason, and I don't do it. You've got to ask questions!"

I asked him if the deductible got him to ask more questions. It did. "When you're laying out the money, you think about things more!"

I told him he'd made my day. He was doing just what the architects of high deductible health plans were hoping for. I said "if more people did what you do it would keep us doctors on our toes! We recommend a lot of things out of habit and they don't really need to be done. Do you encourage friends to ask questions the way you do?"

He did. A woman friend's gynecologist was recommending expensive tests on a regular basis. She didn't know why - "I just do what the doctor tells me I need to do." He said "you've got to ask!" When she did it turned out that the tests were really optional. She thanked him.

In 2009 approximately 23 million Americans had plans like the one my swimming companion had. If five percent asked questions the way he did that would be a million people. If that million persuaded five friends to do the same we'd be up to five million. To paraphrase the late Senator Everett Dirksen - "a million people here, a million people there - pretty soon we're talking real public education."

I spent thirty-five years of my practice life with a not-for-profit HMO. I think a group practice of that kind, in which patients and clinicians collaborate in planning the wisest way to use resources, is ideal. But that model didn't catch on widely, which is one reason consumer directed plans are selling like hotcakes.

I really admired and learned from my swimming companion. He was just a smart guy who thought for himself - not a health policy geek like me. If we had a groundswell of people like him who approached health care like prudent consumers it would be the strongest possible force for health reform!

Managed Care and Accountable Care Organizations

I recently received the following note from a mental health clinician I know to be clinically excellent and fair-minded as well:

I am aware a number of providers are disturbed with their experiences with [XYZ Managed Behavioral Health Organization] and I wanted to share my experience. Basically, the reviewer was belligerent from the get-go and I had no chance to present my experience. I felt like a defendant on the witness stand with the D.A. confronting me. I still don't know the result of the review, but it certainly was unprofessional and unfair to my patient and painful to me.

I thought of Yogi Berra - this was deja vu all over again!

In the 1990s I studied managed mental health care the way an anthropologist would - I sat with clinicians as they spoke with managed care reviewers and sat with managed care reviewers as they spoke with clinicians. What my observations showed was good people brought into conflict by a flawed technology that came into being to fill a vacuum my colleagues and I had created.

We clinicians were schooled to believe that it was unethical to consider anything other than the interests of our individual patients. This was often said with a kind of smug theological certainty, with the implication that only a moral imbecile or callous monster could disagree. "Doctor," I often replied, "that's an admirable view. Since it's unethical to consider anything but the interests of your patient, that means if your patient needs a heart transplant and you are the only good match, you would be a donor."

In these exchanges I often thought of my hero from college days - Socrates. The colleagues I had this exchange with felt I was pulling a fast one on them and trying to make the worse appear the better cause. For defending the aims of managed care as ethical I was at risk for being fed a jug of hemlock.

In all of my practice years I never experienced third party telephonic review. In my public sector role we had an explicit budget we had to work within. And in my not for profit capitated medical group role we again managed ourselves within the budget set by the capitation we received.

Since costs must be contained, there are only four choices for a health system. (1) Manage via the market, with individuals buying their own care. (2) Provide insurance, with each doctor/patient dyad deciding what should be paid for. (3) Enlist medical expertise in allocating funds via what is now called "accountable medical organizations." Or, (4) ask insurers to do the job for us via third party review.

When clinicians responsible for providing care to their patients and reviewers responsible for managing the available funds are connected by an 800 number, the kind of fiasco my colleague describes is inevitable. Clinicians tell each other about unreasonable reviewers. Reviewers tell each other about feckless clinicians. Distrust builds.

The reviewer described in the note I received could have been a bad apple put into the wrong job, but also could have been a well-intentioned person, who had seen many examples of bad practice, and was overly vigilant.

In the 10 - 15 years since physicians and the public revolted against managed care we've come closer to recognizing that if we don't want the economy to go down the tubes, costs must be managed. In the next 10 - 15 years we'll see a burgeoning of "accountable medical organizations," in which clinicians and patients learn to co-manage resources. The required new learning won't be easy, but if we do the job well we'll be following the Institute of Medicine's urging to cross the quality chasm!

Recission Wasn't Always a Moral Crime

An editorial in today's New York Times celebrated the end of the insurance practice of "recission" - voiding of the insurance contract on the basis of fraud.

Health insurers received well-justified disgrace when they terminated coverage for seriously ill persons for what Timothy Noah in a Slate column called "chickenshit errors":

Rescission (also known as "post-claims underwriting") is the process whereby health insurers avoid paying out benefits to treat cancer and other serious illnesses by seeking and often finding chickenshit errors in the policyholder's paperwork that can justify canceling the policy. In one job evaluation, the health insurer WellPoint actually scored a director of group underwriting on a scale of 1 to 5 based on the dollar amount she had managed to deny through rescission. (The director had saved the company nearly $10 million, earning a score of 3...

Robin Beaton, a retired nurse in Texas, was rescinded last year by Blue Cross and Blue Shield after she was diagnosed with an aggressive form of breast cancer. Blue Cross said this was because she had neglected to state on her forms that she had been treated previously...for acne. Beaton eventually persuaded her congressman, Rep. Joe Barton, to twist Blue Cross' arm, but the delay meant it was five months before she could receive her operation. Otto Raddatz, a restaurant owner in Illinois, was rescinded in 2004 by Fortis Insurance Co. after he was diagnosed with non-Hodgkins lymphoma. Fortis said this was because Raddatz had failed to disclose that a CT scan four years earlier had revealed that he had an aneurism and gall stones. Raddatz replied — and his doctor confirmed — that he had never been told about these conditions (the doctor said they were "very minor" and didn't require treatment), but Fortis nonetheless refused a payout until the state attorney general intervened.

There's no way that cancelling coverage for a patient with breast cancer because she had not listed treatment of acne on her application for insurance can be justified. But see what you think about a situation that first brought the issue of insurance fraud, recission, and fairness to my attention.

More than two decades ago X became my patient after discharge from a hospital for a heroin overdose. X had a longstanding pattern of heroin use. The overdose was not a suicide attempt. X and I defined a set of treatment objectives.

I was surprised to receive a question from the administration of the not-for-profit HMO I was part of. X had enrolled as an individual, which required filling out a health statement. Several questions were about drug use. X repeatedly reported using no illegal drugs. An algorithm had flagged the hospital discharge diagnosis of "heroin overdose." The administrator asked if the diagnosis reflected a "pre-existing condition."

My immediate reaction focused on responsibility to my patient. What possible reason could justify breaking Hippocrates' 2500 year old precept: "All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal"? From the perspective of the doctor-patient relationship the answer was a no-brainer - I'd have to keep silent.

In addition to the hallowed medical commitment to respecting confidentiality, I thought about my patient's dilemma. I believe that a civilized society should ensure that all citizens have access to decent health care. My patient was self-employed and could only get insurance as an individual. Standard insurance practice required individuals to fill out a health statement, as part of an effort to prevent people from taking out insurance only when they knew they had a problem requiring care. After all, we don't let people wait to see the smoke before they take out fire insurance! In the U.S. system X couldn't (a) tell the truth and (b) get health insurance.

But then I thought about the other members of the HMO. The HMO budget for care was created by the premiums its enrollees paid. The enrollees were not responsible for the unjust U.S. health system. They were playing by the rules of that system. Should they be responsible for paying for X's care? From the perspective of the HMO membership, recission seemed unfortunate, but fair.

If we believe the media stories, some of the large, for-profit health plans have abused the practice of recission in order to extrude high cost patients. But apart from that abuse, insurance is only there for us when we're sick if we pay into the insurance pool when we're healthy. If we try to be "free riders" - not contributing when we're healthy and enrolling only when we're sick, recission is our just desert.

If we had the universal health system that all developed countries but us have put in place, there would be no such thing as recission. But in the unjust system we have tolerated right up to the present, recission has been an inevitable component.

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

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

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

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

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

Here's my six step explanation of what's happening:

1. No one wants to acknowledge the need to manage health care, because doing so requires acknowledging how much we physicians don't know and how ultimately vulnerable we mortal beings are.
   
   
2. In the 1990s, when public policy asked insurers to take on the nasty business of managing care, some insurers - especially among the for-profits - seized the opportunity to rip revenues out of the system, without much worry about the impact on patients. But some, like the not-for-profit plans in Massachusetts, did the job well, as judged by clinical and ethical criteria.
   
   
3. Providers turned against the concept of managed care itself, not just badly managed care. Public opinion and politicians followed them, creating an unstoppable backlash.
   
   
4. Insurers were then told not to manage care.
   
   
5. Between the backlash against managed care and the consolidation of providers into larger groups with power to demand ever higher payment, costs have soared into the economic stratosphere.
   
   
6. Now, with Massachusetts in the vanguard, insurers are pilloried for the how much care is costing.

To show how fast the social learning curve is evolving, consider the following statements:

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

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

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

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

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

The wild rumpus has moved from Washington DC to Massachusetts!

Massachusetts Health Insurers Sue the State

The health reform pot is boiling over in Massachusetts!

In a post three days ago I described how the Governor rejected 235 of the 274 insurance rate proposals for individuals and small businesses that were to have gone into effect on April 1. Yesterday Blue Cross and Blue Shield of Massachusetts, Harvard Pilgrim Health Care (where I direct the ethics program), Tufts Health Plan, Fallon Community Health Plan, Health New England, and Neighborhood Health Plan filed a suit against the state to reverse the decision. Here's the statement made by the Health Plan Association:

Last week’s decision by the Division of Insurance to set an artificial cap will do nothing to fix the real problem of rising health care costs. The Division’s effort to artificially cap rates is a reckless decision that is based in politics and will wreak havoc on the entire health care system. It ignores recent reports from the Attorney General and the Patrick Administration, including the Division, that have pointed to a number of factors for rising premiums, most notably the market clout of providers and provider rate increases.

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

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

Massachusetts is home to the country’s best health plans, which are consistently rated tops in terms of quality and member satisfaction according to independent national accrediting organizations, including the National Committee for Quality Assurance. We will continue to work with the Legislature on meaningful reforms to help address the underlying factors driving health care costs to provide real, long-term and substantial relief to small businesses this year.

The insurers suing the state are all non-profit organizations. 90% of the premiums they receive are used to pay for medical services. One observer compared trying to control health costs by capping insurance premiums to trying to stop the incoming tide with a line in the sand! I speculated that the Governor understands this, and that in addition to playing politics by attacking insurers, he might by trying to shake the system by applying a two by four to a vulnerable (and politically advantageous) point - the insurance industry.

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

Ten years ago Tufts Health Plan tried to reject the price increases Massachusetts General Hospital and the other Partners HealthCare members were demanding. Partners withdrew from the Tufts system. Tufts subscribers raised a ruckus. After nine days, Tufts backed down. The Boston Business Journal summed up the situation this way (see here):

Until about a year ago, insurers were in the driver’s seat. Now, the big hospital networks, especially Partners, have been calling the shots. The likely outcome, say experts: significantly higher premiums for Bay State employers.

Blaming one cog in the health system wheel may be good short term politics. Having applied a two by four to the state health system, the Governor should now convene insurers, providers, employers, and public leaders to work together with the state to bring down health costs. That would be real leadership.

Tiered Physician Networks - a Promising Development in Ethics and Economics

The most recent issue of the American Journal of Managed care features an interesting article on "Consumer Experience with a Tiered Physician Network" (here), by Anna Sinaiko and Meredith Rosenthal, at Harvard Medical School and School of Public Health, and an accompanying editorial by Peggy O'Kane, President of the National Committee for Quality Assurance (here).

The public thinks of "managed care" as a form of insurance. But on the ground care is managed by physicians and the institutions within which they practice. When insurers actually tried to manage care in the 1990s they succeeded in slowing the cost trend significantly, but they were blown out of the water by provider and patient backlash.

We in the U.S. have a very childlike understanding of health care and a very immature health system. This makes it relevant to consider how children morph into responsible, "well managed" adults.

Children learn through "soft power" - values, incentives, well-timed nudges, and peer influence. Insurance tiering is an effort to influence health care quality and cost by using the same kind of soft power. Here's what Peggy O'Kane says about pharmacy tiering in her editorial:

Tiered pharmacy benefits are one of the few successful cost containment strategies in the past 2 decades. Evidence indicates success on 2 fronts: (1) a positive impact on pharmacy costs and (2) acceptance by members that their choices will affect their own out-of-pocket costs. Against the background of other health plan cost-containment strategies, some of which were subsequently thwarted by public policy and others of which suffered from poor execution and/or lack of provider and patient acceptance, drug tiering stands out as a singular success. It is both ethical and logical to structure choices so that costs are more transparent to consumers and to ask them to bear at least part of the differential cost for a comparable but more expensive product, as long as individuals are not forced to accept lower quality in the favored product. As Americans, we are used to the idea that if we choose a more expensive product, we pay more for it. Third-party payment interrupts the connection between purchasing choices and resultant costs to the individual, but the idea of reference pricing (the third-party payer pays for an equivalent choice at the lowest price, and if the individual chooses a more expensive version, he or she pays the difference) is familiar, and well accepted by customers, in scenarios like auto insurance.

Sinaiko and Rosenthal surveyed consumers about their responses to tiered networks that were part of the insurance offered by the Massachusetts Group Insurance Commission (GIC), a state agency that provides health insurance and other benefits to 300,000 state employees and family members. Here's what GIC Executive Director Dolores Mitchell says about tiering in the 2009 Annual Report:

Throughout Fiscal Year 2009, the GIC was in the forefront of efforts to frame the debate on how best to control rising health care costs while improving quality. The GIC’s Clinical Performance Improvement (CPI) Initiative continued its ground-breaking work -- analyzing differences in provider efficiency and quality and giving members incentives through lower copays to see better performing providers. The program has helped spark debate in the health care community about the role providers must play in improving quality and cutting the overuse of resources...the GIC’s Clinical Performance Improvement (CPI) Initiative, now in its fifth year, seeks to:

Share responsibility– providers, members, health plans, and the GIC - for reducing costs and improving quality

Maintain comprehensive benefits and choice

Emphasize health care quality and safety

Adopt modest member share increases

Educate members about provider performance

Encourage healthy behavior

Under the CPI Initiative, the GIC requires our health plans to provide de-identified claims for their entire book of business to our consultants for aggregation and analysis for each provider’s efficiency and quality relative to his or her peers. After this process, the results of the analysis are given to the health plans who then use the information to develop tiered networks in which members are given modest co-pay incentives to use better performing doctors.

***Tier 1 (excellent) – lowest copay
**Tier 2 (good) – middle copay
*Tier 3 (standard) – highest copay

In general, approximately 20% of physicians earned a Tier 1 rating, 65% were in Tier 2 and 15% were in Tier 3.

(Tiering is largely limited to the specialties for whom enough claims data is available, but some plans tier primary care physicians as well.)

Sinaiko and Rosenthal's basic finding was that as of 2007, only half of the employees enrolled in tiered networks realized that tiering was part of their plan. Of concern for those who believe in tiering, 58% didn't trust the tiers to tell them which doctors were best. Only 20% would trust either their employer or their health plan to establish the tiers. The highest level of trust for tiering (49%) would go to a medical society.

There was, however, some evidence for use of tiering in ways that the GIC hoped to see. Of the 20% who knew the tier rating of at least one of their doctors, 50% learned about the tier rating before their first visit and reported that the information was important to their choice of who to see.

Patients may not yet be paying much attention to tiering, but physicians are intensely aware of the ratings they receive. The Massachusetts Medical Society has brought a suit against the GIC tiering program (here) - a court hearing on the merits of the suit is pending.

Most physicians who have thought deeply about how best to manage quality and cost believe we need to establish a budget for health care, with physicians responsible for providing the best possible care within that budget. This is the vision Grumbach and Bodenheimer argued for 20 years ago in their seminal Health Affairs article "Reins or Fences: A Physician's View of Cost Containment." In our current political climate, however, budgets are seen as part of "socialized medicine" and "government intrusion." Tiering of providers is a second best approach to the effort to improve value (quality per unit of cost) in health care. It's an ethically solid concept for which the key challenge is getting the tiering system right. The Sinaiko/Rosenthal study shows that we're just putting our national toe into the tiering waters. But it's an experiment well worth working on!

Massachusetts Association of Health Plans Ethics Forum

Yesterday I attended a goodbye party for Dr. Marylou Buyse, who has been President and CEO of the Massachusetts Association of Health Plans (MAHP) since April 2001. MAHP is a trade association representing 12 Massachusetts health plans that together provide coverage for 2.3 million Massachusetts residents. Marylou is moving to Texas to become chief medical officer at Scott & White Health Plan.

When I first met Marylou in 2001, 6 months after she started working at MAHP, I proposed a cockeyed idea - that MAHP should sponsor a statewide ethics forum to bring together health plans and interested others to discuss ethical issues in managed care. Her immediate reaction was - "that's a great idea - let's do it!"

Anti-trust regulations are designed to prevent enterprises in the same economic sector from conspiring to create an anti-competitive cabal. Without an umbrella to convene public discussion, the kind of collaborative discussion and education I envisioned would run afoul of anti-trust law. MAHP stepped in, and Marylou became the godparent to a process that is still going strong.

The first forum, in March 2002, took off from two controversial cases about coverage for liver transplant for patients who were HIV positive. The twenty fourth forum - "Is Rational Public Conversation about End of Life Care Possible?" - was held three weeks ago. Other topics include: "Ethical Challenges in Managing Pharmacy Benefits: Can Good Management be good Medicine?" (2003); "Bariatric Surgery: Exploring the Ethical Issues" (2004); "The Ethical Dimensions in Public Reporting of Clinical Performance Data" (2005); "Ethical Challenges of Massachusetts Health Care Reform" (2006); "Medical Tourism – an Emerging Ethical Issue" (2007); and, "Virtual Visits: What are the values-related questions for health plans in promoting electronic visits in the information age?" (2008).

I've co-chaired the forum discussions - first with Dan Rome and then with Paul Fulton, both medical directors at Tufts Health Plan. A guest opens the meeting with a 5-10 minute overview of the area. The rest is discussion. In light of anti-trust concerns the forums don't involve action planning of any kind. We typically have 30 - 40 attendees, from health plans, government, NGOs, and industry. The discussions have been rich and thoughtful. The fact that so many busy people come to a 7:30 AM event is a vote of confidence in the value of the event.

In learning to write for publication and in mentoring younger colleagues the most useful question to raise is - "so what?" With regard to the MAHP Ethics Forum attendees have responded to the "so what?" question with reasons like these, which I've reconstructed from conversations I've had:

1. "We're all in our silos with noses to the grindstone. It's helpful to step back and ask - 'what are the ultimate purposes for what we do?' Doing that helps me get back to what's most important in our work."
   
   
2. "I take a lot of things in the insurance world for granted. The forums have led me to raise some useful questions about the work."
   
   
3. "Raising questions isn't always popular. It helps hearing from colleagues who like to turn things upside down the way I do."
   
   

I've tried to stimulate other states to develop their own forums but so far I've struck out on that effort. Hospitals are familiar with ethics committees and ethics consults, but that kind of going back to first principles is new to the insurance world.

In our parting conversation Marylou suggested that we try to do the same thing in Texas. Lone Star State - here we come!

A Practical Approach to Organizational Ethics

I've been meeting with a number of organizations to help them develop new ways to deal with the ethical dimensions of their activities. They've asked for practical pointers on how to get started. I've presented this list of six:

1. Understand two meanings of "should." Even the most collegially managed organizations have an underlying heirarchy. "Higher levels" can tell "subordinates" what they should do. Ethics is about values - what we should do. One reason organization are uneasy about formal ethics activities is fear that ethics folks would feel empowered to tell the organization what it should do in the managerial sense of "should," supplanting the CEO and Board. This isn't a question about the organization's commitment to values, but rather a question of who is in charge. We need to understand the distinction between the "managerial 'should'" and the "ethical 'should'."
   
   


2. Ensure managerial authority. If the CEO isn't "Chief Ethics Officer," organizational ethics activities will be a waste of time. Explicit endorsement and support from senior leadership is a requiremnt. An organizational ethics committee wouldn't have influenced Enron!
   
   


3. Ensure moral authority. Managerial authority comes via delegation. Moral authority comes from the respect pertinent others have for those who take the lead in organizational ethics activities. To be effective, organizational ethics activities require both managerial sanction and moral authority.
   
   


4. Ensure appropriate leadership skills. Organizational ethics consultation isn't an academic activity. Analytic and conceptual skills are required, but they have to play out with a wide range of people inside and often outside of the organization. Facilitation, relationship management, and solid understanding of the full range of organizational function are also crucial leadership skills for organizational ethics. To conduct effective organizational ethics activities in hospitals, group practices, and health plans, it's necessary to be comfortable dealing with both clinical and administrative matters and personnel.
   
   


5. Apply stakeholder theory. Here's how the excellent AMA Institute of Ethics publication "Organizational Ethics in Healthcare" defines stakeholder theory:
   
   
   "The core thesis of stakeholder theory is the normative
   claim that the interests of all the parties involved in any
   transaction ought to be considered in determining how
   to act ethically. In order to determine how an organization
   ought to act in a particular situation, it is necessary first to
   identify each of the parties (individual and collective)
   with whom the organization interacts and what each
   party has at stake. Second, one must ask how the
   organization ought to act in relation to each party, and
   then how the organization’s several obligations to these
   parties ought to be ranked, both in general and in the
   situation at hand."
   
   
   
   Faith-based organizations use guidance from their creed in dealing with complex ethical questions, but secular organizations typically find ethical reasoning that draws on the perspectives of its stakeholders more comprehensible and persuasive. Except in the rare situation in which a secular health organization embraces an ethical credo from outside of the organization, the stakeholder approach is most effective.
   
   
   
6. Monitor and adapt as needed. In an ethics class the analytical conclusion is the end point. But organizational ethics consultation isn't a classroom exercise. Well-managed organizations apply a quality improvement approach to all of their activities, including organizational ethics. It's great to make a timely decision, but greater yet if that decision works on the ground. If it doesn't it needs to be tweaked.

I'll probably modify this list of pointers over time, but for the moment these six have been useful in a range of settings.

Obesity, Health Insurance, and Employer Incentives

Federal health reform is the front page news, but states and businesses are the laboratories for change. Next to Governors, who have to deal with hideous budget problems driven by declining revenues and escalating Medicaid costs, employers who offer health insurance to their employees are most directly concerned about health care costs.

Health reform requires three ingredients: (1) facing facts, (2) thinking strategically and (3) embracing individual and population concerns. Given the virulent divisiveness of current U.S. politics, employers who offer health insurance are the most promising venue for applying this triad in a "businesslike" manner!

In previous posts I've written about how IBM promotes primary care and encourages employees to find a medical home (here), how Foundation Coal and Peabody Energy understand and act in accord with comparative effectiveness concepts (here), and how the Hannaford supermarket chain rewards employees who have surgical procedures like joint replacement in Singapore, where high quality services are available at lower cost (here). An article in yesterday's New York Times - "Health Care Savings Could Start in the Cafeteria" - describes a pilot collaboration between employers, a health plan, and The Full Yield, a start up health improvement company.

Starting in January, employees at John Hancock and the City of Boston will be able to enroll in a year-long Full Yield program that will provide access to healthful prepared meals, nutrition coaching, and other self-management tools. At John Hancock participants will get $100 worth of coupons that can be used at the office cafeteria and at local supermarkets that carry the Full Yield products. At the City of Boston, participants will have a series of biometric measurements taken at least three times during the year. The Full Yield is partnering with Harvard Pilgrim Health Care, the not for profit insurance company for which I run the ethics program, to administer and evaluate the program.

The Safeway company has apparently achieved the near-miracle of keeping its employee health insurance costs level since 2005. Steven Burd, the CEO, attributes its success to "creating a culture of health," part of which involves incentives for managing tobacco use, healthy weight, blood pressure and cholesterol levels. For achieving targets in those four areas, employees can reduce their contribution to health insurance premium, by up to $780 per year for individuals and $1,560 per year for families. (see here)

Incentives - especially if they're guided by insights from behavioral economics - work. (See, for example, this article in JAMA by Kevin Volpp and colleagues.) And, since obesity is a highly stigmatized condition that tracks closely with socioeconomic status, the wrong kinds of incentives could reinforce prejudice and discriminate unjustly. But those risks are reasons to use incentives carefully and monitor for negative impacts as well as success - just as good clinicians do for the treatments they administer - not reasons to avoid incentives altogether.

I continue to believe that employer/employee collaboration on behalf of promoting health and constraining health care costs within the workplace "family" is an extremely promising approach to transforming our national health non-system!

Nicholas Kristof on "Unhealthy America" - One Grand Slam and One Stikeout

I greatly admire New York Times columnist Nicholas Kristof's reportorial thoroughness and passion for social justice. So I wasn't surprised that I agreed with the opening passage in his November 5 column on "Unhealthy America":

The moment of truth for health care is at hand, and the distortion that perhaps gets the most traction is this:

We have the greatest health care system in the world. Sure, it has flaws, but it saves lives in ways that other countries can only dream of. Abroad, people sit on waiting lists for months, so why should we squander billions of dollars to mess with a system that is the envy of the world? As Senator Richard Shelby of Alabama puts it, President Obama’s plans amount to “the first step in destroying the best health care system the world has ever known.”

That self-aggrandizing delusion may be the single greatest myth in the health care debate...

Kristof goes on to cite multiple studies that show just how mediocre our overall "system" is. This is educative journalism at its best.

Then he stumbled:

I regularly receive heartbreaking e-mails from readers simultaneously combating the predations of disease and insurers. One correspondent, Linda, told me how she had been diagnosed earlier this year with abdominal and bladder cancer — leading to battles with her insurance company.

“I will never forget standing outside the chemo treatment room knowing that the medication needed to save my life was only a few feet away, but that because I had private insurance it wasn’t available to me,” Linda wrote. “I read a comment from someone saying that they didn’t want a faceless government bureaucrat deciding if they would or would not get treatment. Well, a faceless bureaucrat from my private insurance made the decision that I wouldn’t get treatment and that I wasn’t worth saving.”

The flow of Kristof's article makes it clear that he is presenting Linda's painful story as an indictment of the inurer. But there are three basic possibilities for understanding Linda's tragic situation, only one of which is malfeasance. Kristof invites readers to see the insurer as guilty as charged, just one more example of insurer "villainy."

This is bad journalism, especially coming from a brilliant and ordinarily trustworthy reporter like Kristof. He missed an opportunity to educate his readers by making these important distinctions:

1. The medication Linda wants is a validated, "evidence-based" form of chemotherapy and the insurer knows this, but chooses not to cover it, duplicitously claiming that it is not "medically necessary." A court that found an insurer guilty of doing this would, and should, levy hefty punitive damages.
2. There are new findings about the medication or about Linda's particular condition that the insurer has not given proper weight to. In this situation, an appeal that documents the rationale for why the medication should be seen as effective should succeed. I have been part of an insurance appeals process and have seen numerous situations over the years in which decisions were seen in a new light when new information was introduced.
3. The medication Linda wants is ineffective, but an uninformed or overzealous physician has told her it's what she needs. In the 1990s, bone marrow transplant for advanced breast cancer was covered on the basis of faith and hope. Insurers who refused to cover it were sued. In a famous case (Fox v Healthnet) the plaintiff's family was awarded huge punitive damages. The treatment was ultimately found to be ineffective, but only after 30,00 women had received it, often with the result of increased suffering and shortened survival. (False Hope, by Richard Rettig and others describes the the painful saga in detail.) If this is the situation Linda should receive clear explanation and compassionate care, but not agreement that the insurer has committed a moral crime. And the physicians who are misleading her should receive a combination of reeducation and chastisement for giving such bad advice.

The fact that one of our best journalists is contributing to our national failure to understand the need for clinically informed, ethically justifiable limits says a lot about how difficult the learning curve will be. As I've often said in this blog, even if Mother Theresa was in charge of an insurance plan, she would not cover every cancer chemotherapy that we petition for.

(Norman Daniels and I discuss these issues in detail in Setting Limits Fairly.)

Are Health Insurers Villains?

Since I direct the ethics program at a health insurer (Harvard Pilgrim Health Care - a regional non profit company serving 1.1 million members in Massachusetts, New Hampshire and Maine), I've thought a lot about our national assault on insurers as "villains."

I've come to see the dissing of insurers as arising from five sources: (1) incidents of real "villainy"; (2) a critical view of the U.S. "system" of competing insurers; (3) lack of public acceptance of the need for stewardship; (4) societal PTSD from the managed care era; and, (5) politicians' need for a scapegoat.

1. The biblical story about Lucifer indicates that even angels commit evil deeds. If angels can't avoid sin, it's not surprising that virtually every human enterprise includes "villainy." Large organizations, such as insurers, are especially vulnerable to flying at 30,000 feet and not seeing the impact of what they do on the individuals they deal with. And, having many employees increases the risk that an individual employee will be inept in ways that cause harm or deliberately roguish. This risk is just as true for churches, hospitals, schools and other organizations. There's no reason to think that health insurers are cut from a different cloth than the rest of us. But because health care is a sacred calling, examples of bad behavior outrage us.
   
   
2. A substantial number of Americans regard the current structure of the U.S. health "system" itself as unethical. I agree. For many, that view leads to blaming health insurers for the rules of the game they are playing in. It's as if a pacifist blamed football teams for tackling each other when their real critique is of the game itself. The system we're currently in requires insurers who want to remain solvent to screen people who enroll as individuals for preexisting conditions. If Mother Theresa were made CEO of an insurer in the U.S. she could not discontinue the practice. (Because the "system" requires practices of that kind she would turn down the job and stay in Calcutta!)
   
   
3. I've written many times about our national failure to understand that containing health care costs is a ethical requirement, not a moral abomination. For the public, caring about patients ("fidelity") is "good," while managing costs ("stewardship") is "evil." We confuse the aphorism "life is priceless" with economic truth. Much political rhetoric asserts that what the physician prescribes is ipso facto "medically necessary" and therefore should not be questioned. Since provider behavior drives the cost of insurance this puts insurers an the unenviable position - the only positive role for them is to pay for what the physician or hospital recommends.
   
   
4. In the 1980s/1990s U.S. social policy asked insurers to manage care. Except for organizations like Kaiser Permanente and Group Health Cooperative this split caring for patients ("fidelity") and responsibility for health care funds ("stewardship") into opposing camps. The public, and physicians in fee for service practice, believed that physicians cared about patients and were "good," while insurers cared about money and were "bad." This was especially true with for profit insurers, but all health insurers are still tarred by the managed care brush.
   
   
5. Politics proceeds via sound bites designed to arouse emotion. Politicians need enemies. For the conservatives it's "socialized medicine" and "takeover by government." For the administration it's "greedy health insurance villains." These simplified, reflexive positions fire up the political base but create a major obstacle to thoughtful political discourse. We saw this process in clearest form in the mindless conservative rants about "death panels," but the global vilification of health insurers as "villains" is equally mindless.

Much of the journalism I've read in venues like the Boston Globe, Los Angeles Times, New York Times and Washington Post has been thoughtful and sophisticated. What's not yet clear is how much we - the public - have learned thus far from the health reform process. My pessimistic self says we're stuck in sound bite mud. But my optimistic self says we're inching forward in our understanding of the ethics of our health system.

The answer isn't yet in!