Serving God in our Patients

In 2009 I had the privilege of spending two days at the Swami Vivekananda Hospital in Saragur, India. (See here for a post about my visit.) Since that visit I've followed a blog by Dr. R. Balasubramianiam ("Balu"), founder of the Swami Vivekananda Youth Movement, sponsor of the hospital.

In a recent post, Balu wrote about Dr Swaminath ("Swami"), a psychiatrist in Bangalore who has visited the Saragur hospital every month for fifteen years. Swami sees 35-40 patients at each visit. Along with colleagues, Swami founded Chittadhama, a refuge for homeless mentally ill. Balu visited Chittadhama, and wrote about it as follows:

Swami confided in me that he was concerned that Chittadhama be able to provide every person who came in looking for solace and treatment, with food to eat to their heart’s content. He was narrating how these people are misunderstood and consequently ill-treated by their families and society. Many of them go without baths for months and eat only when some kind-hearted soul gives them food...This is a place where one can give so much to people - people who will truly make us feel privileged and happy that we are given an opportunity to serve the God in them.

Although I'm a secular person in terms of theological beliefs, I regard health care as a calling, and Balu's comment about "serving the God" in one's patients resonated. I Googled Dr. Swaminath and found links to excellent articles in the Indian Journal of Psychiatry on doctor-patient communication, psychoeducation, "cinemadness," truth telling, and counterfeit drugs. I was struck by the overlap of our interests in ethics, clinical practice, and health policy.

Over the years I've thought a lot about where the health care "calling" comes from for those who do not base their calling on an explicit theology. I believe that being part of a community with a shared ethical commitment is part of the ground for a "non-theological" calling. To my understanding, Balu's concept of "serving God in our patients" is essentially the same as my belief that the right orientation towards our patients is the form of "love" that Martin Buber conceptualized as "I-Thou."

Internet and search engines create potential for a global moral community. I feel moral solidarity with Dr. Swaminath, a fellow psychiatrist who I will probably never meet.

Insurance Executive Compensation and Medical Ethics

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

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

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

The doctor was right!

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

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

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

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

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

Doctor's Notes, Political Beliefs, and Medical Ethics

On February 19, during the protests against Governor Scott Walker's union-busting proposal, a video appeared showing physicians offering to provide "doctor's notes" for protesters at the rally, presumably to be used with employers to excuse absences. I infer from the video that physicians who supported the protests provided notes to protesters as an act of solidarity with an advocacy cause.

Yesterday it was reported that eleven physicians who are believed to have been providing doctor's notes at the protests have received complaints from the Wisconsin Department of Regulation and Licensing. Responses are due on March 21.

I supported the protests, and if I'd been a physician in Wisconsin I would have joined protesters at the capital, but I would not have given out doctor's notes. During the Vietnam era psychiatrists were not infrequently asked by draft age men to provide medical testimony that they suffered from a psychiatric illness that would make them undraftable. Colloquially this was called "copping out on a nut."

I opposed the war and frequently participated in marches and rallies against it, but I didn't write cop-out-on-a-nut letters. Physicians are given a special status in society through licensure, laws that create a framework for practice, and social respect that abets healing potential. I regarded truthfulness in medical testimony as one of the underpinnings for the profession's ability to function. Truthfulness was part of our implicit contract with society. As a citizen it was my duty to advocate in accord with my political beliefs and values. As a physician it was my duty not to use the privileges society gives the profession deceitfully.

(This doesn't mean that truthfulness trumps all other values. If a physician in Nazi Germany knew that his patient was a Jew and was asked by the SS, the ethical answer would have been "no." But Scott Walker is not Adolph Hitler.)

It's not uncommon for patients to ask psychiatrists and primary care physicians for letters to excuse absences from work caused by alcoholism. These requests sometimes created opportunity for a valuable conversation that went something like this:

Patient: "Doc, I missed work on Monday. I had a terrible headache and couldn't drag myself out of bed. Could you write a letter for me so I can get paid?"

Physician: "We've talked a lot about the problem you're having with alcohol. Was that involved here?"

Patient: "I guess so. I really tied one on this weekend."

Physician: "I'd like to see you get paid, and you did miss work for legitimate medical reasons, but I'm not sure you'll want me to write a note."

Patient: "Why's that? That's what I'm here for!"

Physician: "I would want to write a true medical letter. You really were out because of illness. The illness is alcoholism. It's a serious illness and for some people it's fatal, but it's definitely treatable. Some employers understand this and want to help their employees get a grip on the condition. Does that apply to your employer?"

Occasionally the employer understood alcoholism as a treatable condition, and we enlisted the employer along with the family in developing a treatment plan. More often the patient said "let's forget about the note." But the discussions gave a chance to reinforce the view that alcoholism is a chronic condition, difficult to treat but definitely helpable.

In the overheated political atmosphere in Wisconsin the note-writing physicians could be at risk for severe penalties, such as suspension or even loss of license. That outcome would be too severe. These physicians were presumably acting on principle with the aim of supporting a healthy body politic. I don't favor using ethics education as a disciplinary response to situations like sexual boundary violations where the rights and wrongs are obvious. The problem with doctor-patient sex is behavior, not understanding. But in the Wisconsin situation there are real questions and controversies. An appropriate penalty might be some form of community service combined with a group assignment to write an ethical analysis critiquing their decision to write the notes and discussing the ethics of advocacy.

(When I put "doctor's notes" into Google I discovered that there's a thriving industry in fake letters (see here for an example).

Jawboning Health Care Costs in Massachusetts

For the moment, Massachusetts is the jawboning center of the U.S. health system.

We in the U.S. are can-do activists. If there's a problem overseas, we're ready to invade. But with regard to health care costs we've been stunningly passive. We've wrung our national hands and simply watched as costs have gone up and further up.

The impotent spectator stance is coming to an end in Massachusetts. By U.S. standards, Massachusetts is going like gangbusters on health insurance access, with 98 percent of the population insured. But costs have continued out of control.

On February 17, 2011, Massachusetts Governor Deval Patrick filed "An Act Improving the Quality of Health Care and Controlling Costs by Reforming Health Systems and Payments." The proposed legislation puts the Commissioner of Insurance into the middle of the cost spiral by threatening to impose price controls. The Commissioner would be empowered to declare the acceptable rate of cost increase, and the insurer is prohibited from contracting with a provider at a rate exceeding the allowable amount.

What's important in this legislative concept is that instead of bashing insurers for the health cost trend the Governor is now directing insurers to drive hard bargains. This repositions the insurer from being the enemy of the public to being the agent of the public.

In Massachusetts, where the three major insurers are locally based not for profit organizations, repositioning insurers from enemy to agent makes sense.

In addition to jawboning by public officials, Massachusetts media have fastened on health care costs as a public issue. The Boston Globe publicized the payment differentials received by hospitals that had strong brand identity even when quality measures did not warrant the premium. And in recent weeks, when Blue Cross revealed the size of the golden parachute given to its former CEO and the level of payment to its board members, the story was front page news. (See this post on the topic.) In response, the Blue Cross board voted to suspend its stipends, and both Harvard Pilgrim and Tufts Health Plan, the other two major insurers in the state will address the topic at their next board meetings.

Health care costs will only come into line when patients, providers, payers, politicians, and the wider public (note the five Ps) come to see cost containment as an ethical imperative on behalf of society, not a moral crime committed by proponents of death panels. Massachusetts is a promising venue for this kind of learning and collaboration. The state is proud of what it has achieved in access to health insurance. But continued cost escalation will kill those achievements. And it's finally dawning on the public and its leaders that health care is only one of many socially valuable expenditures. However valuable health care may be, it's strangling other public objectives that provide even more value.

Pumping out Prescriptions

A story on the front page of today's New York Times caught my eye - "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy." For psychiatrists of my generation who've had the privilege of treating our patients in a comprehensive manner - psychotherapy when it was called for and medications when they were needed - it's a sad story.

The article describes Dr. Donald Levin, 68, who early in his career did primarily "talk therapy," with 50-60 patients in his practice who he saw for 45 minute appointments, typically weekly or twice weekly. Now he has a panel of 1,200, who he sees intermittently for 15 minutes to prescribe and manage medications. For psychotherapy they see social workers or psychologists.

Dr. Levin has done a real service with his candor. He comes across as a competent, caring person, who is trying to make a middle class living and can only do it by changing himself from a "therapist" to a "prescriber." The reporter was able to interview some of Dr. Levin's patients, who spoke warmly of him. Dr. Levin was surprised at their reactions. "The sad thing is that I’m very important to them, but I barely know them. I feel shame about that, but that’s probably because I was trained in a different era."

My professional colleagues blame the transformation of the profession on managed care. The accusation is half right.

It doesn't take a PhD in economics to recognize that fees paid to psychologists and social workers are lower than fees paid to MDs. In many areas of the country, well educated, skillful non-physician clinicians are readily available. For patients whose primary need is psychotherapy, using the insurance pool to pay a higher fee would only be justified if psychotherapy done by MDs produced better outcomes. For relatively healthy patients for whom medication isn't needed, there's no reason to see medical training as a necessary component of effectiveness. For these patients, insurers are right to pay for psychotherapy at the lower, non-MD level. Psychiatrists can do this form of psychotherapy, but won't be paid a premium for doing it.

But many patients require medication and monitoring of their physical health, combined with psychotherapy. Here, insurers have often carried over the model of split treatment in a rigid and short-sighted manner. Many years ago my psychiatrist friend Bill Goldman, then medical director of United Behavioral Health, demonstrated that integrated treatment of depressed patients with medication and psychotherapy, done by a single psychiatrist, was actually less costly than split treatment for comparable patients, with the psychiatrist handling medication and a non-MD providing psychotherapy.

In past decades, my guild made a typical guild error. We claimed that psychotherapy done by psychiatrists was better than psychotherapy done by non-MDs. For patients who needed integrated treatment, my guild's claim is true. For patients whose need was for psychotherapy alone, our claim was false.

Our defensive posture weakened our bargaining position with insurers, and the insurers' short-sightedness about the validity of integrated treatment with a subset of patients made them hard to bargain with. The result has been a large scale transformation of the profession into one where psychiatrists do intermittent "med checks," described in poignant detail by Dr. Levin in the New York Times.

In 1975 I joined the practice in a not for profit HMO, in which the insurance function and the medical group were part of a single organization. I and my psychiatrist colleagues shaped our practices so that we cared for patients for whom our medical training provided additional value. Patients who needed psychotherapy alone went to our excellent non-physician colleagues. This arrangement was (1) satisfying for patients, (2) satisfying for clinicians, and (3)an efficient use of the insurance pool. It required trust between the clinical and insurance components of the organization.

If the anticipated trend to encourage the development of accountable care organizations - medical groups that take responsibility for quality and cost - unfolds as predicted, we'll see recalibration of psychiatric practice. Psychiatrists will be paid to talk and prescribe, but only for the subset of patients who require their combined expertise. That could foster good clinical care, good professional life, and good economics!

(For more about the transformation of psychiatry, see my post "Psychiatrists should talk with patients, not just give pills.")

Paying Health Care Executives and Board Members

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

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

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

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

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

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

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

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