Should President Obama come out of the Closet on Rationing?

An editorial in yesterday's Washington Post challenges President Obama to come out of the closet about rationing and fess up to the American public about the need for limits and sacrifice. Here's the essence of the argument:

PRESIDENT OBAMA sometimes presents health-care reform as a pain-free proposition, as simple as choosing the red pill over the blue -- one that's no more effective but costs twice as much. Asked at his news conference whether "the American people are going to have to give anything up in order for this to happen," Mr. Obama's basic answer was no. "They're going to have to give up paying for things that don't make them healthier," he said...

But Mr. Obama's soothing bedside manner masks the reality that getting health costs under control will require making difficult choices about what procedures and medications to cover. It will require saying no, or having the patient pay more, at times when the extra expense is not justified by the marginal improvement in care. Mr. Obama is right that sticking with the status quo is a bad alternative, but he isn't leveling about the consequences of change...

The current system is untenable and getting worse, with employers dropping insurance and premiums rising for those who still have it. Reform is essential. But Mr. Obama does the public a disservice by acting as if it will not require anything from them in return.

Of course the editorial is correct about the need for rationing. But is its conclusion good advice for political leadership?

On May 13, 1940, Winston Churchill spoke to the British Parliament as the new Prime Minister. He didn't mince words about the need for sacrifice. Perhaps the Washington Post has Churchill in mind in their advice to President Obama:

I have nothing to offer but blood, toil, tears, and sweat. We have before us an ordeal of the most grievous kind. We have before us many, many months of struggle and suffering.

You ask, what is our policy? I say it is to wage war by land, sea, and air. War with all our might and with all the strength God has given us, and to wage war against a monstrous tyranny never surpassed in the dark and lamentable catalogue of human crime. That is our policy.

You ask, what is our aim? I can answer in one word. It is victory. Victory at all costs - Victory in spite of all terrors - Victory, however long and hard the road may be, for without victory there is no survival.

Let that be realized. No survival for the British Empire, no survival for all that the British Empire has stood for, no survival for the urge, the impulse of the ages, that mankind shall move forward toward his goal.

Metaphorically, the U.S. is facing the same situation the Brits were in 1940. Our public dream of a Garden of Eden in which all pain and illness can be banished is a "tyranny" that threatens the survival of the country as we know it. But the threat posed by an economic cancer does not galvanize society the way an external enemy does.

So how can the President align the ethics of honesty with the requirements of political effectiveness? If I were advising him I'd argue for statements like this:

My fellow Americans. Our country is facing a grave and devious threat in runaway health care costs. Health care costs are a form of virulent, but potentially treatable cancer. If we let the status quo continue health costs will strangle our economy and rob us of our strength. Al Qaeda's best strategy for weakening us would be to induce us to continue with the status quo...I know that many are afraid that change means rationing. They're 100% right to be concerned. Every other country in the world has chosen to ration health care. Unless we tackle avoidable waste we'll have to do the same thing. Making large changes can be frightening, but we have not been a nation of cowards...

President Obama needs to invoke an external enemy more effectively than he has done thus far. As wrong as they are, that enemy isn't the Republicans or the Blue Dog Democrats - it's the economic cancer of the status quo. His task is made difficult by the fact that the enemy isn't a foreign power - it's our own cowardice about facing facts in the arena of health care. As Pogo said in the 1950s - "We have met the enemy...and he is us!"

To move health care reform forward President Obama needs to channel Winston Churchill more effectively. If he doesn't create more of an external danger we'll just continue to fight with each other. That dynamic has scuttled every previous effort at meaningful reform.

Professor Obama's Health Care 101 Lecture

It's worth giving a careful reading to the transcript of President Obama's July 22 press conference. It can be read as the opening lecture of the course on "Health Care Economics and Ethics 101." The President is the Professor. I've done a Cliff Notes analysis of what I see as his major themes, in the form of excerpts (slightly edited) followed by my comments in bold italics.

1. "A lot of Americans may be wondering: What's in this for me? How does my family stand to benefit from health-insurance reform?"

Health policy is a form of job creation program for learned wonks. Unfortunately, the many illuminating analyses that are available are largely read only other wonks. I would guess that the distance between public understanding and expert knowledge is greater for health care than for almost any other area of public policy. Professor Obama is wise to start the course by recognizing and addressing our ignorance and skepticism.

2. "Two-thirds of the cost of reform can be paid for by reallocating money that is simply being wasted in federal health-care programs...We in the United States are spending about $6,000 more than other advanced countries where they're just as healthy...That's money that could be going into people's wages and incomes. Over the past decade we basically saw middle-class incomes flatlined. Part of the reason is [that] health care costs are gobbling that up."

Here Professor Obama is introducing us to the concept of opportunity costs. Health care is valuable. But it's only one of many values. Each of us is unwittingly subsidizing wasteful health care spending. Waste has no value for us as individuals - it's like tossing $6,000 out the window. Those who found it on the street are happy to have it, but he's asking us - do we really want to spend our money that way? 3.

Question from Steve Koff of the Cleveland Plain Dealer: "Can you guarantee that this legislation will lock in and say the government will never deny any services, that that's going to be decided by the doctor and the patient, and the government will not deny any coverage?"

The President: "No. The whole point of this is to try to encourage changes that work for the American people and make them healthier...We want to create an independent group of doctors and medical experts who are empowered to eliminate waste and inefficiency in Medicare."

The reporter invited the President to indulge in managed care bashing, but Professor Obama declined the invitation. The vision of "empowered" experts is a mechanism for managing care. As I've said in numerous posts, the best way to manage care is through global budgets for not-for-profit accountable medical organizations in which the physicians are salaried. But insofar as Medicare remains in a fee-for-service configuration an entity with some of the characteristics of the U.K.'s National Institute for Health and Clinical Excellence (NICE) is just what we need. His response to the reporter's question was politically courageous!

4. "If somebody told you that there is a plan out there that is guaranteed to double your health-care costs over the next 10 years, that's guaranteed to result in more Americans losing their health care, and that is by far the biggest contributor to our federal deficit, I think most people would be opposed to that. Well, that's the status quo. That's what we have right now. So if we don't change, we can't expect a different result...Now, I understand that people are feeling uncertain about this. They feel anxious, partly because we've just become so cynical about what government can accomplish; that people's attitudes are, even though I don't like this devil, at least I know it. And I like that more than the devil I don't know...But my hope is that when people look at the cost of doing nothing, they're going to say, we can make this happen. We've made big changes before that end up resulting in a better life for the American people."

Education is about the potential for change. In my first year philosophy class in a discussion of Nietzsche the professor asked us - "how many can refute Nietzsche's argument here?" None of us raised our hands. "Since you can't refute him, I assume you are all going to change your lives." We continued to sit on our hands. His point was even more powerful than Nietzsche's argument. We were treating education as words on a page, with no implications for action or our own futures.

I think Professor Obama is shaking us up here in a constructive manner. Like my freshman philosophy section, most of us in "Health Care Economics and Ethics 101" are sitting passively in class, listening without real engagement. Suddenly we're confronted with the consequences of our passivity, followed by a diagnosis of why we're sitting on our hands - it's because since President Reagan identified government as the problem, not the solution, our default stance has been cynical disbelief in public action (unless that action involves sending smart bombs to Iraqi targets).

Experienced psychotherapists know that the most important work is with the patient's resistance to change. Slogging through those resistances can be tedious and slow, but without addressing them therapy will be a waste of time. I think there's a chance that the political process we're seeing represents that kind of engagement with the beliefs and fears that have made change in health care so difficult.

I think Professor Obama has launched our course in an excellent way. But whether we're ready to learn remains to be seen!

Peter Singer on Rationing

In yesterday's New York Times magazine, Peter Singer presents a patient, lucid explanation of the ethical and economic necessity for health care rationing. (See here.)

If you've read any of my 37 previous postings on rationing you know that I see rationing as (1) obviously necessary, (2) done every day in our health "system," (3) mandatory for ethical health care in the 21st century, because (4) there are more potentially beneficial interventions available than we can afford. As Peter Singer puts it:

When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?

Given the undeniable truth of Singer's conclusion, how do we account for the steady drum of histrionic rhetoric warning the public that health care reform will mean "rationing"? What comes to mind is Schopenhauer's famous comment on an arcane philosophical argument:

As a serious conviction it could be found only in a madhouse: as such it would then not need so much a refutation as a cure.

I don't believe that the conservative legislators and commentators who warn about rationing are mad. I assume they know that their pretense that rationing is evil and will only occur if President Obama gets his way is nonsense, and are simply playing politics. Alas, the "rationing" accusation is effective politics, and the disinformation it embodies contributes to the madness of our national discourse on health care.

So how can that madness be cured?

Lucid argument of the kind Singer makes is useful, if only to firm up the resolve of the choir to keep singing. But to move the general public we'll need a combination of political leadership and time. If I were a political advisor, which I'm not, here's the line of thinking I'd recommend:

1. Our health system rations now by not insuring close to 50 million and spending so little on primary care that many well insured folks can't get to a personal physician.

2. We know that at least 30% of what we spend on health care is unnecessary and possibly harmful.

3. We need to reform the system so everyone has insurance and can get good care. That reduces the amount of rationing that is going on.
4. We need to wring out the unnecessary clinical and administrative expenditures. By doing that we reduce the potential need for rationing.

5. By taking no action and allowing runaway costs to continue we ensure that more and more poorly thought out rationing will occur, as occurs at present.

6. In case rationing is ever necessary in a reformed health system, let's tip toe up to thinking about how it could be done in the wisest and most ethical manner.

There's so much to do to capture the low hanging fruit of clinical and administrative waste that trying to focus the public on the need to ration is a distraction. Better to use the spectre of rationing as a prod to ourselves and the health system to remove our enormous expenditures on things that aren't needed before we engage in the truly difficult debates about what beneficial interventions we will forgo!

Letter to the Massachusetts Legislature

Dear Massachusetts Legislators -

This fall you will be considering whether to put the Payment Reform Commission's recommendations for moving health care to a system of global budgets into law. (See my post from July 17 for the story.) This is an opportunity we should seize. If we do, we'll rescue our own health care reform process and we'll help the national reform dialogue get real about controlling runaway costs. Here are some of the key reasons for supporting the Commission's recommendations:

1. Cost control. President Obama has told the U.S. public that containing runaway health costs is a moral imperative. We're starting to understand that health care costs are strangling the economy and way out of line with what other countries spend for equal or better results. Cost containment will not happen without true budgets for health care. There is simply no other way.

2. Mature discipline. Learning to live within our means is a key element of becoming a responsible adult. The recession we're in is teaching us a lesson we should have learned in growing up - no matter how many credit cards we have, there's no free lunch! Budgets for health care reward us (patients, the public and the medical community) for using our brainpower to live within the means that society decides to allocate to health care.

3. Reduced waste. Over the years I've asked colleagues I respect most in every medical discipline how much could be saved without loss of quality if they were in charge of their area of medicine. No one ever said less than 25% and a good number said 50%. Research supports the idea that we can remove at least 30% of what we spend on medical care without impairing outcomes.

4. Improved quality. Our fee-for-service system was exactly right in the horse and buggy era, when health care consisted of solo physicians prescribing nostrums for their patients. But it's ideally unsuited to an era that requires coordination among individuals and institutions. Fee-for-service payment penalizes physicians for spending time communicating with colleagues, families, and social agencies. Global budgets encourage these activities. Wider communication and better coordination = improved quality.

When you take up the Payment Reform Commission's recommendations you will hear from genuinely concerned constituents and self-interested fear mongers. Here are some suggestions on how to respond.

1. "This means rationing!" Of course you understand that rationing happens now and, in the sense of allocating our limited funds wisely to multiple good uses, is an ethical requirement, not an abomination. But it will take presidential leadership and time to move public understanding. Given that for now the "R" word is a debate-stopper, you should say that global budgeting is the best way to avoid the necessity of rationing. Cost containment should start by (a) eliminating interventions that are not needed but can cause harm (as by side effects) and (b) substituting equally effective but less costly interventions, such as generics for branded drugs, or prudent watchful waiting for doing a costly test today. The more we do (a) and (b) the less we'll need to do (c) ration - in the sense of deliberately choosing not to provide an intervention likely to be beneficial.

2. "Doctors will earn more by withholding care!" This fear could be real if physicians are allowed to keep large amounts of unspent funds as income. It's OK to point out that fee-for-service payment rewards us for how much we do, even if it's not the right thing. But arguing "fee-for-service is just as bad as capitation" isn't the way to go. You should build into the legislation that unspent funds should primarily be used for innovation and practice enhancement. The public will trust variation in income that's driven by solid quality and patient satisfaction measures, but not variation that tracks with budget alone.

3. "Global budgets let doctors decide everything - what about the idea that patients should be consumers?" Patients should be central to shaping their health care. The key pathway to achieving this is strong partnerships with their clinicians. Collaboration with patients is mainstream medical ethics in the U.S. now - fee-for-service payment isn't required to bring it about. And, legislation can require the accountable medical organizations that it calls for to include patients at the level of the organizations' boards or in advisory committees.

4. "Global budgets will stifle research and innovation!" Global budgets will encourage health care providers to be more hard nosed about the claims of new products. That won't stifle good research. It will, and should, discourage the rampant development of "me too" products that we see today - such as tweaked "new and improved" molecules that miraculously appear just as the parent drug is going off patent. Encouraging our drug and device industry to to invest in products that will achieve the best results at the lowest cost is all to the good.

Massachusetts can take pride in our superb health care assets - schools, hospitals, clinicians, medical groups, researchers, policy mavens, and entrepreneurs. You and the governor have a once in a lifetime chance to draw on our tremendous strengths to catalyze a transformation of our health system. Seize the opportunity!

Payment Reform in Massachusetts

The other shoe just dropped in Massachusetts.

Two months ago I wrote about the potential demise of fee-for-service payment in Massachusetts. Yesterday the ten member Payment Reform Commission unanimously recommended that Massachusetts move to a system of global payments for health care. (See a Boston Globe article here.)

Massachusetts's approach to health care reform is somewhere between bold and reckless. The state chose to start by addressing access, knowing that it would ultimately have to come to grips with runaway costs. It gambled that enthusiasm, pride, and perhaps also the shame of failing with a national spotlight on it, would help it grapple with the cost problem if and when it succeeded in improving access.

At this point 97% of Massachusetts residents have health insurance - the highest rate in the nation. But in the recession the program is unaffordable, and both services and membership are being scaled back, at least temporarily. Without cost containment the promising reform program will go down the tubes.

Ever since I joined the practice at the not-for-profit Harvard Community Health Plan HMO (now Harvard Vanguard Medical Associates) in 1975, I've been a strong believer in the clinical, financial and ethical reasons for budgets in our health care system. Learning to live within budgets of money and time is one of the core components of becoming a mature and responsible person. It's a piece of moral insanity that we've allowed our insurance system to follow the cost trend in a passive manner.

Global budgets for health care make it easier - and imperative - to take a holistic view of patients and their care. It becomes financially feasible to spend more time with patients and in communicating with other clinicians, social agencies and family members when these activities will promote better health.

In the 1980s, when I was responsible for components of the Harvard Community Health Plan practice, one of our best primary care physicians said to me - "Jim, if you want to save money, the best way is to give us more time with our patients...make the basic appointment 20 minutes rather than 15." I believed that at least for physicians like him this was true. (Alas, for a range of reasons I wasn't able to do the experiment.)

Now the ball is in the court of the Massachusetts legislature. I hope it will have the wisdom and the guts to follw the Payment Reform Commission's recommendation. Another bold step in Massachusetts might prod Congress to get real about costs. Rather than fighting about where we'll find another trillion dollars and pretending that comparative effectiveness studies and market competition will miraculously bend the cost trend, Congress will ultimately have to accept the fact that affordable health care requires budgets.

(See here for my previous argument that more money without global budgets will mean worse care and unhappier doctors.)

Praying with and for patients

I recently attended an inspiring forum sponsored by Andover Bread Loaf, "a private, non-profit organization based at Phillips Academy in Andover that works with U.S. and international public and private school teachers and students to enhance the teaching and learning of writing and to help catalyze educational renewal in classrooms, schools, school systems, and communities."
Teachers from New Orleans described programs they are developing in an effort to rebuild education and community after the Katrina disaster. A young teacher ended her presentation by saying - "if you pray, please pray for my students."

Her request got me thinking about a patient of mine with chronic schizophrenia who I had seen intermittently for several years, a sweet man who - though quite impaired by his ailment - radiated honesty and integrity. He was going through a bad patch in which his baseline anxiety and paranoia were more severe. We reviewed stressors, coping mechanisms and medication. As he left the office he said "please remember me in your prayers." I immediately replied "I will."

I've thought a lot about my response. I don't do petitionary prayer and don't believe in a divine being who might listen and respond. But I felt that I was being truthful with my patient. I interpreted his request to mean something like "I want you to care deeply about my well being," and because I did, my reflexive response was to confirm that I would indeed remember him in my prayers. If he had said "when you go to bed tonight please go onto your knees and ask God to make me better" I would have said something like "doing that isn't my custom, but I hope you know that in my heart I wish for you to be well..."

The U.K is in the midst of a flap about the ethics of prayer in the context of clinical care. Earlier this year a nurse, Caroline Petrie, was temporarily suspended for asking a patient whether she would like to be prayed for. The incident was widely publicized. Comments were highly polarized, some attacking "absurd political correctness" and "discrimination against Christians" while others found "invoking a non-existent deity in the course of medical care is foolish at best and potentially offensive."

This month the following motion will be brought to the British Medical Association:

That this Meeting:

• (i) recognises that the NHS is committed to providing spiritual care for patients;
• (ii) notes the position on inappropriate discussion of faith matters in GMC Guidance on Personal Beliefs and Medical Practice;
• (iii) while welcoming the constructive and necessary advice in the document "Religion or belief", is concerned that some paragraphs suggest that any discussion of spiritual matters with patients or colleagues could lead to disciplinary action;
• (iv) believes that offering to pray for a patient should not be grounds for suspension;
• (v) calls on Health Departments to allow appropriate consensual discussion of spiritual matters within the NHS, when done with respect for the views and sensitivities of individuals.

My guess is that one of the paragraphs of concern to those who are bringing the motion to the BMA is the following:

Proselytising

Members of some religions, including Mormons, Jehovah’s Witnesses, evangelical Christians and Muslims, are expected to preach and to try to convert other people. In a workplace environment this can cause many problems, as non-religious people and those from other religions or beliefs could feel harassed and intimidated by this behaviour. This is especially the case when particular views on matters such as sexual orientation, gender and single parents are aired in a workplace environment, potentially causing great offence to other workers or indeed patients or visitors who are within hearing. To avoid misunderstandings and complaints on this issue, it should be made clear to everyone from the first day of training and/or employment, and regularly restated, that such behaviour, notwithstanding religious beliefs, could be construed as harassment under the disciplinary and grievance procedures. Where one or more people from the same religion are working in the same environment, an individual could be pressured to conform to certain religious practices, which is again a form of harassment. There may also be differences of opinion on conformity within groups, for example between orthodox and reformed branches of certain religions, which could cause tensions and make an individual feel under pressure because of his or her religious beliefs.

If Ms. Petrie was trying to convert her patient the suspension would have been warranted. If her patient had asked to be prayed for it would unquestionably have been reasonable to agree to do so.

But what about offering to pray, which is what Ms. Petrie did?

If I were in charge of policy for Ms. Petrie's district or for the NHS I would find it hard to make a rule about offering to pray for a patient. It's clear from multiple research studies that when patients feel that their clinician genuinely cares about them they do better. If Ms. Petrie had a gentle, unintimidating manner, knew that her patient liked to pray and said "I'm a person who likes to pray for those I care about...would you like me to include you in my prayers tonight?" I would find that acceptable. But if she asked in a strong way "would you like me to ask Jesus to touch you with his healing hand?" I would find the episode unacceptable.

It's not a matter of the clinician's freedom of speech or religion. The guiding principle is that we clinicians should shape what we bring into the care relationship based on a reasoned judgment of what's best for the individual patient. (A "reasoned judgment" can come rapidly, as for me with the patient I agreed to remember in my prayers.) It would be wrong to forbid responding to a request to be prayed for. And I would not want to legislate that no clinician should ever offer to pray for a patient, but I would want my colleagues to be capable of distinguishing between their own beliefs about what is best for others (for example, belief in Jesus, Buddha, Allah or in no god) and a thoughtful assessment of what is best for this particular patient.

That's what clinical responsibility entails. But if clinicians at a hospital or in a district were blurring the boundary between preaching and caring, a prohibition would be required.

Should Health Plans Spend Money on Community Service?

A couple of weeks ago I received the 2008 Annual Report from Harvard Pilgrim Health Care, the health plan at which I direct the ethics program. The theme of this year's report is "making our communities healthier." It describes the wide range of community activities Harvard Pilgrim funds through its Foundation and the community service done by staff, individually and in teams.

It's an excellent report (it's OK for me to praise it - I had nothing to do with writing it), but I'm not going to summarize it here. But the report got me thinking about whether in our wildly overexpensive health care system it makes sense for health organizations to spend money on anything other than their basic function.

It's easy to be cynical about corporate social responsibility programs. It's still possible to find material on the web about the Enron Foundation. Every company involved in the bailout that I've looked up has an impressive corporate responsibility statement. The wolf probably told Little Red Riding Hood - "Trust me - I'm with the corporate social responsibility program!" If community investment didn't pay off for publicly owned companies stockholders would demand that the community dollars go into dividends.

But for health organizations I think programs like the one at Harvard Pilgrim are tremendously valuable. Well planned investments, whether of money or human effort, can produce direct benefits in the community. But for a health plan, getting a lot of staff involved in hands on service strengthens the soul of the organization. It's so easy to get caught up in the organizational silo we live in that we lose sight of the human realities that health organizations serve. This is just as true in a Medicaid or Medicare office as in a private insurance company. And if God organized her angels into a corporate structure the same dynamic would probably apply.

Health organizations are specialized, but individual people and our communities aren't. For five years I was part of a board most of whose members had serious psychiatric disorders. I'd treated folks like the board members for all of my clinical career. But seeing them in a setting where we were fellow board members, working on common interests and chatting about our lives before and after the meetings, made me a better psychiatrist and, I hope, a wiser human being.

Well chosen corporate philanthropy is good public relations. That may strengthen the corporation's external image, but it doesn't make it a better version of what it's supposed to be. But involving members of the corporation in activities that evince the values the corporation is created to serve strengthens the "human capital" of the organization. Done right these activities have a direct impact on the community. But the impact on the corporation's culture and values lead to carrying out the basic health-related function better. I can't prove it, but I know it's true!