Monday, November 30, 2009
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!
Wednesday, November 25, 2009
What is the actual harm to the patient? I have found countless articles and sites that claim dr. patient sex is "obviously harmful to the patient." Well, I am not a medical professional and not all the reasons are obvious to me. I am however somewhat of a victim in this sort of case (with a diagnostic consultant) and am trying to understand what happened. All I know is he gave me hope and then killed it through abandonment, etc. He made lots of promises and didn't keep them.
The comment got me thinking. To the best of my knowledge, every medical specialty in all of the countries whose medical ethics I'm familiar with finds doctor-patient sex unethical. But as the questioner noted, it's not clear what the basis of that ethical condemnation is.
I did some on line browsing in the literature and came upon an excellent article - "Arguments for Zero Tolerance of Sexual Contact between Doctors and Patients" - by R.M. Cullen, a GP in New Zealand.
Dr. Cullen examines four common justifications of the zero tolerance view of doctor-patient sex and finds them all inadequate to the task:
- Sex with patients is always harmful. Cullen points out that the evidence base for this conclusion is skimpy. There are no surveys of large numbers of patients who have had sex with their physicians to see how many have been harmed. What we have is powerful case reports of individual situations that were harmful to specific individuals. These don't prove that doctor-patient sex is inevitably harmful.
- Sex with patients always violates the principles that define an ethical sexual relationship: trust, equitable power balance, and consent. Cullen quotes a position paper by the College of Physicians of Ontario that concludes that because of the inevitable power imbalance between physician and patient, valid consent is never possible. But here too it is possible to imagine doctor-patient relationships that do not violate the principles.
- Sex with patients is always inconsistent with the virtues that characterize the ethical physician. Here Cullen cites an argument that to be ethical a physician must be self-effacing and self-sacrificing, and that these virtues rule out deriving sexual satisfaction with a patient. Once again Cullen concludes that we can imagine circumstances in which a self-effacing and self-sacrificing doctor falls in love with a patient and is loved in return.
- Finally, Cullen considers the argument that the intrinsic nature of medicine may forbid sexual contact with patients on an a priori basis. Edmund Pelligrino makes the strongest argument of this kind, in "Toward a Reconstruction of Medical Morality" and elsewhere. Pellegrino argues that three phenomena – the fact of illness, the act of profession, and the process of care – if understood properly, provide a coherent basis for professional ethics, including the prohibition of doctor-patent sex. But here, too, Cullen finds it possible to postulate examples that could evade this perspective.
Cullen's own argument for the zero tolerance position is simple and practical:
It first attempts establish that, as a matter of policy, sexual contact between doctors and patients ought to be prohibited. Then, [it asserts] that doctors have a moral obligation to comply with such a prohibition. If this is true then it follows, as a matter of definition, that doctors who have sexual contact with patients have behaved immorally.Cullen argues - in my view correctly - that it is not necessary to prove that every instance of doctor-patient sex will be harmful, contrary to principles and virtues, or inconsistent with the fundamental nature of medicine, to establish that doctor-patient sexual relationships are unethical. The medical profession can, and should, adopt a zero tolerance ethical stance based on (a) the potential for harm to the patient with (b) no offsetting potential benefits for the patient, combined with (c) the inevitable harm to trust in the medical profession itself, and via that loss of trust, loss of healing capacity.
[This] counterfactual argument may be summarised as:
Proposition. If sexual contact between doctors and patients were allowed then there would be unacceptable consequences.
Conclusion. Sexual contact between doctors and patients should not be allowed.
Once the medical profession has committed itself to the zero tolerance standard, every member of the profession is bound by that commitment. A physician who participates in a sexual relationship is by that very act an unethical physician, regardless of his motives or whether the patient is harmed.
Monday, November 23, 2009
In his superb series of "Pulling it Together" columns, Drew Altman, President and CEO of the Kaiser Family Foundation, nailed the leadership issue earlier today. He argues that President Obama has been wise to keep his cards close to his chest so far, and that the time to come on strong about his detailed positions will be "when there is a bill in conference; then again when that bill moves from conference to the floor of the House and the Senate and is the focus of intense lobbying and national debate." It's a (short) column well worth reading.(See here for the column.)
Perhaps I'm a cockeyed optimist, but I see the summer's folly about death panels and the eruption about the Preventive Services Task Force recommendations as part of a societal learning process.
In the teaching I do about health care limits I often point out that limits are part of sharing finite resources within a population and that the way we learn about sharing as children teaches important political lessons.
Sharing toys doesn't come naturally. Parents (a) give cognitive messages ("it's fair that Johnny gets a turn with the toy") (b) provide emotional succor for the tantrums that follow, while (c) being firm about the need to share in order (d) not to raise selfish monsters. This process takes lots of time.
Some of the death panel madness was fomented by duplicitous politicians and talk radio hosts, just as we saw during the Bush years at the end of Terri Schiavo's life. But some people truly experienced the idea of end of life counselling as an assault on life and freedom by a death-dealing government. If 2 year olds could speak as adults I expect that they would respond to being asked to share their toys in similar fashion - "This toy means my whole life to me - you're killing me by asking me to share it - this idea of sharing is worse than a death panel!" We don't expect the child to learn all at once, and we can't expect the same from the body politic.
Unfortunately, the duplicitous politicians and audience-hungry talk show hosts are like bystanders who would rush up to the child having a tantrum to say - "you're right - it's outrageous that you've been asked to share your toy - your parent is a socialist!" This will make the learning harder and slower.
The mammogram furor is related, but different. The ever-changing recommendations are genuinely confusing, and people of intelligence and integrity can reasonably disagree. But seeing a government plot in the very idea of the new recommendations has to be understood in light of Kubler Ross's stages of grief theory. Recognizing that mammograms are not a magic bullet that can be counted on to ward off breast cancer confronts us with mortality. Denial of the epidemiological facts about the limitations of the test, combined with our suspicion that the government is a harsh parent insisting that we share all that is important to us with others, underlies some of the backlash we are seeing.
For those who understand the need for limits and for evidence-based health policy, what's needed is the patient persistence that good parents have in teaching us to share. This doesn't mean that fellow citizens who understand end of life counselling to mean death panels or see epidemiology as government conspiracy are childish. Surprising as it is to those of us who obsess about health policy and health system ethics, not everyone has been wonkishly immersed in these issues. Societal learning takes time.
The differential diagnosis between between an honorable person on a learning trajectory and a duplicitous politician can be difficult. But it's hard to believe that people as smart as Newt Gingrich and John Boehner really believe the death panel drivel they indulged in. I leave it to Rahm Emanuel to devise the best responses to duplicitous opportunism. But for all those who are open to learning, President Obama's ability to explain and inspire are what's needed. And as wise parents know, he'll have to do it again and again!
(For an excellent discussion of playground learning, see Steve Almond's op ed here. And for an important analysis of the death panel madness, see a discussion by Representative Earl Blumenauer here.)
Wednesday, November 18, 2009
This post is in praise of the much abused act of "bean counting."
When I first began to practice at the not-for-profit Harvard Community Health Plan HMO in 1975 I had a young patient with severe alcoholism. While drunk he got into a fight and was admitted to a psychiatric hospital. I'd been in charge of a psychiatric hospital unit before coming to the HMO and I knew that my patient would be better served by an alcohol treatment program, which would also, it happens, be cheaper. That's the basic definition of win/win.
But when I called the attending psychiatrist about my patient, to urge discharge to my care, I heard him say to the chief of the unit, who had been a teacher of mine during residency - "I have Sabin on the phone...he used to care about patients, but now he cares about money!"
I was really p - - - - d off by the comment, but it led to many years of thinking about how our health system can do a better job of caring about patients and caring about money. (See here for an article I wrote with that title 15 years ago.) I've come to use a framework that encourages all participants in health care to embrace two core values – compassionate fidelity to the needs of individual patients and responsible stewardship of the resources we place in public and private insurance pools.
Fidelity is about individuals. Stewardship is about populations. These two values are the pillars of an ethical health system.
Fidelity - the commitment to seek benefit for the patient and to avoid doing harm - has been at the heart of medical ethics since the time of Hippocrates. As long as health care was a transaction between a single patient and a single physician paid for by the patient’s own funds (or by barter), there was no need for insurance. Population concerns and stewardship were not important considerations.
But as health care became more complex and vastly more expensive societies created insurance mechanisms through which people pool funds to help them pay for care when they need it. In countries like Canada and England, where coverage is universal and paid for by taxes, the ethical importance of stewardship is easy to understand. As important as health care is the public has many uses for its funds. These societies see responsible stewardship as a moral requirement
In the complex U.S. health system it is much harder for the population and its leaders to understand how insurance funds are created. As a result, our society has not recognized stewardship as an ethically justifiable process. That's how we've come to demean attention to the cost of care as “bean counting.”
In the mind of the public (and some political leaders) “stewardship” is often confused with “rationing.” In health care, rationing refers to withholding beneficial services, such as very expensive cancer therapies, because of their cost. In reality, stewardship is the best way to avoid a need to ration! Responsible stewardship by insurers involves (a) seeking elimination of interventions that are not needed but can cause harm (as by side effects), (b) substituting equally effective but less costly interventions, such as generics for branded drugs, or prudent watchful waiting for doing a costly but unnecessary test today, and (c) careful contracting. The more insurers do (a) - (c) the less need society will have to (d) ration - in the sense of deliberately choosing not to provide interventions likely to be beneficial.
Stewardship isn't just a job for public and private insurers. It's best seen as a responsibility for all who are concerned with health and health care. As individuals we are stewards of our own well-being, even if most of us do a poor job. The provider community - physicians, nurses and other clinicians - is in the best position to differentiate between efficient and inefficient health care and to provide what patients need in the right way, at the right place, at the right time. And the employers who pay for insurance would rather invest more in employee wages and research and development than in ever-increasing health care costs.
Ideally, the health reform process would move our society along a learning curve towards better understanding and appreciation of the moral importance of stewardship. But so far the voices changing "bean counters - up against the wall!" have been the loudest.
Sunday, November 15, 2009
Although I'm a strong supporter of accessible abortion services, I see abortion as a a sad human event, to be avoided as much as possible.
And I respect the views of the majority of the "pro-life" community who oppose abortion in a thoughtful, conscience-driven manner and who respect those who hold the "pro-choice" position in an equally thoughtful, conscience-driven manner. Unfortunately the hate-laden screamers and the madness of committing murder on behalf of purported "reverence for life" has tainted the anti-abortion position, just as suicide bomber-murderers have tainted the noble traditions of Islam.
If Representatives Stupak and Pitt, their supporters, and the Conference of Bishops, were simply trying to ensure that health reform would continue the 33 year history of the Hyde amendment in prohibiting direct federal funding of abortion, I would be with them. (See here for the wording of the Stupak-Pitt amendment.) Abortion is currently an unresolvable moral conflict in the U.S. about which people of conscience cannot agree. Protecting access to abortion when states wish to fund the services or private insurance contracts include them while not allowing federal tax money to pay for abortion is a fair resolution. It won't leave anyone fully happy. That's something a mature democracy must be able to accept.
But Stupak-Pitt appears to have a much wider scope than the Hyde amendment, including prohibiting abortion in private insurance sold through any "exchange" created by the legislation. If the amendment is trying to extend constraints on abortion by hijacking health reform to achieve that aim the supporters ought to put their cards on the table and acknowledge that blackmail is their aim: "We think further restraint of abortion is more important than reforming our health system, so unless we get our way we'll block any legislation." If that's not their intent they should work with leadership to achieve a fair resolution.
Threatening to kill health reform unless abortion constraints are extended would be a misguided way of witnessing one's conscience. If abortion opponents take this path "pro-choicers" will take an equally hard line. The U.S. would miss a rare opportunity to tip toe towards greater social justice in health care.
Tuesday, November 10, 2009
On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.Today's New York Times reported that Dr. Hasan was in contact with a jihad-supporting cleric in Yemen many months ago (see here) and that he bought the gun that was allegedly used in the crime at Fort Hood shortly after arriving in Texas. Those public reports lead me to these thoughts about psychiatric education and the ethical responsibility for self scrutiny.
A central component of clinical education in psychiatry is that we clinicians need to observe ourselves as carefully as we observe our patients. Our thoughts and feelings are important sources of "data" - they can give information about our patients. In my residency the training director told us that "no human being is truly boring. If you feel bored while you're with a patient it's either because the patient is talking to hide what's important, which makes what he's saying an empty shell, or what he's saying threatens you, and your boredom is a defense."
In more than 40 years of practice since hearing that precept it has served me (and fellow residents) well. Whenever I felt bored I went into action - which of the two alternatives was going on?
The news reports suggest that the idea of criminal action entered Dr. Hassan's mind long before he carried it out. Honest human beings acknowledge that all manner of things come into their minds. The most notorious failing on the part of psychiatrists is sex with patients. The proper professional response to sexual thoughts about a patient is "differential diagnosis." Why is this reaction occurring? Is it telling me the patient is lonely, or making an erotic appeal? If so, that's the proper focus of therapeutic attention. But if the reaction is more about me, then the professional should ask - what is it telling me about myself? What do I need to do? The proper professional response is to ask for consultation when the answers aren't clear.
Psychiatric ethics are unambiguous about sexual involvement with patients - whether it is a current or former patient, sexual involvement is always unethical. If a psychiatrist found himself beginning to rationalize why the ethical principles do not apply to him it is as much of a danger signal as hearing about suicidal plans from a patient. Immediate consultation is required.
Similarly, it wouldn't be a sign of "pathology" if a thought of harming others were to enter a clinician's mind. The same training director told a story to make the point that aggressive thoughts were not in themselves unhealthy, and might even be constructive: "It was the minister's 50th anniversary of what looked like a very happy marriage. A mischievous parishioner asked 'Minsiter - tell the truth - in 50 years of marriage did you ever think of divorce?' After a moment of thought the minister responded - 'divorce, never....murder, often...'"
But if a fantasy about harming patients, colleagues or others took on a life of its own it would call for immediate consultation with a colleague and some form of corrective action. It's when aggressive and erotic fantasies are kept secret that they fester and turn dangerous.
Saturday, November 7, 2009
The moment of truth for health care is at hand, and the distortion that perhaps gets the most traction is this:Kristof goes on to cite multiple studies that show just how mediocre our overall "system" is. This is educative journalism at its best.
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...
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:
- 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.
- 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.
- 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.
Tuesday, November 3, 2009
In my clinical practice I often encouraged patients to use prayer as part of their "management strategy" for handling their conditions. And when patients with serious ailments asked me to remember them in my prayers I said I would, even though I do not do petitionary prayer. (I generally interpreted the request to be about concern for their well being and commitment to them, which is why I felt comfortable saying "yes" to the request.) But when prayer for patients by others has been subjected to experimental study it has not been effective. Mandating ineffective treatments is exactly what legislatures should not do.
The article quotes Erwin Chemerinsky, dean of the UC Irvine School of Law, as saying the provision raises serious questions about government support of religion: "I think when Congress mandates that health companies provide coverage for prayer, it has the effect of the government advancing religion." I disagree.
If prayer were shown to be effective in curing disease (and it hasn't been) it would seem just as reasonable for insurance to cover it as to cover acupuncture or hypnosis. For insurers to say "we will cover Christian prayer, but not Muslim prayer" or vice versa, would appear to be government endorsement of a particular religion. But endorsing a practice (prayer) doesn't require endorsing a belief (in a supreme being).
The reason for opposing the provision for covering prayer under insurance is that interventions that have been tested and found to be ineffective should not be paid for by communal funds. That should be a no-brainer in a rationally governed health system. But rational governance is not a covered benefit in the U.S. health "system"!
Sunday, November 1, 2009
The Massachusetts legislature is beginning to deliberate about the Special Commission on the Health Care Payment System's recommendation that the state phase out fee-for-service payment and replace it with global payments to "Accountable Care Organizations" (ACOs). At a conference this past Friday, Representative Harriet Stanley, Chair of the Massachusetts House Committee on Health Care Financing, told the audience that “cost containment is absolutely essential,” that she and other legislators want to see short term (1-2 years) cost savings, and that legislative action is likely before next summer.
Most reports sit on the shelf until they die of old age. That's not likely to happen with the report from the Special Commission. It, and the state, deserve, and will probably get, a lot of attention, as Massachusetts locks horns with the problem of costs! Massachusetts health reform will continue to be an important laboratory for federal policy developments.
Here's the moral conundrum the state will have to grapple with:
- ACOs (combinations of hospital(s), groups of physicians, and other providers) will be responsible for caring for a population within a budget. To do this, and to promote integrated care, they will want to provide maximum care from within the ACO's own network.
- But the Special Commission wasn't naive - it understood that in the era of capitation, consumers demanded free choice and rebelled against staying within networks. Here's what the report says - "While payments to ACOs will follow the enrollee’s choice of a primary care physician, patients will not be restricted (unless as a condition of their insurance contract) to providers in their primary care physician’s ACO" (p 57).
- #1 and #2 point in opposite directions - #1 implies physician-guided treatment within the ACO while #2 implies patient-guided treatment within the entire community of clinicians (not necessarily restricted to Massachusetts).
- I've had an opportunity to pose this conundrum to a member of the state legislature. The legislator gave a two part answer. Here's Part I of the answer - "If a patient wants a 'branded' service and equally good alternatives are available within the ACO, it's OK to be kept within the ACO. But if patients can't get the services they need within the ACO, that's a different story."
- If our measurement of quality was precise enough and showed that surgeon A/hospital B (within the ACO) got results that were just as good as surgeon C/hospital D (outside the ACO), this principle would work well. It would be clear that the patient's wish reflected "preference," not "need." Saying "no" could readily be justified as a fair, evidence-based decision.
- Unfortunately, we almost never have this information! I asked the legislator what happens then. Part II of the answer was - "we're thinking about this all the time - my staff would be interested in talking about it with you..."
- I was glad to hear that the legislature is fretting over the question of how to adjudicate among the values of choice ("liberty"), efficiency, and integration of care (quality). Better information will make the tension among these values easier to address, but I don't see any way of avoiding some tough choices.
If Massachusetts is going to get a grip on its very high medical cost structure the state - probably starting with the Governor - will have to address the conundrum of "choice versus efficiency." We'll try to wiggle out of confronting the conflict between core values, but I don't think we'll be able to. This will be a real test of leadership!