High School Students and the Vocation of Medicine

Yesterday evening I had the pleasure of meeting with students at a distinguished independent school who were taking an elective in medical ethics. The class was reading "Setting Limits Fairly," the book Norman Daniels and I wrote about the ethics of resource allocation and rationing, and the instructor invited me to a special evening session.

Although my main topic was the ethics of resource allocation, I was especially moved by our discussion of the distinction between medicine as a "job" and as a "calling," a topic I touched on in a posting - "Searching for a Secular Health Care Ethic" - a year ago.

I gave the students a vignette from my practice. A man in his 40s with chronic schizophrenia who I had seen monthly for many years when we monitored the regular white count that has to be done for people taking clozapine asked me to remember him in my prayers. My patient was Catholic. I told the students that I am (a) Jewish, (b) something of a "theological slacker" and (c) do not practice petitionary prayer. I asked them how they thought I should respond to his question.

I was blown away by the thoughtfulness of their responses. Given that teenagers often want to tell it like it is whatever the consequences, I was surprised when every student expressing an opinion thought I should tell the patient I would indeed remember him in my prayers.

One young woman was moved to tears by the story. From my tone she correctly discerned that I was very fond of my patient, respected his courage in the face of significant disabilities, and admired his integrity. Her tears were for his struggle and bravery. Another student could have been channeling my own thoughts from the time of the exchange with my patient. Here's what she said:

"You should tell him you will remember him in your prayers. When he uses the term 'prayer' I think he means 'I want you to care about me deeply and hope for the best for me.' I don't think he means 'I want you to kneel down, put your hands together, and ask God to take away his symptoms.' Given what I think he meant, you would be telling him the truth if you said 'yes.'"

The students clearly found medical ethics a gripping topic. The instructor is planning to expand the scope of ethics education. I suggested that if this expansion is successful the school could offer curricular modules and faculty development to other schools.

Given the low level of political dialogue about health care issues, wider education about health care ethics could contribute to a more health literate public. Our system's key need is more educative political leadership than the U.S. has seen to date (always excluding former Oregon Governor John Kitzhaber), but every bit of broader understanding of resource allocation ethics and social justice issues will help. The thoughtfulness of the students I met with yesterday left me optimistic about the potential for meaningful education at the high school level.

Emergency Room Meditations

My wife and I are hosting a close friend from India - a poet and professor who is doing readings at several U.S. colleges. Yesterday after he read and spoke at Wellesley College he started to experience groin pain. He ate nothing at the celebratory dinner, and by the time we got home even I as a psychiatrist could diagnose a hernia bulge. When the bulge didn't go back where it belonged by early morning I took him to a suburban emergency room.

Before we went I asked him about insurance. Luckily he had taken out a travel policy before leaving India. When we got to the emergency room, as I had prepared him to expect, the first interaction all had to do with money. The intake "financial counselor" was considerate, friendly and polite. We were told that on leaving we would be directed to pay $500 because of his out-of-the-country status.

The medical care reflected U.S. medicine at its best. The facility was clean and attractive. The nurses were efficient, warm and attentive. The physician explained his diagnosis (threatened strangulated inguinal hernia) clearly, and, in response to our questions, the mechanisms behind the symptoms my friend was experiencing. He told us that with good luck he would be able to reduce the hernia in the emergency room. An IV was started and morphine was given. Despite hefty doses of morphine the procedure was VERY painful, but it worked. I said to my friend - "this is like labor pains, except here your bulge went back in, and in labor it comes out."

The follow up advice was clear an to the point. On standing there was no new hernia bulge. The physician explained the risks of recurrence, and advised about the pros and cons of doing an elective repair in the U.S. before returning to India or back at home. The acute problem was solved, questions were answered well, and the caretaking experience engendered trust.

When we were told we could leave we were not directed, however, to go to a financial office to make a $500 payment. We wondered what this meant. I suggested to my friend "maybe they put your travel insurance through and it's all taken care of." In light of one of my favorite aphorisms - "it is better to ask for forgiveness than for permission" I suggested that we leave. "The hospital has my phone number and can call me if they need to."

When my friend called his uncle in New York to tell him he would not be coming to NYC today and explained why, his uncle's first question was "is your insurance OK?" And in conversation my friend told me that despite his having insurance his fear of what he might have to pay led him to tell me last night that he thought the hernia was starting to go back in and to resist going to the emergency room this morning.

I think all of us as citizens should think about the costs of health care and how they can best be covered, just as we should think about the costs of other basic goods like housing and education. But my friend's experience reinforced my belief that the U.S. doctrine that "skin in the game" will encourage more responsible use of health care resources is a loose policy cannon. Allowing a hernia to strangulate is potential suicide, not "prudent use of resources."

This experience, just 16 hours from the first pain until the resolution of the problem was a microcosm of health policy. We saw pain, uncertainty about what to do, reluctance to make use of needed care because of financial worry, and the caretaking vocation exercised with skill and compassion.

Solving the U.S. Health Care Mess

Neither Obama's nor McCain's health plans comes to grips with the out-of-control U.S. health system. I don't blame them. The public needs to understand some difficult truths, and candidates don't want to prescribe bitter pills in a political campaign!

The October 23 New England Journal of Medicine has two excellent articles written for whoever wins next week's election - "Three 'Inconvenient Truths' About Health Care" (by the distinguished health economist Victor Fuchs) and "Slowing the Growth of Health Care Costs - Learning from International Experience"(by Karen Davis, president of the Commonwealth Fund).

Here are Victor Fuchs's "inconvenient truths":

1. Over the past 30 years, U.S. health care expenditures have grown 2.8% per annum faster, on average, than the rest of the economy. If this differential continues for another 30 years, health care expenditures will absorb 30% of the GDP - a proportion that exceeds that of current government spending for all purposes combined.

2. Advances in medicine are the main reason why health care spending has grown 2.8% per annum faster than the rest of the economy.

3. Universal coverage requires subsidies for the poor and those too sick to afford insurance at an actuarially appropriate premium; it also requires compulsion for those who don't want to help pay for the subsidies or who want a 'free ride,' expecting that they will get care if they need it.

In other words, there's no point talking about health care reform without tackling costs head on, and we can't pretend that managing "waste, fraud and abuse" will do the job for us.

Karen Davis shows that costs can be controlled - but only if we have guts and leadership. In what is perhaps the understatement of the year, Davis comments that "the United States has been slow to learn from countries that have systematically adopted policies that curtail spending and enhance value." Davis's analysis draws on experience in Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom: (1) Achieve universal health insurance; (2) Develop comparative cost effectiveness information in a big way; (3) Disseminate IT that allows patient information sharing across sites and supports evidence-based decision making; (4) Shift the balance between primary and specialty care; (5) Get the government involved in negotiating payment for care; and, (6) Have payment systems reward preventive care and improved outcomes for chronic conditions.

None of this is rocket science. But none of it is easy. Starting with Medicare reform may be the most feasible approach. The new president can take his first speech on health care from the two New England Journal articles.

Psychiatry, Pharma and Conflict of Interest

I've been critical of the way psychiatry and the American Psychiatric Association (APA) have handled conflict of interest over drug company money (here and here). Today I want to praise Dr. Nada Stotland, president of the APA. Here's her letter from today's New York Times:

"Your Oct. 11 editorial “Drugs and Disclosure” expressed fear that the integrity of medical research is being threatened by conflicts of interest and the manipulation of scientific data. The American Psychiatric Association shares your concerns and supports full disclosure and transparency.

We deplore transgressions of the laws and regulations. Equally important, we worry about the impact of accusations and revelations concerning a small number of psychiatrists on those undergoing or in need of treatment.

Psychiatrists and patients have struggled with stigma for millenniums. It is less than one month since Congress approved, and President Bush signed, a landmark bill requiring coverage for care for mental disorders to be on a par with other medical conditions. It would be a tragedy if the possible misdeeds of a few were to undermine this historic achievement."

To a casual reader this letter might seem perfunctory.

It's not!

When Dr. Stotland refers to "the possible misdeeds of a few" she's being bold. She is acknowledging (in diplomatic language) that two of the most eminent psychiatrists in the U.S. - Dr. Charles Nemeroff (Emory) and Dr. Alan Schatzberg (Stanford), president elect of the APA - may have committed "misdeeds." In my view, this is courageous and spot on.

As bad as the revelations about how Drs. Nemeroff and Schatzberg have handled their ties to Pharma look, they are "accused," not "convicted." The word "possible" reflects our tradition of presupposing "innocence" until proven otherwise. But "misdeeds" acknowledges that what has been published doesn't smell right.

Being president of a professional society is a tough job. Dr. Stotland's letter to the New York Times puts patient care and the need for public trust first without either rushing to judgment of her colleagues or brushing off the allegations against them. Hat's off!

Why Health Plans Should Have Ethics Programs

On Thursday I'll be speaking about "Ethics, Health Plans, and State Health Plan Associations" at the AHIP (America's Health Insurance Plans) state issues conference in Chicago. I'll be urging health plans - both not for profit and for profit - to create meaningful ethics functions/ethics committees, using Harvard Pilgrim Health Care's 12 year experience as an example.

Here, in italics, are some questions I hope I'm challenged with, followed by my answers:

1. "What do we need an ethics program or ethics committee for? Are you saying we're not ethical people?" "No, I'm not saying you are unethical. I believe our major health insurance companies and the individuals who work for them want to do the right thing. But health care poses exceptionally complex ethical questions that often involve trade-offs among our deepest values. Health plans operate at the intersection of business (health care is the largest single sector of the U.S. economy) and calling (the origins of the care taking role go back to early religious roots). Our shared human nature, alas, finds it easier to react in either/or terms ('either we're a business or we're a calling...') rather than both/and ('we have to make a margin to serve our mission - we can't be true to our calling unless we run our business well').

The Harvard Pilgrim Ethics Advisory Group (EAG) includes HPHC staff, who understand the business realities of the health plan, employers, who understand the impact of the ever rising premiums, physicians who practice in the network, who understand how insurance affects their ability to care for their patients, and consumers, whose health is what the whole enterprise is about. This kind of gathering of perspectives brings a broad spectrum of values and perspectives into its deliberations and broadens the organization's understanding of the ethical dimensions of its work."

2. "Big deal! What does an ethics committee offer that a smart management group doesn't already have?" "Well functioning hospital ethics committees are valued for the consultation they offer to the patient, family and clinical team. In hospitals the clinical team is like the management team at a health plan. The team only consults the ethics committee when it feels that additional perspectives might help it meet its objectives better. Harvard Pilgrim operates the same way. No issues have to come to the Ethics Advisory Group. The EAG only enters in when the responsible manager asks for its advice."

3. "What evidence do you have that what you describe is worthwhile? What's the bottom line on this?" "I was hoping you'd push me on this, so I asked two leaders at Harvard Pilgrim. Here's what one said:

'The industry we are in addresses issues of critical importance to patients, providers and the public. We are involved with allocation decisions that are often fraught with tension and difficult to figure out. Just as there are ways of working out other business processes, there are ways of working through the ethical dimensions of what we do. The value of the program comes from teasing out the ethical issues and helping to design processes to deal with them in new and better ways.'

The other person I spoke to said:

'We can't do an economic analysis of the value of the ethics program, so I evaluate it by asking five practical questions: (1) Is the EAG membership broad based? (2) If it is, do the members attend and participate? (3) Do I hear complaints from my staff about the time it takes? (4) Is there a shortage of topics? and, (5) Do the consultees get what they are looking for?'

An ethics program isn't free, but it won't cost much. The key ingredients are support for the idea from the top, and the right kind of leadership."

I'll hope to have something interesting to say about all of this when I'm back from the conference.

Market and Rights in the Colombian Health Care System (2)

I wrote my first post about Colombia prior to attending the Colombian Health Economics Association conference. I'm writing this follow-up post in the Bogota airport before my flight back to the U.S.

I was tremendously impressed with the thoughtfulness, openness and warmth of the participants at the conference. There is a growing cadre of well trained health economists and policy experts in Colombia. This all to the good. Colombia is at the edge of a roller coaster ride through the thorniest questions in global health policy. I told my hosts that Colombia may provide a key learning opportunity for other countries the way Oregon did at the inception of the Oregon Health Plan.

With the passage of Law 100 in 1993, Columbia embraced (a) a commitment to achieving universal health insurance coverage and (b) the theory of market competition as the driving force for improvements in quality and cost. It's not quite there with universal access, but insurance coverage is actually at 90%, with the greatest gains being in the informal sector and non-urban populations. The Colombian experience is close to confirming the finding in many other countries (sadly, always excluding the U.S.), that a social insurance approach can achieve universal coverage.

Evidence about the efficacy of managed competition in driving cost and quality improvements is less clear. Insurers have not been competing on price, and the provider community has not been confronted with the kind of incentive for improved efficiency that the theory postulates.

Here's what's especially challenging and exciting about Colombia's situation. As one speaker put it - the Constitutional Court has "thrown a bomb into the health system." The Colombian Constitution creates a "right to health" for citizens. In a what I see as a constructive "bomb," the Court has directed the health ministry to bring about full coverage and equalization of the benefit package between the Contributory Regime and Subsidized Regime (see previous post).

But the Constitutional Court is driving Colombia into new territory in terms of what the "right to health" means in the real world. Here are three major questions Colombia will be grappling with in the next few years:

1. The Court appears to have decreed that the individual physician is the arbiter of what kind of care is necessary to fulfill the right. This is a recipe for near term disaster. Given all we know about unwarranted variations in practice and widespread failure to practice evidence based medicine, it makes no sense to allow each physician to define the contours of what the "right to health" means in terms of health care.

If the law plays out this way I can imagine a suit based on the claim that allowing each and every physician to define "medical necessity" impedes the overall right to health by creating threats to patient safety and depleting the available funds!

2. The Court has focused on access to health care. But we know that health care accounts for a relatively small proportion of population health gains. In the U.S. we see how runaway health care costs diminish health by "stealing" funds from other drivers of health - employment, education, housing and more. Colombia will have to thrash out this dilemma under the spotlight created by the Constitutional Court.

3. The Constitutional Court's ruling appears to imply that withholding potentially beneficial services is inconsistent with the right to health. Perhaps in paradise there is no need for rationing. But on earth rationing is an inevitable necessity in health care. The only question for societies is whether rationing is done fairly, with clinical wisdom, in a way that the population can understand and, over time, accept.

In my presentation at the conference I suggested that the "accountability for reasonableness" framework that Norman Daniels and I have developed (see here) might be useful in sorting out the conflict between the right to health and the reality of rationing. But whatever happens with that suggestion, Colombia will be a hot spot for health system learning in the next few years.

Market and Rights in the Colombian Health Care System

I’ll be in Bogota this week, speaking to the Colombian Health Economics Association about the ethics of resource allocation and rationing. I’ve been reading about the Colombian health system. It’s a fascinating story.

Prior to 1993 Colombia had health insurance for less than a quarter of the population. This sparked passage of Ley 100 (Law 100), which created a new system, modeled on the principles of managed competition. Ley 100 created two separate insurance programs. The Contributory Regime is for the formal sector and self employed workers, and is financed by employer and employee contributions. The Subsidized Regime is for the poor and is publicly financed. Consumers choose from a set of health plans which act as purchasers for enrollees.

Ley 100 specified that the benefit package, which was more extensive for the Contributory Regime and more limited for the Subsidized Regime, would become equal by 2000, resulting in a single universal system. However, although insurance has increased from close to 20% to 74%, the benefit package for the poor remained much more limited.

If Colombian citizens believe that an intervention that is not covered by their benefit package is “medically necessary,” they can sue the health plan or public provider based on the constitutional right to health. These claims (called “tutela”) have quadrupled between 1999 and 2005.

Courts focus on individuals and their rights. One result of the tutela system is that therapies costing more than 100,000 in USD get covered for individuals at the same time that the Subsidized Regime leaves out elements of basic care for the poor.

Since the 1993 implementation of Ley 100, the Constitutional Court has been tracking health-related tutelas. In the past year it ruled that the pattern of claims demonstrates repeated violation of the right to health. The ruling stressed health as a fundamental right with the physician as the competent authority to establish which services are required. The court recognized that the right to health is not unlimited, but required that the limits be “reasonable,” with priority given to children, pregnant women, elderly and handicapped persons and special attention to the rights of the neediest.

To an outsider (me) it appears that Colombia is experiencing a face-off between a market approach to health care, reflected in its managed competition system, and a human rights approach. As the U.S. health system sees every day, markets don’t create fair access. Only the state can ensure reasonable coverage for all.

In Colombia the Constitutional Court has spoken for equity and universality. But the court system can’t be expected to allocate resources in a field changing as rapidly as medicine, especially if individual physicians, with all that we know about practice variation, are empowered to decide “medical necessity.”

The face-off between the Constitutional Court and the Ministry of Social Protection has an almost mythic structure. The Court speaks the language of rights. The Ministry speaks the language of market competition. This tension is at play in the U.S. as well, but in a much less explicit manner. The opportunity to learn more about Colombia and to speak to the Health Economics Association is a privilege, for which I thank Professor Diana Pinto of Universidad Javeriana in advance!