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!

Nicholas Kristof on "Tussling Over Jesus"

Readers who have followed the controversy within the Catholic Church over the abortion done at St. Joseph's Hospital in Phoenix to save a pregnant woman's life should read Nicholas Kristof's powerful op ed in today's New York Times.

Kristof correctly locates the St. Joseph's controversy in the struggle in every faith group between dogmatic fundamentalists and compassionate humanists. "Faith group" is not limited to religions. The controversies about the U.S. Constitution between strict constructionists and those who - correctly - recognize that the Constitution was designed to be a living document, rests on the same dynamic.

Here are the key paragraphs from Kristof's piece:

To me, this battle illuminates two rival religious approaches, within the Catholic church and any spiritual tradition. One approach focuses upon dogma, sanctity, rules and the punishment of sinners. The other exalts compassion for the needy and mercy for sinners — and, perhaps, above all, inclusiveness.

With the Vatican seemingly as deaf and remote as it was in 1517, some Catholics at the grass roots are pushing to recover their faith. Jamie L. Manson, the same columnist for National Catholic Reporter who proclaimed that Jesus had been “evicted,” also argued powerfully that many ordinary Catholics have reached a breaking point and that St. Joseph’s heralds a new vision of Catholicism: “Though they will be denied the opportunity to celebrate the Eucharist, the Eucharist will rise out of St. Joseph’s every time the sick are healed, the frightened are comforted, the lonely are visited, the weak are fed, and vigil is kept over the dying.”

Hallelujah.

(My own posts about St. Joseph's can be seen here, here, here, and here. My most recent post on the topic shares Kristof's admiration for the noble Catholic traditions of commitment to the poor and to social justice.)

Ground Rules for the Single Payer Debate in Vermont

The national debate about health reform has been dominated by sloganeering. Polling suggests that the public does not understand the drivers of health care costs or the amount of redundancy, waste and harm in the system. The Obama administration has concluded that it should have done more to educate the public and shape the debate.

The states are the key laboratory for health reform now. I've written about how Vermont is giving serious attention to a single payer proposal (see here). Nationally, that concept has been largely off the table, shot down by slogans about "socialized medicine" and "government takeover of health care."

I was happy to see an editorial in the Burlington Free Press suggesting ground rules for how political debate should proceed (for overseas readers - Burlington, with a population of 40,000, is the largest city in a small state). Here are the key passages:

The most important task before advocates of health care reform is to explain the proposals put forward by the state consultant in a way that ensures the debate remains focused on the facts...Vermonters deserve an informed discussion about the future of health care in our state. As those who pushed through national health care reform discovered, how the Shumlin administration and lawmakers explain the plan will be as important as what is in the plan.

On one extreme are the many people suspicious of an expanded role for government in their lives and have little faith that government can do things better. On the other are those who feel that everyone has a right to adequate health care and that can only be achieved under a government-run system.

There is nothing constructive in an exchange of heated rhetoric designed to stoke fear or that attempts to demonize the other side. There is no point in coming to a conclusion before all sides fully digest the proposed changes and explore the issues.

The drive toward single-payer health care system for the state is, perhaps, the most ambitious and among the most controversial item on Shumlin's agenda. Understanding the proposals and how they will affect Vermonters is the first step to any meaningful discussion. The matter is too important to be left to nasty sound bites and empty slogans that bear little resemblance to the issues on the table.

Newly elected Governor Shumlin is the crucial player in determining whether a serious innovative proposal is given thoughtful attention and a fair chance at being implemented and tested in action. At 620,000, Vermont is approximately 1/500th of the U.S. population. If the state can apply the thoughtful process the Burlington Free Press suggests, it will be doing a disproportionately important job for the entire country!

Dr. Andrew Wakefield's Fraudulent Claims about Autism

This month the British Medical Journal (BMJ) published a three part series by Brian Deer, detailing the fraud by which Dr. Andrew Wakefield led parents to see the MMR (measles, mumps and rubella) vaccine as a potential cause of autism.

In 1998, Wakefield and 12 colleagues published a paper in Lancet - "Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children." The article presented 12 cases from the Royal Free Hospital in London, alleging that a severe form of autism and gastrointestinal disorders closely followed administration of the MMR vaccine.

Wakefield's "findings" catalysed a massive anti-vaccine movement in the U.K., U.S. and elsewhere, and suits against the vaccine manufacturers for injury. Unfortunately, as Deer's seven years of research documented, Wakefield's conclusions were not simply wrong, they were based on fraud and driven by rampant financial conflict of interest.

Prior to the "study" reported in Lancet, Wakefield had gone onto the payroll of a lawyer who was preparing to sue vaccine manufacturers for causing autism. Families of developmentally disabled children who believed their children had been injured by MMR were solicited to bring the children to the Royal Free Hospital. Intrusive tests that were not clinically indicated were performed on the children. And, as a massive investigation by the General Medical Council (GMC), conducted nine years after publication of the original article demonstrated, the case reports were distorted and outright falsified to support the "conclusion."

Deer details the business ventures that Wakefield and the Royal Free Hospital concocted, to profit from diagnostic tests Wakefield had patented that purported to allow diagnosis of MMR-induced injury. He also describes, in painful detail, presenting his findings in 2004 to Lancet, only to be met with what appears to have been a coverup.

Deer describes being fought against, blocked from gaining access to sources, and sued, during his long journalistic crusade. The GMC investigation ultimately confirmed all of his conclusions. Wakefield and one of his co-authors were stripped of their medical licenses.

Wakefield's fraud has caused multiple injuries, including: (1) distressed parents of children with autism have been duped into believing the cause of their childrens' disorder is known; (2) uptake of MMR has declined, with episodic outbreaks of all three conditions as a result; and (3) public skepticism in research integrity has been intensified.

Sadly, as the U.S. is seeing with regard to the lies about a government plan to create "death panels," it's vastly more difficult to impugn false claims than to make them in the first place. Initial comments on Deer's BMJ articles include many defenses of Wakefield as the victim of a campaign to hide the truth about vaccines, not as the disgraced perpetrator of fraud that he is.

(For Brian Deer's remarkable articles see here, here and here. And for an accompanying BMJ editorial see here.)

Physicians Treating Framily Members

Randy Cohen, who writes "The Ethicist" column for the New York Times, is my ego ideal for this blog. I admire his down to earth,humorous way of responding to the questions put to him. Yesterday Randy responded to an interesting medical ethics situation:

My elderly aunt became ill and phoned me, a physician, to ask if she should call an ambulance. I surmised that she was severely dehydrated. From my hospital, I took a bag of saline, IV tubing, an IV lock and a needle. An unsuspecting nurse handed me the tape that secures the needle. I gave my aunt these fluids at home, and she soon felt better, as did I: my stealing $50 worth of medical supplies saved the taxpayers more than a thousand dollars for an E.R. visit. Did I do right? E.G., NEW YORK

I love the hint of zany hijinks in the words “an unsuspecting nurse.” I respect your concern for your aunt and admire your ingenuity in curbing costs, but — there is a but — I am wary of your conduct. You were deceitful with your own hospital and imprudent in taking over your aunt’s treatment.

One doctor, the medical director of a large public hospital, e-mailed me to say: “We frown upon treating family members. It’s incredibly difficult to be objective in the best of circumstances.” He added: “The aunt’s bedroom is not the optimal environment for diagnosis or treatment. This physician took many shortcuts and may have done his aunt a great disservice by not performing a complete assessment.” He makes a persuasive case that while your diagnosis was correct, it was not certain to be: your aunt might have had other problems requiring a more drastic response.

Your altruistic pilferage, while thrifty, was ethically dubious, requiring you to betray the trust of your co-workers. The medical director I spoke to suggests a less buccaneering alternative: “If he had asked for the supplies, his hospital would have undoubtedly given them to him.”

The real solution to such problems is to arrange health care so as to avoid so stark a dilemma, perhaps by providing local clinics or health professionals who make home visits, changes unlikely to occur any time soon. Given the current circumstances, I should offer a word in your defense from another doctor, Paul R. Marantz, director of the Center for Public Health Sciences at Albert Einstein College of Medicine, who acknowledged that what you did was stealing, but said in an e-mail that “purloining $50 (more likely $20) worth of medical supplies while saving hundreds (more likely thousands) seems a good choice compared with the more burdensome alternative of a visit to the E.R.” I agree that those who practice medicine in imperfect institutions might — must — sometimes choose imperfect actions, but believe that your supply-room raid still fell short.

Randy's response to E.G. is right on. The question E.G. asked - about the materials he took from his hospital - is easy, but trivial. It's wrong. He should have asked, and the materials probably would have been given. And who hasn't taken pens and the like from their workplace?

The question E.G. should have asked was about treating his own aunt. As the public hospital medical director correctly reported, this is a practice the medical establishment "frowns upon," since family relationships can distort objective judgment and lead to errors in treatment. But given what happens to frail elderly folks who come to emergency rooms, the medical director's claim that "The aunt’s bedroom is not the optimal environment for diagnosis or treatment," is dubious. The home environment often provides clues that are invisible in the emergency room. And the medical director's conclusion - "This physician took many shortcuts and may have done his aunt a great disservice by not performing a complete assessment" is also dubious.

Sometimes a "complete assessment" turns up non-obvious findings that allow for effective treatment. But all-too-often, a full court press emergency room workup leads to finding "incidentalomas" - ostensibly "abnormal" findings that have no clinical meaning. The radiology report may say "I cannot rule out XYZ." Even though there is no reason to have suspected XYZ, finding an incidentaloma may lead to further tests and procedures, all of which can have side effects.

For me, the key ethical question is about care, not cost. A lot of money is wasted by unnecessary emergency room visits, but E.G. shouldn't try to balance the health care budget on the back of his elderly aunt. If saving money was his motive, I'd chastise him.

But if E.G. had experience allowing him to make a probable diagnosis for his aunt, and if he knew her to be a frail person for whom an emergency room visit stood a high chance of being traumatic and a source of avoidable harms, I believe he gave proper balance to the competing values. Treating our family members is, on average, a bad idea. But the rule of thumb isn't an absolute - it can be outweighed by other values, such as protecting his aunt and allowing her to be ministered to in the safest and most congenial manner.

Saving money for the health system wouldn't have been a reason for treating his aunt at home, and it's not the justification for what E.G. did. But from my reading of the story, E.G. did the right thing, though be imperfect means.

A Blog Post about Harvard Pilgrim Health Care

I just came upon this post by Paul Levy, who until recently was CEO of the Beth Israel Deaconess Hospital, about Harvard Pilgrim Health Care, where I direct the ethics program. Paul's excellent and very widely read "Running a Hospital" blog has been renamed - "Not Running a Hospital."

It's a very thoughtful post, with an illuminating follow up comment from Eric Schultz, the CEO of Harvard Pilgrim.

(For an earlier post about the Harvard Pilgrim ethics program, see here. For a Health Affairs article on the program, see here.)

States are the Hotbed for Medical Ethics

On Tuesday, by voting to repeal the Patient Protection and Affordable Care Act (ACA), all 242 Republicans in the House of Representatives proved the truth of Winston Churchill's famous comment about us Yanks - "Americans can always be counted on to do the right thing...after they have exhausted all other possibilities."

The law is a prototypical legislative sausage - it's the best we could do at the time given the virulent politics of health care. I'm not a political pundit, but I anticipate that Tuesday's piece of Republican theater will backfire on the party in 2012.

But what is clear is that the states are emerging as the crucial laboratories for health system reform. It's symbolic that on the same day that the Republicans voted in favor of marching backwards to our failing status quo, the Vermont legislature received a bold proposal to create a distinctive state-based single payer system.

Here in New England, Massachusetts, New Hampshire and Vermont, are all hotbeds for creative efforts to get a grip on our failing health system. Massachusetts has achieved the highest level of insurance for any state, using an approach that includes a individual mandate. New Hampshire is conducting a vigorous pilot program of accountable care organizations. Vermont is entertaining a single-payer proposal that has been kept off the federal table by two dreaded words - "socialized medicine." And, with luck, "red" states will test out market-based reform ideas in serious ways.

We can't reform the health system without engaging with deep questions of values: what level of our resources should be allocated to health? how do we balance individual responsibility for our own health with communal responsibility for the vulnerable? what level of health services should a civilized society guarantee to its members? These, and many others, are serious ethical questions, and people of intelligence and good will can differ in their responses.

At the state level, especially in states with relatively small populations, it's easier to keep the political debate at a thoughtful, civil level. Nationally, that's been much more difficult, as evidenced by the "death panel" fiasco. I know from leading classes and meetings on ethics topics that it's crucial to create a safe space for gathering facts, identifying key values, explicating conflicts among the values, designing options, and making choices. As a country of 300 million, tremendous diversity, and limited public understanding of health system complexities, we've done poorly. At the state level, we're doing better. That's where the key learning is likely to occur.

(If you're interested in more on Massachusetts, New Hampshire, and Vermont, there are tabs for each of the states on the blog.)

Single Payer Proposal in Vermont

On May 27, 2010 Vermont Act 128 - "An act relating to health care financing and universal access to health care in Vermont" - was signed into law.

Vermont is a no-BS state. The bill doesn't pussyfoot around the problem: "The escalating costs of health care in the United States and in Vermont are not sustainable...Only continued structural reform will provide all Vermonters with access to affordable, high quality health care."

The Assembly specified nine principles that health reform must satisfy:

1. "All Vermonters must have access to comprehensive, quality health care."
   
2. "The state must ensure public participation in the design, implementation, evaluation, and accountability mechanisms in the health care system."
   
3. "Primary care must be preserved and enhanced."
   
4. "Every Vermonter should be able to choose his or her primary care provider, as well as choosing providers of institutional and specialty care."
5. "The health care system will recognize the primacy of the patient-provider relationship, respecting the professional judgment of providers and the informed decisions of patients."
   
6. "Vermont’s health delivery system must model continuous improvement of health care quality and safety and, therefore, the system must be evaluated for improvement in access, quality, and reliability and for a reduction in cost."
   
7. "A system for containing all system costs and eliminating unnecessary expenditures, including by reducing administrative costs; reducing costs that do not contribute to efficient, quality health services; and reducing care that does not improve health outcomes, must be implemented for the health of the Vermont economy."
   
8. "The financing of health care in Vermont must be sufficient, fair, sustainable, and shared equitably."
   
9. "State government must ensure that the health care system satisfies [these] principles."

Act 128 created a Commission charged with proposing three models, one of which had to be a single payer, to the Assembly by the end of the year. The Commission hired Professor William Hsiao, a brilliant economist based at the Harvard School of Public Health to lead the design process. Bill Hsiao has worldwide experience working with governments to reform health systems, most recently in Taiwan, where he developed a well-functioning single payer system.

Professor Hsaio presented his report to the Vermont legislature yesterday. His team guided itself by six design parameters:

1) We must maximize federal funds for Vermont.

2) There must be no increase in overall health spending and therefore all funding for the options must derive from savings.

3) No option could result in an overall increase of the health care cost burden faced by employees or employers.

4) No option could yield a reduction in the overall net income received by physicians, hospitals or other health care providers.

5) The implementation of any option must move Vermont toward an integrated health care delivery system that allows for a transition to global budgets and risk-adjusted capitated payments.

6) No option could entail changes for Medicare beneficiaries in Vermont.

Among the three models he presented, Hsaio recommended a system of single payer insurance administered through a combination of public and private mechanisms, with oversight by a board composed of citizen, provider, employer and government representatives. He envisions the delivery system being configured into accountable care organizations paid largely through risk adjusted capitations.

As a small state with a small population (617,000 in 2009), Vermont has sustained a relatively thoughtful and civilized political climate. It will be able to consider a thoughtfully proposed single payer model without fear that the two magical words Republicans brandish on the national scene ("socialized medicine") will induce terror and bring rational inquiry to a dead stop. Its newly elected governor - Peter Shumlin - favors the single payer concept. And Bernie Sanders, formerly Representative and now Senator from Vermont, identifies himself as a socialist!

U.S. political dialogue about health system reform has been stymied by our refusal to even consider alternatives to the hodge podge of public and private entities we've allowed to grow like Topsy over the decades. The national result is economy-busting costs and mediocre results. Vermont is doing the U.S. a crucial service by putting a true alternative onto the table of political possibility!

(For readers who want more detail on the Vermont process, Bill Hsaio's ten page statement is clear and easy to read.)

Six More States Join the Anti-Mandate Suit

The Associated Press reported today that Iowa, Kansas, Maine, Ohio, Wisconsin and Wyoming, all with Republican Attorneys General, have joined the Florida suit that claims the individual mandate is unconstitutional.

At this point, 25 states, all but one with Republican leadership, are suing the mandate provision!

This is a fascinating piece of U.S. politics. My guess is that when historians and political scientists delve into the issue 10 - 20 years down the road, the suit and the Republican repeal effort in the House of Representatives, will look like a combination of: (1) the latest manifestation of what Richard Hofstadter called the "paranoid style in American Politics" (see here for a post on Hofstadter), triggered by the fact that the individual mandate is an intrusive piece of legislation; (2) theological belief that market solutions are always best; (3) reluctance to embrace the communitarian values the law embodies; and (4) a hefty dose of cynical political opportunism.

There's no way to contain runaway health costs without bringing the entire population into the risk pool and, one way or another, creating an overall budget for health care that we - the body politic and our health institutions - must learn to live within. The highly complex health reform law is an effort to do that without paying for health insurance collectively through taxes. If the Supreme Court ultimately rules against the mandate, or if a Republican sweep in 2012 leads to its repeal, we'll have to look for a new way to broaden the risk pool and create a health care budget.

If the mandate bites the dust, I would predict that politicians may turn to the kind of proposal Ezekiel Emanuel made in Healthcare, Guaranteed. Emanuel envisions a tax supported system that provides individuals with vouchers for purchase of insurance. While a tax is as intrusive as a mandate, we're accustomed to paying taxes, but not to being penalized for not making a purchase. A dedicated health tax may be more politically acceptable than the mandate mechanism. And vouchers that individuals use to purchase health insurance from independent entities make use of market mechanisms. This would reduce concern about "federal takeover" of healthcare and "creeping socialism." (See here and here for Maggie Mahar's excellent 2008 discussions of Emanuel's proposal.)

The process we're seeing is a combination of ethics (a civilized society should ensure that all citizens have access to good health care), economics (a prudent society doesn't let one sector consume disproportionate resources), and politics (the way the problem is addressed must be compatible with public beliefs and values). There's no way this can be a tidy, settle things for once and all, process!

Public Attitudes Towards the Health Reform Law

I've been pouring over an Associated Press-GfK poll done last week on health care reform.

Overall support for (40%) and opposition to (41%) the bill are in a statistical dead heat, but the number opposed is the lowest it's been since January 2009, which is surprising, given the drumbeat of Republican anti-reform rhetoric.

But with regard to the bill itself, 19% want Congress to leave it as it is, and 43% wish it did more to reform the health system! 26% want it to be repealed completely, down from 31% two months ago.

The poll showed strong public support for "requiring most medium-size and large companies to offer health insurance to their employees or pay money to the government as a penalty if they don’t," with 59% in favor and 32% opposed.
The individual mandate is by far the most unpopular aspect of the bill, with 59% against it and only 31% supportive. The fact that 50% favor "requiring insurance companies to sell health insurance to a person who is currently sick or has had a serious illness in the past," which isn't possible without bringing the full population into the risk pool, suggests that many do not understand the rationale for the mandate.

Approximately one third opposed (a) requiring medium and large employers to offer insurance, (b) requiring insurers to serve all comers, and (c) forbidding insurers from not reinsuring customers who develop a serious illness. It isn't clear what underlying perspectives drive these responses. Paul Krugman believes it's a matter of irreconcilable political philosophies:

One side of American politics considers the modern welfare state — a private-enterprise economy, but one in which society’s winners are taxed to pay for a social safety net — morally superior to the capitalism red in tooth and claw we had before the New Deal. It’s only right, this side believes, for the affluent to help the less fortunate.

The other side believes that people have a right to keep what they earn, and that taxing them to support others, no matter how needy, amounts to theft. That’s what lies behind the modern right’s fondness for violent rhetoric: many activists on the right really do see taxes and regulation as tyrannical impositions on their liberty.

My guess is that driving force is more a hatred of government than absence of caring about needy members of the population. For implementing the health reform law, it's important to understand the passion(s) the law has aroused.

I haven't seen any thoughtful alternatives coming from the Republican opposition. Their rhetoric appears to be catering to the keep-government-off-my-back sentiment. While there appears that a third of the population holds that view, a companion AP-GfK poll indicates that the public trusts Democrats (49%) over Republicans (37%) to do a better job handling health care.

The political theater over the Republican move to repeal the law will be a kind of national political Rorschach. The AP-GfK polling suggests that the Republican histrionics is not working. My guess, and hope, is that the strain of communitarian concern for our fellow citizens will outweigh our longstanding national anti-government tilt.

Sacred Moments in Medical Care

This month's issue of the American Journal of Psychiatry has a fascinating clinical discussion - "Perspectives on 'Sacred Moments' in Psychotherapy."

The "case" describes a psychotherapy session in which a patient in her 40s talks, for the first time, about what she calls "paranormal" experiences around the time of the death of a beloved mentor. The story is presented as a dialogue. What stands out is the way the therapist - a psychoanalyst - responds to his patient:

Patient: For me [the experience she had just spoken about] was very special.

Therapist: That was very special indeed.

Patient: [Crying a bit more intensely] I have never told anyone about this until now. These moments will always be special to me.

Therapist: They should be. It's a very beautiful love story.

Patient: It's also surprising to me. Does this routinely happen?

Therapist: The sort of love you had with Dr. Brown [her mentor] is hardly routine.

Patient: [Crying a bit more heavily] But do other people have experiences like this with people who have died?

Therapist: Only if they are extremely lucky.

The therapist doesn't interpret anything about the patient's narrative. Rather, he shows deep interest in and tender appreciation of her experience. He doesn't enter in to the question of whether the mentor's spirit transcended death and spoke to the patient, or whether a blip of brain chemistry created the phenomena. His response is to what the experience means to the patient, not to his own beliefs about the "paranormal."

Dr. James Lomax, the therapist and lead author of the article (he is joined by a historian of religion and a psychotherapy researcher), is a professor of psychiatry at Baylor, but his interventions weren't rocket science. His responses to his patient provide guidance and a model for all health professionals, not just psychotherapists.

I titled this post "Sacred Moments in Medical Care," not "Sacred Moments in Psychotherapy," because I know from colleagues in other areas of medicine that they hear stories of this kind as well. And I remember my own father telling me, shortly before his death in his late 80s, that his father, who had died when he was 21, would be visiting him in a dream soon, something his father apparently did with some regularity. These visits were a source of comfort to my father throughout his life. I never met my grandfather, but I felt that his visits to my father were a form of visit to me as well.

The lesson I take from the lovely clinical story and the rich discussion that follows it is that our role as health professionals is to listen with curiosity and appreciation. Our own beliefs about life after death and the paranormal don't matter.

Four hundred years ago, Hamlet gave the same advice to Horatio:

Hamlet: Swear by my sword
Never to speak of this that you have heard.

Ghost: [Beneath] Swear by his sword.

Hamlet: Well said, old mole, canst work i' th' earth so fast?
A worthy pioneer! Once more remove, good friends.

Horatio: O day and night, but this is wondrous strange!

Hamlet: And therefore as a stranger give it welcome.
There are more things in heaven and earth, Horatio,
Than are dreamt of in your philosophy.

If Hamlet were speaking to us now he would say - "Evidence-based medicine is an excellent thing, but remember - there are more things in heaven and earth than are dreamt of in your philosophies!"

(This link to the American Journal of Psychiatry article shows the first page and offers purchase of access. And, you can read about a conference sponsored by the Menninger Clinic and the Institute for Spirituality and Health at which the work was presented.)

Drugging America

In the December issue of the American Journal of Psychiatry, an article on "National Trends in Outpatient Psychotherapy" and an accompanying editorial on "The Changing Face of U.S. Mental Health Care" document a sea change in our mental health system.

The findings were drawn from in-person interviews from the Medical Expenditure Panel Survey in 1998 (22,000) and 2007 (29,000). The percentage of Americans who received one or more psychotherapy visits was stable at slightly over three percent. Approximately one-third made one or two visits, and only one in ten made more than 20. The estimated number of Americans receiving mental health treatment increased from 16 to 23 million, but the increase was almost entirely in use of medication. In 1998 44 percent received psychiatric medication without any psychotherapy. In 2007 the percentage increased to 57. The mean number of psychotherapy visits dropped from 9.67 to 7.92. Although total health expenditures increased by 88 percent during the study period, expenditure for psychotherapy declined by a third, from $10.9 billion to $7.2 billion.

The data do not allow comparison of outcomes in 1998 to 2007. But I'd take odds that a quality of care assessment would suggest that we're currently using too much medication and too little psychotherapy. The shift away from psychotherapy and to more use of medication is based on financial incentives and drug company marketing, not evidence about effectiveness.

Sadly, we mental health professionals contributed to the problem by not managing psychotherapy utilization ourselves. The managed behavioral healthcare organizations ("carve outs") that manage the coverage for more than 170 million filled that vacuum. During my training and early career in the 1960s and 1970s, psychotherapy was "prescribed" in larger "doses" than necessary for the outcomes being sought. Now the pendulum has swung the other way, and it is underprescribed.

In my practice at the Harvard Community Health Plan HMO we were expected to take new referrals on a regular basis, but it was left to us as to how we managed our practice panels. Shortly after I joined the practice in 1975 I divided my schedule into 30 minute blocks. When I wanted more time with a patient I put two blocks together. By working with my patients to create the most efficient psychotherapeutic approaches that worked for them, I was able to handle psychopharmacology and psychotherapy as a combined practice.

Alas, with the current anti-psychotherapeutic swing of the pendulum, this kind of balanced practice is much less common in the world of insurance-financed treatment. Don't expect the situation to change until medical groups take charge of managing their own resource use, as is envisioned for accountable care organizations. The day when clinicians could say "trust me to use resources prudently without being accountable" is long gone.

(Links to some of the clinical articles I wrote on managed care psychiatric practice can be found here, here, and here. I apologize for the fact that the journals haven't made the full articles available on line.)

President Obama's Tucson Speech

I'm in Washington DC for three days of meetings of an Institute of Medicine committee whose assignment is to advise Secretary Sebelius on the interpretation of "essential health benefits," a key part of the health reform law.

I just read President Obama's Tucson speech on line. He was at his eloquent best. I found his summing up especially moving, for reasons connected to the work I'm doing in DC and to the practice of medicine itself:

But what we can't do is use this tragedy as one more occasion to turn on one another. As we discuss these issues, let each of us do so with a good dose of humility. Rather than pointing fingers or assigning blame, let us use this occasion to expand our moral imaginations, to listen to each other more carefully, to sharpen our instincts for empathy, and remind ourselves of all the ways our hopes and dreams are bound together.

After all, that's what most of us do when we lose someone in our family – especially if the loss is unexpected. We're shaken from our routines, and forced to look inward. We reflect on the past. Did we spend enough time with an aging parent, we wonder. Did we express our gratitude for all the sacrifices they made for us? Did we tell a spouse just how desperately we loved them, not just once in awhile but every single day?

So sudden loss causes us to look backward – but it also forces us to look forward, to reflect on the present and the future, on the manner in which we live our lives and nurture our relationships with those who are still with us. We may ask ourselves if we've shown enough kindness and generosity and compassion to the people in our lives. Perhaps we question whether we are doing right by our children, or our community, and whether our priorities are in order. We recognize our own mortality, and are reminded that in the fleeting time we have on this earth, what matters is not wealth, or status, or power, or fame – but rather, how well we have loved, and what small part we have played in bettering the lives of others.

What the President said captures something at the heart of a career in health care. The intimate relationship with patients - the responsibility for ministering to their needs in the best way we can - can do just what the President said a deep tragedy like the killings in Tucson can do. In entering into other lives we are prompted to go more deeply into our own. If we're lucky, our contact with patients encourages humility, deepens out moral imagination, strengthens our capacity for empathy and our sense of connection to the wider community of humankind. And engaging deeply with the aims of the Patient Protection and Affordable Care Act also brings us into contact with our society's effort to minister to people in need.

For me, the President's meditation on the tragedy was leadership at its bet!

The Ethics of Using Placebos in Clinical Practice

The most interesting research study you may ever read about was published last month in PLoS - "Placebos without Deception: A Randomized Control Trial in Irritable Bowel Syndrome."

Placebos have been the focus of much attention in medical ethics. We know that placebos can produce positive effects in many conditions, but it has been believed that deceiving the patient was necessary for a placebo to be effective. Clinicians (and students in ethics classes) confronted what appeared to be a choice between helping patients feel, and be, healthier, and truthfulness in the clinical relationship.

Many years ago I was referred an elderly Russian woman who, after a severe stroke, was left with a severe anxiety state. None of the "conventional" interventions I tried helped her at all. At that point her daughter asked me to give her a placebo and to tell her that the placebo would help her. In as non-judgmental a way as I could muster I said "In the U.S. we believe we should be truthful with our patients and don't like to deceive them." The daughter replied - "You're being self-centered. That's your way. I'm recommending what we would do in Russia!"

I thought she had a point. I checked with a colleague who treated many Russian immigrants. He confirmed that his Russian patients saw benign deception as something good doctors would, and should, do.

I decided to do what the daughter had requested. The pharmacy my practice used was surprised to be asked about placebos, but could make one available. But at this point the family moved, so I didn't get to see if we could alleviate her symptoms with an impressive looking sugar pill.

Still longer ago, as a 25 year old medical intern I was, alas, much more cavalier. In my clinic I had a patient who was chronically agitated by what I thought were trivial matters. When my most likely inept efforts at counselling produced no results I gave her a bottle of brightly colored placebos I'd gotten from the pharmacy and told her they would calm her nerves. (I wish I could say I conducted a deep ethical analysis before going ahead, but that would be a deceptive claim.)

My patient did indeed experience reduced anxiety. To my surprise, her diabetes also came into better control. I've never doubted the power of the placebo effect since then.

In the project reported in PLoS, patients with IBS were invited to join a study in which they would receive "either placebo pills, which were like sugar pills which had been shown to have self-healing properties" or no treatment. Those who were randomized to the placebo group were told (1) the placebo effect is powerful, (2) the body can automatically respond to taking placebo pills like Pavlov's dogs who salivated when they heard a bell, (3) a positive attitude helps but is not necessary, and (4) taking the pills faithfully was critical.

You can guess where this is heading. Over the three week trial, symptoms and overall quality of life improved substantially more in the placebo group than in the control group. In the context of the study, deception wasn't necessary.

However well the findings hold up in the efforts at replication that are sure to follow, the study points in a clear clinical and ethical direction. Clinicians who (a) believe that placebos could help their patients, but (b) also believe that deliberate deception is to be avoided except in unusual circumstances, can (c) prescribe a placebo with a clear explanation of the kind given in the study.

I've always thought it was shortsighted to use the word "just" before the words "placebo effect." The placebo effect is powerful and real, whether it is mediated by mental state, endorphin secretion, or some other set of mechanisms. We don't say "it was just the surgery" when a patient's life has improved post-operatively. The word "just" suggests our dis-ease and ambivalence about use of placebos.

If we can harness the power of suggestion and the power of truthfulness at the same time, it will make for a real advance in clinical practice!

Catholic Social Vision and the Diocese of Phoenix

With regard to the abortion done for a patient who was 11 weeks pregnant and on a rapid trajectory towards death from pulmonary hypertension at St. Joseph's Hospital in Phoenix, I wondered if Fr. John Ehrich wanted to stand by the comment he made on May 21, 2010:

"She consented in the murder of an unborn child" said the Rev. John Ehrich, the medical ethics director for the Diocese of Phoenix. "There are some situations where the mother may in fact die along with her child. But - and this is the Catholic perspective - you can't do evil to bring about good. The end does not justify the means."

I went to his website to find the answer. He does.

Fr. Ehrich graduated from college in 1998, so he's probably in his 30s. A Fox News video from December 23 shows a young man pontificating with great certainty about complex existential issues involving theology, ethics, the patient's personal morality, and medical practice. Fr. John evinces what to my eye was smug assurance, not the loving humility one hopes to see in religious leaders.

What I find most painful about the St. Joseph's controversy is that by what many - including committed Catholics - see as a reasonable interpretation of directive 47 of the Ethical and Religious Directives for Catholic Health Care Services, the care at St. Joseph's hospital was religiously, ethically, and medically the right course of action:

Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.

If what the caretakers at St. Joseph's saw as a nearly one hundred percent certainty of maternal and fetal death caused by the increased cardiovascular demands of the pregnancy is not "a proportionately serious pathological condition of a pregnant woman," it's hard to imagine what would qualify as "proportional."

The controversy about St. Joseph's is not a replay of the all-too-familiar "pro-life" and "pro-choice" stalemate. It's about interpretation of Catholic teachings themselves. An excellent 2008 article in the American Journal of Public Health by Lori Freedman and colleagues - "When There’s a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals" - reports on interviews with physicians who practice at Catholic hospitals. At some hospitals ethics committees forbid doing an abortion procedure if the fetal heart is still beating, however tenuously, even if other facts make it clear that the fetus cannot survive to birth. At others, such as St. Joseph's, directive 47 is interpreted as being focused on saving the life of the mother when the fate of the fetus is already sealed.

In the research and teaching I've done in India, I met many Catholic volunteers and health professionals working in NGOs serving patients with HIV who were abandoned by others. Mother Theresa is only the tip of the iceberg for the Catholic social mission. Catholic individuals and institutions committed to caring for the poor embody the best ideals in health care. The moral and religious perspective of the caretakers motivated by the Catholic vision of health ministry would not bless the decisions of the Diocese of Phoenix that condemn an otherwise dying patient who reluctantly agreed to terminating her pregnancy as a murderer!

Governor Patrick Throws Down the Gauntlet on ACOs

Two days ago I described the current moment in Massachusetts Health Care Reform as "crunch time," with a number of tough choices to be made.

Yesterday, in his address to the legislature, Governor Patrick ran with the "tough choice" theme. Here's what he had to say about health care, with my comments interlaced in bold italics:

...The times demand that we face the hard choices before us with candor and courage, and that we act -- because doing so today will make us stronger tomorrow...We must demand more of ourselves than rhetoric that divides us and leadership that kicks every tough decision down the road. We must demand more not just of our public leaders, but also of our private ones – and of ourselves as individual citizens. Generational responsibility belongs to all of us. Every one of us owes a debt to the future payable only by making the kinds of choices today that build a better, stronger Commonwealth for tomorrow.

This is fine inspirational rhetoric. But if our state really wants to grapple with health care costs, we'll need a lot of encouragement and inspiration along the way. The governor will have to use his excellent communicative skills to help us understand what has to be done, why it has to be done, and how we can do it, again and again.

We can’t be satisfied until health care is as affordable as it is accessible. That means creating incentives for all providers to work together to deliver better care at lower cost, improving transparency in the charges for services, reforming the medical malpractice system, and getting excessive paperwork out of the way of the relationship between doctor and patient. It means a new emphasis on wellness and prevention.

If Governor Patrick can make real progress on these issues, he'll be a hero when he leaves office. Unfortunately, while health insurance is MUCH more accessible, health CARE isn't, especially primary care. Remedying that problem will not be a quick fix! "Better care at a lower cost" is the key sound bite here. I hope the reference to "medical malpractice reform" signals a real intention. While economists say that malpractice reform will only have a minor influence on costs, the liability system has a major influence on how physicians see the world. The impact is poisonous. The Democrats missed an important opportunity when they left malpractice reform out of the health care reform legislation.

And it means that we must change the way we pay for health care. So, we will file legislation in the coming weeks to address health care cost, including significant payment reform and simplification. This will be a challenge. There will be great debate and resistance to change. But working families, small and large businesses alike, and governments, too, need a solution – and they need it now.

The governor can propose legislation, but word on the street is that the legislature is not yet sold on the idea of payment reform. Legislators will be lobbied hard by constituents from their districts who are fearful about global payments. There will be strong temptation to kick the problem down the road.

Some steps we can take immediately without waiting for new laws. At my direction, MassHealth, the Health Care Connector and the Group Insurance Commission will implement pilot programs to demonstrate new, more cost-effective ways to buy health care. To get different results, we need to start trying different things. And we need to start now.

This is the approach New Hampshire is taking. It has launched a five year pilot of five Accountable Care Organizations. Next month I will have the privilege of meeting with the project steering committee to discuss the ethical concerns that will have to be addressed for ACOs to thrive. The "death panel" fiasco shows how vulnerable changes that are uncontroversial among physicians and nurses are to misunderstanding in the public arena.

We will work on these and other plans with our partners in the health care industry and in Washington, as well as with patient advocates. Everyone -- insurers, hospitals, physicians, nurses, and other medical professionals, and especially patients -- needs to be a part of this solution. But let me be clear: The time for talk is over. The time for action has arrived.

The governor is on target here. To achieve better care at a lower cost every stakeholder will have to take steps that scare them, and may have to make real sacrifices. Any one of the groups the governor names can block progress. Keeping stakeholders in a cooperative process is the key thing the governor needs to do.

Crunch Time in Massachusetts for Cost Containment and ACOs

The time has come for Massachusetts to walk the talk of health care reform.

We've done a good job with the easier part - increasing access to health insurance. (98 percent of the Massachusetts population is insured.) Now we have to make sure that our citizens have access to high quality care at an affordable cost.

Two years ago a state commission proposed an end to fee-for-service reimbursement and recommended a system of global payments to accountable care organizations. But since then the health care cost problem has gotten progressively worse, and the commission's recommendations are sitting on the shelf.

If the commission report was the first shoe to drop, participants in health care are now expecting shoe number two. In his swearing in ceremnony yesterday, Governor Patrick made health costs a top priority for his second term. Here are the brief, optimistic comments he made in the inaugural address:

I know we can have more accessible and more affordable health care for ourselves and our families. But it will take transparency among clinicians and health insurers, a system of care that makes more use of community settings, simplified administrative systems, and government stewardship for the whole for the good of the whole.

It will take more than optimism to change the cost trend. Health care spending, which was 21 percent of the state budget in 2000, is now 37 percent, and rising (see here for details). There's no way to get a grip on the trend without making tough choices. Among the tough questions that must be faced, four are arguably most important:

1. Municipal employees: According to the President of the Massachusetts Mayors Association "without the passage of real reform by the governor and Legislature, health insurance increases will bankrupt cities and towns. For most cities and towns, annual increases in health insurance costs swallow up any increase in revenue we can generate." Cities and towns want the same flexibility the state has, through its Group Insurance Commission, to set important elements of insurance plan design, without union approval. Unions, understandably, don't like the idea. Legislators are reluctant to oppose public worker unions. Property owners are reluctant to pay higher property taxes and see town services going down at the same time. Something has to give!
   
   
2. Medicaid managed care: There are three ways to curtail Medicaid costs - (1) reduce eligibility (which increases the uninsured), (2) slash payments across the board (which reduces provider willingness to participate in the program, or (3) use managed care techniques that have been well-developed by the state's not-for-profit managed care programs (clearly the best of the three alternatives). Harriet Stanley, co-chair of the Legislature Committee on Health Care Financing recognizes that “We now have to begin messing with Medicaid" but warns that while "Everybody says it...no one is willing to be the bad guy and do something about it.’’
   
   
3. Prices: The way health care costs show up for the insured population is through their health insurance premium (plus the deductibles, copayments and coinsurance that are often part of the plan). From that perspective, health care cost inflation looks like insurance inflation. But there's a growing awareness in Massachusetts that the not for profit plans that insure the majority of the state population are paying out 90 percent of the money they receive to providers of care. Insurance premium inflation reflects provider price inflation. Massachusetts is proud of its largely not for profit health system, and health institutions are major employers in the state. To some extent, making health care more affordable will mean income loss for current employees and reduced opportunity for potential employees. Making health care more affordable for those who purchase it will come at a cost to some of those who provide it.
   
   
4. Public perception: Insofar as Accountable Care Organizations provide more coordinated care with true accountability for their performance, quality will improve. I practiced for 35 years with what was essentially an ACO, and I, along with my family, have received our own care from the organization. Health services research showed that outcomes in not for profit HMOs was as good as or better than care in the "free choice" system. But as a body politic we rebel against any constraint on our free choice. Arcane research won't change our reflexive values. We'll only change if we're persuaded - by the medical community, and by trusted leaders.

Massachusetts has demonstrated that a population can be (almost) fully insured without resorting to the "un American," "socialist" forms of tax financed methods that Canada, the UK, an most of the industrialized world have applied effectively. But it hasn't shown that our mixture of private and public institutions can function without cancerous destruction of the economy. That question will be put to the test in Massachusetts in the next few years.