Grady Hospital Dialysis Patients Have a Home - For Now

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

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

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

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

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

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

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

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

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

Playing Ping Pong with Desperately Ill Undocumented

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

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

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

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

Grady and Fresenius are pointing fingers at each other:

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

[Grady] responded indignantly. "There cannot be a debate about one thing. This group of patients has been under the care of Fresenius and their doctors for two years. If Fresenius decided to discharge a patient because they are unable to pay, that is Fresenius’s decision, having nothing to do with Grady."

Continuing to cover continued dialysis wouldn't be a big deal for Fresenius. But it would turn Fresenius into a safety net organization, and private providers would avoid contracting with public facilities in the future, for fear of being left with patients the Gradys of the world would stop paying for.

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

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

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

Dialysis, Immigration, and U.S. Law

Since 2007, I've written a series of posts about safety net care issues - most notably, the problem of providing dialysis to undocumented persons.

This week's New England Journal of Medicine has an article from Baylor in Houston describing in some detail what happens when the undocumented are blocked from having scheduled dialysis and rely on emergency room treatment. It's a classical lose/lose situation. The patients suffer, the taxpayers pay more than would be required for "regular" treatment, and the physicians providing care are distressed by the substandard care they are forced to provide.

The authors are not naive. Here's how they pose the basic problem for clinical care, public policy and ethics:

This issue lies at the intersection of debates over the soaring cost of health care and the need for immigration reform. Do we have an ethical duty to provide the same standard of care for all sick patients within our borders? Or would mandating the provision of health care (and of maintenance-dialysis treatments) create an incentive for illegal immigration and worsen the current situation?

There's no easy answer. But we're better off for facing the problem squarely. Thanks to Drs. Rajeev Raghavan and Ricardo Nuila for helping us do that!

Treating the Poor - No Good Deed Will Go Unpunished

Physicians and teachers are the focus of a major societal effort to reward excellence, encourage improvement, and weed out poor performers. The intent of these efforts is noble and good, but they also entail major risks.

Since biblical times, many health professionals have been drawn to caring for disadvantaged, vulnerable populations. I see this in applicants for the primary care residency program for which I am part of the faculty. These young physicians are among the best, the brightest, and the most idealistic.

But a recent article in JAMA - "Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings" - suggests that they may be heading for trouble!

A research team studied 162 primary care physicians in the Massachusetts General Hospital system. All were hired and credentialed by similar criteria. They shared the same compensation plan, had similar staffing resources and the same advanced electronic medical record system. This was an experienced group, averaging almost 19 years from medical school graduation.

The researchers created a composite quality score based on 9 HEDIS measures commonly used for quality assessment. On the basis of these measures, they grouped the physicians into thirds. Then they adjusted their results for patient variables - age, sex, number of comorbidities, race/ethnicity, primary language spoken, and insurance status. When these adjustments were made, 6 in 10 physicians changed more than 5 percentiles and one third change more than 10. 14.3% of the bottom third increased in ranking to the middle third. 25% of the middle third moved into the top or bottom category. The 34 primary care physicians whose quality rankings increased by more than 10 percentiles were more likely to be practicing at community centers, with larger panels, a higher proportion of minority, non-English speakers, and more who were uninsured or insured through Medicaid.

A quality ranking system that did not adjust for patient variables would have penalized PCPs who work with a poor, vulnerable population. If quality rankings drove differences of income, the system could worsen health disparities by diverting resources away from patients with greatest need and rewarding physicians for avoiding these patients.

In evaluating teachers, systems have been developed that take student vulnerability into account. If a district or state looks at all students at the same level of vulnerability, it can compare teachers in relation to the same student "inputs." That's the meaningful comparison, rather than comparing teachers in the inner city or poor rural areas to teachers in the wealthiest suburban systems.

It's vital to measure our performance in health care and work to do the best that can be done. But if we apply physician ratings without careful attention to patient panel characteristics, we'll prove once again that no good deed will go unpunished!

Death Postponed for Safety Net Dialysis Recipients

Uninsured patients with kidney failure - especially undocumented immigrants - who would be dead without dialysis, are caught between the financial plight of safety net hospitals and the disgracefully rudderless U.S. health system.

In January I predicted that the problem, which first showed its head at Grady Hospital in Atlanta, would become epidemic. This week, a report by Kevin Sack, who has been following the story for the New York Times, showed how our society chips away at ethical problems without yet coming to grips with the root causes.

Grady, a prototypical safety net provider, was in deep financial trouble, and decided to close its dialysis clinic, which was losing several million dollars each year. But who would take on care of the patients? Leaving them to fend for themselves would violate the precept against abandonment. But continuing the clinic as it was would contribute to Grady's decline, which would lead to harm to other patients.

Grady encouraged undocumented immigrants to return to their home country by paying for air fare and three months of dialysis. But poor patients can't get ongoing dialysis in Mexico, where most of the undocumented came from. Ultimately Grady agreed to pay for dialysis for 38 remaining patients, most of whom are undocumented immigrants, at Fresenius, a German-owned, Fortune 500 dialysis company, until August 31.

It appears that a new agreement will forestall avoidable death for the 38. Fresenius has agreed to take on 5 as "charity cases." DaVita, another Fortune 500 dialysis company, will also take on 5. Emory University in Atlanta will take on 3. And, for the moment, Grady will scrape together funds to pay Fresenius, for continued care for the remaining 25.

This Rube Goldberg arrangement allows 38 chronically ill people to continue life-prolonging treatment, at least for now. But in a sloppy way it does more. A year ago, Grady Hospital owned the problem alone. Now it has two Fortune 500 companies and a leading University holding the problem with it.

In my January post I proposed a comprehensive approach to the safety net problem:

We need to convene a working group to scope out the dimensions of the problem and identify options for action. The ideal convener would be the Secretary of Health and Human Services (or her designate - perhaps the Assistant Secretary for Health). The Medicare End Stage Renal Disease Center would be a key participant, as would the National Association of State Medicaid Directors and safety net providers, perhaps via the National Association of Public Hospitals & Health Systems. Because a substantial portion of the patients who are put at risk by program closure are immigrants, the Office of Citizenship and Immigration Services should be represented. And, because programs sometimes try to send immigrants back to their countries of origin, largely in Mexico and Central America, the Bureau of Western Hemisphere Affairs in the State Department should have a voice.

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

The problem isn't an easy one. But we should not be leaving it to individual safety net programs to struggle on their own, either by swallowing what will ultimately be unsustainable debt or by taking emergency action based on an inevitably narrow perspective.

Nothing of the kind has happened since January. But the likelihood of our taking a comprehensive approach to the problem is improved by Grady having succeeded in involving DaVita, Emory, and Fresenius in sharing responsibility for its solution.

Ethical deliberation shows us the right direction to go in, but doesn't tell us how to get there. I hope I'm right that by sharing the problem with three powerful partners, Grady is helping us inch towards doing better by this group of 38 patients and those facing similar problems at other safety net sites.

The Looming Epidemic of Safety Net Hospital Dialysis Program Closures

I've done three recent posts on the crisis at Grady Hospital in Atlanta that has led to closure of its dialysis program. (See here, here and here.)

As I predicted, the problem is spreading. Now Jackson Health System in Miami-Dade county is closing a dialysis program that has been serving 175 South Florida patients.

Jackson is a prototypical safety net program, as evidenced by these statements from a video about the system: “we proudly step forward when others step back,” “people turn to Jackson when they have nowhere else to go,” and “when there is nowhere else to turn we reach for the impossible every day.”

The details about Jackson are different from Grady, but the underlying theme is the same. Like Grady, Jackson serves large numbers of uninsured patients. In 2008 it spent more than $500 million on charity care. But it ran a deficit of $200 million, which is clearly unsustainable. The dialysis program was losing $4 million per year. I haven't been able to ascertain how many of the 175 dialysis recipients are undocumented immigrants.

For the moment, none of the dialysis patients are in a crisis situation. Some have been able to get onto public insurance programs. Some are having their treatment continued for now at the dialysis centers Jackson contracts with. And some are coming to the emergency department for emergency treatment, which is paid for by emergency Medicaid funds.

The next steps in the scenario are predictable. Jackson will be blamed for (a) not caring and (b) poor management. Undocumented immigrants will be blamed for coming to the U.S. and "milking the system." Government - county, state and federal - will be blamed for underfunding. Citizens will be blamed for refusing tax increases.

There's probably a bit of truth in each blame statement. But the result of all the finger pointing will be more impasse. The dialysis recipients will suffer, and some may die prematurely.

This isn't just a Miami problem, any more than the Grady situation is just an Atlanta problem. Insofar as the dialysis patients are uninsured citizens it's a national problem. And insofar as some are legal or undocumented immigrants, it's an international problem.

I'm not wise enough to know what the best solution for this safety net problem is, but I do know the best way to find it.

We need to convene a working group to scope out the dimensions of the problem and identify options for action. The ideal convener would be the Secretary of Health and Human Services (or her designate - perhaps the Assistant Secretary for Health). The Medicare End Stage Renal Disease Center would be a key participant, as would the National Association of State Medicaid Directors and safety net providers, perhaps via the National Association of Public Hospitals & Health Systems. Because a substantial portion of the patients who are put at risk by program closure are immigrants, the Office of Citizenship and Immigration Services should be represented. And, because programs sometimes try to send immigrants back to their countries of origin, largely in Mexico and Central America, the Bureau of Western Hemisphere Affairs in the State Department should have a voice.

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

The problem isn't an easy one. But we should not be leaving it to individual safety net programs to struggle on their own, either by swallowing what will ultimately be unsustainable debt or by taking emergency action based on an inevitably narrow perspective.

Unfortunately, we are more likely to leave the problem to our frayed safety net than to kick it upstairs, where it belongs. That means that in 2010 and 2011 we'll be seeing more Gradys and Jackson Health Systems

(I learned about the Jackson Health System situation from a recent article by Kevin Sack of the New York Times, who has done brilliant reporting on Grady.)

Tragic Choices at Grady Hospital (3) - Brinksmanship with Human Lives

Grady Hospital has done the right thing, as I predicted it would in a post last week (here):

Clearly, a safety net provider is accountable for using the funds it receives in the most efficient manner possible. But we the public can't be allowed to turf our moral accountability to the Gradys of the world. We the public created safety net providers to care for the underserved, not to take on the burden of our sins in the manner of Jesus. I believe Grady is right to provoke a crisis over dialysis services. If some of its patients are still in limbo on January 3, Grady can't simply set them loose. It will have to continue to provide for them. But it should keep pointing the finger at its funding sources, with the message that Winston Churchill gave in World War II - "Give us the tools, and we will [do] the job," along with this corollary message - "If you choose not to give us the tools, acknowledge that you are the killers, and take responsibility for your decisions!

In his ongoing series detailing the human meaning of the Grady saga, Kevin Sack of the New York Times tells us that Grady has extended dialysis coverage for another month for 50 uninsured patients, mostly undocumented immigrants, for another month "to help give patients more time to make long-term arrangements," according to Matt Gove, who has the thankless job of speaking for Grady.

Grady is still hoping that the patients will take an active role in figuring out what to do. According to Gove “it should be clear to the patients that there’s a responsibility on their side to continue trying to find a long-term plan because at some point this care won’t be available.”

Many of the patients from Latin American countries refuse to return, since they believe - correctly - that access to dialysis of comparable quality will not be there for them. For some, the explicit plan is to go to an emergency room - quite possibly at Grady - whenever funding for dialysis at Fresenius, the private vendor Grady has contracted with, ends.

No one is suggesting that Fresenius will have any obligation when Grady stops paying. That's the difference between being a safety net provider and a private enterprise.

There are three main ways to approach the problem:

1. Send the undocumented patients back to their country of origin, let them fend for themselves with whatever help the country provides, and hope for the best. (Given the national anti-undocumented attitudes, there will be a lot of support for this option. The ethical rationale for this position is that each country is a fully separate entity responsible for its citizens. Radically different standards of health care are unfortunate, but that's the way it is. Who said life on the planet is fair?)
   
   
2. Leave Grady with the problem, which is what's happening right now. (Mother Theresa and her Missionaries of Charity could care for the dying in Calcutta as long as they had nuns who volunteered to do the work and a space in which to do it. Grady's situation is different. Dialysis was costing it $50,000 per patient per year. In its finite budget Grady has to choose which needs to serve. It can't meet them all.
   
   From an ethical perspective, this is the least justifiable alternative. Grady is a public institution, funded by a combination of county, state, and federal funds. We can't make Grady responsible for the choices we force onto it by our budgetary decisions.)
   
   
3. Address the situation internationally as part of global public health. (This won't be easy, but it's the right way to go. If our national policy is to send the undocumented patients back to their country of origin, we should work with those countries to solve the immediate needs of the individuals, but more importantly, to improve health and economic standards overall. If we continue to pretend that nation-states are self-contained islands, we'll just have more and more Grady-like crises. Sadly, this is what we're likely to do for the forseeable future.)

The U.S. created its end-stage-renal-disease program under Medicare when patients on dialysis were brought to Congress to be seen as individuals. That's what Kevin Sack is doing through his series of stories. (He's my candidate for the next round of Pulitzers!) There's no sign yet that we the public, through the higher levels of government, are paying attention. Perhaps that will happen when the one-month extension Grady has created, or the one after that, comes due.

Tragic Choices at Grady Hospital (2) - Undocumented Patients with End Stage Renal Disease

As I've described in a previous post (here), Grady Hospital in Atlanta closed its dialysis clinic on October 3. Grady is a prototypical safety net hospital. It cares for a large number of uninsured patients - U.S. citizens and undocumented immigrants - and has been on shaky financial footing for several years. The dialysis clinic was losing $3 million per year. On January 3 the three month extension of coverage Grady promised to patients who did not have other sources of dialysis support ended.

Kevin Sack of the New York Times, who has been doing a terrific job covering the Grady situation, recently wrote about Monica Chavarria, a 34 year old married mother of 14 and 8 year old boys, who had been on dialysis at Grady and who returned to her original home in the Mexican state of Jalisco when Grady closed the clinic:

On Dec. 22, she exhausted the 30 free dialysis sessions that Grady had provided at a gleaming private clinic in Guadalajara. On her doctor’s advice, she had been stretching out the treatments...by going two times a week instead of the recommended three. Going without dialysis can prove fatal in as little as two weeks, and the twice-a-week regimen has at times left her weak.

...Everywhere, it seems, there are roadblocks to affordable care. The dialysis unit at Guadalajara’s public hospital, which offers heavily discounted prices to the uninsured, has a waiting list that extends for months. Ms. Chavarria is not eligible for the insurance plan known here as Social Security, which is limited to salaried workers. [And] the country’s five-year-old health program for the uninsured, Seguro Popular, does not cover end-stage renal disease.

Sack's article gave a link to an article in this month's American Journal of Kidney Diseases on care for undocumented immigrants with end stage renal disease (here). The authors estimate that there may be as many as 5,500 undocumented immigrants with ESRD in the U.S. If they were U.S. citizens their care would be paid for by Medicare. But the undocumented are not eligible for the Medicare program, and in most states are not eligible for Medicaid either. Safety net facilities like Grady that undertake treatment of undocumented patients are left holding the financial bag. Grady's no-win ethical dilemma was - risk going down the tubes altogether, and depriving a large population of its services, or put some of the dialysis patients at severe risk.

Kidney physicians have addressed the ethics of the situation Grady Hospital encountered in a thoughtful manner:

1. All health care professionals and health care systems have an ethical obligation to treat the sick.

2. The federal government has the ethical and fiscal responsibility to provide care for patients within the US borders.

3. The financial burden of this care should fall not only on states that have the highest number of uninsured citizens or noncitizens, but also should be a national responsibility.

4. Because of the unique nature of ESRD, all citizens and noncitizens with ESRD should be eligible for emergency federal funding if they do not have insurance or resources to pay for renal-related care.

5. Nephrologists should not be expected to act as agents for the Immigration and Naturalization Service and should not be expected to report undocumented noncitizens because of patient confidentiality and the fiduciary nature of the patient-physician relationship.

The kidney physicians are correct in placing the ultimate ethical (and fiscal) responsibility on the federal government. Immigration is a national concern. Safety net facilities like Grady should not be put in the "hot potato" situation of having lifetime fiscal responsibility for the patients it ministers to. If we play that game the safety net will implode.

Given the national backlash against the undocumented population it's hard to imagine that the U.S. will take on open-ended responsibility for the care of undocumented immigrants. This means that addressing the problem in a humane manner requires international cooperation. It's not clinically or ethically acceptable for the U.S. to "dump" undocumented patients back on the always poorer country the patient came from. If nephrologists and public health specialists from the U.S. and Mexico worked together to create a policy and care framework for patients like Monica Chavarria their care, and the services for other patients with ESRD in Mexico, would be improved.

Tragic Choices at Grady Hospital

On October 3, Grady Hospital in Atlanta closed its dialysis clinic. Grady committed itself to cover the cost of dialysis for three months for any of the 96 patients under its care who did not have an alternative source of dialysis. The three month extension is up on January 3. An undetermined number of patients - possibly as many as 50 - do not yet have a settled plan for continued treatment.

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

In 2007, in the context of massive financial losses, the board voted to turn Grady over to an independent 501(c)(3) corporation, hoping that a more business-like board could bring managerial discipline to the hospital and make tough decisions the more political board was not willing to make.

This past summer the board showed it could make tough decisions when it voted to close the dialysis clinic, which was losing $2.5 million each year.

The dialysis clinic is a prototypic safety net program. 35% of the patients are undocumented and uninsured. Another 30% are documented but uninsured. 8% are prisoners. The facility itself is old, with outmoded equipment.

In a September ruling as to whether Grady should be allowed to close the clinic, Judge Ural Glanville of the Fulton County Superior Court recognized the severity of the trade off between Grady's stability and the importance of the clinic to the patients it served:

"Indeed, no value can be placed on human life. Nevertheless, when contemplating the use of injunctive authority, the court is required to balance relative equities, even in cases involving issues of life and death. If the court were to require [Grady] to maintain...the services forming the basis of the complaint, it would likely result in an adverse effect on the services offered to other individuals and the public at-large."

A group of plaintiff's brought a class action suit to block the January 3 funding cutoff, but on December 15 the suit was dismissed.

Predictably, Grady is being vilified as an uncaring killer. When confronted by a City Council member the chair of the Grady board responded by accusing the Council of grandstanding - demanding that the clinic be continued without providing funds to do it. I think this was a useful confrontation.

Uninsured patients, most notably immigrants, and especially undocumented immigrants, are caught in the middle of a life-and-death form of the game of "hot potato." Grady Hospital, as a safety net provider, inevitably loses, since its mission is to care for those who have nowhere else to go. When the public, through its government, stints on funding, safety net programs like Grady are left holding human lives in their care. What is a safety net provider to do if the funds allocated to it by the public don't allow it to meet the needs of its patients?

Clearly, a safety net provider is accountable for using the funds it receives in the most efficient manner possible. But we the public can't be allowed to turf our moral accountability to the Gradys of the world. We the public created safety net providers to care for the underserved, not to take on the burden of our sins in the manner of Jesus. I believe Grady is right to provoke a crisis over dialysis services. If some of its patients are still in limbo on January 3, Grady can't simply set them loose. It will have to continue to provide for them. But it should keep pointing the finger at its funding sources, with the message that Winston Churchill gave in World War II - "Give us the tools, and we will [do] the job," along with this corollary message - "If you choose not to give us the tools, acknowledge that you are the killers, and take responsibility for your decisions!"

(For a previous post on Grady Hospital, see here.)

Immigrants, Refugees, and Medical Ethics

After I wrote yesterday's post about refugees and asylum seekers in the British National Health Service, I read a remarkable article in the New York Times about Luis Alberto Jimenez.

Eight years ago, Mr. Jimenez, an illegal immigrant working as a gardener in Florida, was hit by a drunk driver, resulting in severe traumatic brain injury. Martin Memorial Hospital provided care. Given that no insurance coverage was available, Martin was unable to find a rehabilitation placement for Mr. Jimenez. They kept him in the acute hospital, accumulating a bill of $1.5 million. In the midst of litigation about returning him to Guatemala, which his U.S. guardian was resisting, the hospital hired an air ambulance and flew him back.

While accurate figures aren't available, hospital initiated deportations are not uncommon. Advocates for Mr. Jimenez accuse Martin Hospital of "dumping," but it is hard to see how an individual hospital can be expected to provide open-ended financing in circumstances like that of Mr. Jimenez.

An article in this month's Bulletin of the World Health Organization puts Mr. Jimenez's situation into a global context. 200 million or more people are living outside of their country of birth. Access to health care and the question of who will pay is a problem everywhere.

What we're seeing now is the way ethical problems roll downhill when wider societies choose to ignore them. In the U.K., GPs are asked to violate their most fundamental ethical commitments by refusing to treat undocumented immigrants. In Florida, Martin Hospital is asked to finance Mr. Jimenez's care in an open-ended way. Neither request is ethically justifiable.

The U.S., U.K., and every country that receives legal and illegal immigrants need to address the issues openly. International organizations like the WHO are crucial for helping to establish shared expectations and a broad ethical framework. The rehabilitation hospital in Guatemala that Mr. Jimenez was initially transferred to has an annual budget of $400,000, but appeared to provide excellent care. Rather than saddle Martin Hospital with a $1.5 million bill for inappropriate acute care, all parties would have been better served by a U.S.-Guatamala plan for augmenting services in Guatemala.

GP resistance to making them the agents for a National Health Service problem helps to push the complex ethical issues up to where they belong. In the hospital sphere, the American Hospital Association should do the same, so that hospitals like Martin are not forced to choose between financial ruin and spiriting patients out of the country in James Bond fashion.

British GPs Demand Right to Treat Refugees

In January I wrote (here) about GP resistance to a proposed National Health Service directive that they not treat asylum seekers or undocumented migrants. I concluded:

[W]e should cheer for the petition signers. Refusing to care for sick people – whatever their status – violates fundamental medical, and human, values. A policy that orders health professionals to abandon their historical commitment to provide care is not acceptable.

Since then a British physician friend told me that many doctors are simply ignoring the NHS policy.

An article in today's Guardian reported that the Department of Health has not revealed the extent of advice it has received criticizing the policy. Typically these advisories are made public shortly after submission. The Global Health Advocacy Project obtained a list of those who had submitted comments and obtained most of the materials. (available here) Among these, the submission from Ken Livingstone, the former Mayor of London is especially interesting. Livingstone agrees that well-to-do foreigners who come to the U.K. to seek free NHS treatment can legitimately be charged for care, but argues that asylum seekers and undocumented migrants should be eligible on the basis of medical ethics and public health concerns.

The intersection of globalization and health care will create ever more ethical challenges. Developed countries are siphoning health professionals from poorer locations. In this situation, the rights of individual health professionals to pursue their own interests clash with the health needs of the home countries. Medical tourists from wealthy countries are travelling for care to all sectors of the globe. In that situation, their rights as individuals to seek care where they want it is distorting access to care in the countries they visit.

The British GPs are right in resisting the NHS policy. While it is understandable that local taxpayers, whether in the U.K., U.S., or elsewhere, are reluctant to subsidize care for foreigners, asking nurses, doctors, and others, to act as immigration police, risks undermining the integrity of our own health systems and health care.

The Ethics of the Hospital Safety Net (3)

This is the third in a series of occasional postings about the U.S. safety net system. (See previous posts here and here.)

Yesterday I met for two hours with staff at a safety net social organization in the Boston area. A small group of medical colleagues and I are scoping out a volunteer project to help the staff address mental health issues that impede work with their clients around the organization’s social mission.

The meeting provided a window onto the frayed condition of the health system safety net, and the heroism of those who work to plug the gaps.

The organization receives referrals of severely disadvantaged young adults from public agencies. It acts in the Statue of Liberty spirit, receiving all comers, unscreened. That’s what it means to be part of the safety net.

Recently a client who was secretive about substance use experienced a severe reaction to heroin and had to be rushed to the hospital. Later that day, after successful treatment of the drug reaction, but without any information from the hospital, the client returned. (Presumably the hospital was hamstrung by well-intentioned but clumsy privacy regulations.)

A staff member commented – “we aren’t a hospital, and we’re not health professionals, but society asks us to take care of situations like this.” We discussed other clients whose mental health and substance abuse conditions created challenges for the organization. Our discussion focused on how staff can best process the emotional demands of their stress-laden work, and on ways to promote development of new skills.

My colleagues and I were overwhelmed with admiration for the work done by the organization and its staff. We were all physicians. Regarding the medical ethics, the sixth principle in the AMA code of ethics states:

"A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."

Not so for the people we were sitting with. They could choose not to have a job, but otherwise they had no choice of whom to serve. That receptiveness created the safety net for their clients and the state

By chance I wrote this post in a classroom at Harvard Medical School while the first year students were writing their final exam essays for the "Medical Ethics and Professionalism" course. Classes, articles and lectures are all good sources of learning. But the students and their teachers know that the crucial ethical learning occurs in their front-line care for sick people and efforts to improve the organizations and systems that provide health care.

I left yesterday's meeting wishing that more political and health system leaders would sit with front line safety net workers, and, better yet, have experiences working side by side with them. It is hard to come into contact with the nitty gritty realities of human need without being changed.

For health system leaders, it would be harder to insist on the necessity of providing a high cost technology that provides minimal benefit after seeing our underfunded safety net system up close. For political leaders, it would strengthen their understanding of the opportunity costs of runaway health system expenditures, and perhaps their readiness to tackle the knotty political challenge of reallocating our societal resources. Allowing a bloated health sector to starve the social sector is not something we should accept.

Civil Disobedience in the British National Health Service

This week the UK government considered ruling that GPs in the National Health Service will no longer be allowed to provide treatment to asylum seekers or undocumented migrants.

During the same week, in a highly publicized case, the UK deported 39 year old Ama Sumani to Ghana. Ms. Sumani had come to the UK on a student visa, but had overstayed and was working when, in 2006, she developed multiple myeloma. She developed kidney failure and was on dialysis in Wales when she was deported. Immigration officers escorted her back to Ghana, but the supposed plan for continued dialysis collapsed when Ms. Sumani was not able to make the required $5,000 deposit. The payment was made by a concerned individual in the UK, so three months of dialysis is now assured.

A Lancet editorial described the deportation as “an atrocious barbarism,” and chided medical leaders for not coming forward against it. In response, a petition signed by 276 GPs declared:

“This would impose serious health risks on [undocumented migrants] and on the general public. It would also interfere with our ability to carry out our duties as doctors. It is not in keeping with the ethics of our profession to refuse to see any person who may be ill, particularly pregnant women with complications, sick children or men crippled by torture. No one would want such a doctor for their GP.

We call on the government to retreat from this foolish proposal, which would prevent doctors from investigating, prescribing for, or referring such patients on the NHS.

We pledge that, in the event this regulation comes into effect, we will: (a) continue to see and examine asylum seekers and to advise them about their health needs, whatever their immigration status; (b) document their diagnoses and required clinical care; (c) with suitable anonymisation and consent, copy this documentation to the responsible ministers, [members of parliament] and the press; (d) inform the public of the human costs, to harness popular disgust at what is being ordered by the government in their name; (e) campaign to speedily reverse these ill-advised policies.”

The European Union is facing a real problem. Citizens of poorer countries, not surprisingly, are coming to EU countries in hope of receiving needed treatment that is not available at home. Others, like Ama Sumani, become ill after their [illegal] migration. As we are seeing in the U.S., there is a public backlash against undocumented migrants.

But we should cheer for the petition signers. Refusing to care for sick people – whatever their status – violates fundamental medical, and human, values. A policy that orders health professionals to abandon their historical commitment to provide care is not acceptable.

The Ethics of the Hospital Safety Net (2)

The U.S. hospital safety net is under siege. Today’s New York Times reports on yet another safety net hospital - Grady Memorial Hospital in Atlanta - that is teetering on the edge of disaster. This posting takes up where my December 3 discussion of similar issues at the University of Texas Medical Branch in Galveston left off.

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

Grady is in dire straits. It has major managerial problems, including allegations of corruption. A consultant’s strategic plan, presented in June, 2007, is painful to read. Grady is deeply in debt and hemorrhaging money each month. The consultant recommended radical managerial surgery, but the governing board, subject to strong political pressures, put off action. In November the board voted to turn Grady over to an independent 501(c)(3) corporation, but that effort is currently embroiled in complex local politics.

From the perspective of ethics, Grady, like the University of Texas in Galveston, faces a classic dilemma, which will not go away even if Grady solves all of its managerial problems. Like the Galveston program, it could improve its financial status by dropping the biggest money-losers. But doing this would violate the charitable mission for which it was founded. The impact of internal resource allocation choices go beyond what a society as wealthy as ours can or should accept. But the wider community is reluctant to reallocate its own resources, whether through increased taxes or other means.

Our fragmented health system makes it all-too-easy for us citizens and our leaders to avoid responsibility for what happens. Grady can blame the outside community. Politicians can blame Grady’s management. Atlanta can blame the suburbs. One has to suspect that one of the purposes of our stupifyingly complex system is just this – to give all parties deniability about the bad things that happen.

The Ethics of the Hospital Safety Net

Yesterday the Galveston County Daily News published an educative but heartbreaking story about the ethics of the hospital safety net.

The University of Texas Medical Branch (UTMB), the oldest medical school west of the Mississippi, has been known for its commitment to treating the medically underserved. It is now, however, considering refusing to provide cancer care to indigent, undocumented immigrants.

They must be monsters. Right? No. Wrong!

Almost 25% of the Texas population is uninsured. Medical costs are going up, the number of uninsured is rising, and state funding has been cut. In an effort to control costs the hospital laid off 381 workers last year.

This is, alas, a recurrent challenge for safety net hospitals. We look to them to be the caretaker of last resort, cut their funds, and then blame them for heartlessness.

UTMB is doing citizens and decision-makers a service by bringing the ethical challenge to center stage. Of the action they may take, their own spokesperson says – “it doesn’t feel right!”

Howard Brody, the distinguished director of the UTMB Institute for Medical Humanities, put the ethics cards on the table:

“If what voters of Texas want is Harris County [which would receive patients UTMB did not care for] shouting at Galveston and Galveston shouting at Harris County and everybody pointing fingers and saying ‘You should be doing more than you’re doing,’ then they can have that…If they want indigent folks to get care and want everybody in Texas to at least have a chance to have more access to medical care, then voters of Texas should step up and provide more resources.”

We ask safety net hospitals to turn somersaults on behalf of needy patients. That mission draws idealistic young physicians and nurses to work at safety net sites. But a point comes when trying to do the impossible turns into enabling. That is what UTMB must have concluded.

The Texas public is the legitimate decider about safety net funding. It is entitled to cut funds to the point where people with cancer will be turned away. But if it chooses to do this it should acknowledge the actions it is taking and the consequences of these actions. UTMB’s actions clarify the ethical dimensions of the policy debate and forces the public to own up to the implications of its funding decisions.