Tragic Choices at Grady Hospital

On October 3, Grady Hospital in Atlanta closed its dialysis clinic. Grady committed itself to cover the cost of dialysis for three months for any of the 96 patients under its care who did not have an alternative source of dialysis. The three month extension is up on January 3. An undetermined number of patients - possibly as many as 50 - do not yet have a settled plan for continued treatment.

Grady has been serving the poor in Atlanta since 1892. A quarter of Georgia’s physicians have had at least part of their training at Grady. The hospital has 953 beds. The Grady Health System, which includes nine neighborhood health centers, does 921,000 outpatient visits per year, but has been in dire financial straits for many years.

In 2007, in the context of massive financial losses, the board voted to turn Grady over to an independent 501(c)(3) corporation, hoping that a more business-like board could bring managerial discipline to the hospital and make tough decisions the more political board was not willing to make.

This past summer the board showed it could make tough decisions when it voted to close the dialysis clinic, which was losing $2.5 million each year.

The dialysis clinic is a prototypic safety net program. 35% of the patients are undocumented and uninsured. Another 30% are documented but uninsured. 8% are prisoners. The facility itself is old, with outmoded equipment.

In a September ruling as to whether Grady should be allowed to close the clinic, Judge Ural Glanville of the Fulton County Superior Court recognized the severity of the trade off between Grady's stability and the importance of the clinic to the patients it served:

"Indeed, no value can be placed on human life. Nevertheless, when contemplating the use of injunctive authority, the court is required to balance relative equities, even in cases involving issues of life and death. If the court were to require [Grady] to maintain...the services forming the basis of the complaint, it would likely result in an adverse effect on the services offered to other individuals and the public at-large."

A group of plaintiff's brought a class action suit to block the January 3 funding cutoff, but on December 15 the suit was dismissed.

Predictably, Grady is being vilified as an uncaring killer. When confronted by a City Council member the chair of the Grady board responded by accusing the Council of grandstanding - demanding that the clinic be continued without providing funds to do it. I think this was a useful confrontation.

Uninsured patients, most notably immigrants, and especially undocumented immigrants, are caught in the middle of a life-and-death form of the game of "hot potato." Grady Hospital, as a safety net provider, inevitably loses, since its mission is to care for those who have nowhere else to go. When the public, through its government, stints on funding, safety net programs like Grady are left holding human lives in their care. What is a safety net provider to do if the funds allocated to it by the public don't allow it to meet the needs of its patients?

Clearly, a safety net provider is accountable for using the funds it receives in the most efficient manner possible. But we the public can't be allowed to turf our moral accountability to the Gradys of the world. We the public created safety net providers to care for the underserved, not to take on the burden of our sins in the manner of Jesus. I believe Grady is right to provoke a crisis over dialysis services. If some of its patients are still in limbo on January 3, Grady can't simply set them loose. It will have to continue to provide for them. But it should keep pointing the finger at its funding sources, with the message that Winston Churchill gave in World War II - "Give us the tools, and we will [do] the job," along with this corollary message - "If you choose not to give us the tools, acknowledge that you are the killers, and take responsibility for your decisions!"

(For a previous post on Grady Hospital, see here.)

The Ethics of Virtual Medical Visits

OptumHealth, a division of UnitedHealthGroup, will soon be offering a web-based platform for connecting patients and doctors by video. When the largest health insurer enters the E-visit space we know a change is coming. The Optum program will roll out in Texas in 2010.

I think virtual visits are a great step forward. But I'm chastened by this critique in the article about Optum:

"This is a pale imitation of a doctor visit. It’s basically saying, ‘We’re going to give up any pretense of examining the patient and most of the nonverbal clues that doctors use.'"

If the quote were anonymous I might have dismissed it as fuddy-duddyism. But it's from Dr. David Himmelstein, a friend, a superb primary care physician, a brilliant policy researcher, and co-founder of Physicians for a National Health Program (PNHP - the single payer advocacy group) - the opposite of a fuddy-duddy!

Experience with E-care is just beginning to emerge. In January, the Hawaii Medical Service Association (HMSA - Hawaii's Blue Cross Blue Shield) began offering 24/7 access via telephone and the web to physicians in its network who sign up to provide the service. Hawaii is a natural place to start, since for a number of patients, seeing a doctor in person would require flying to another island. If I were a primary care physician in Hawaii, I'd sign up to do it!

The infrastructure is provided by American Well, a Boston-based company that provides secure infrastructure for web visits, automated billing, and care coordination. The technologies involved aren't new, but packaging them to create tools easy for patients and clinicians to use is a valuable step forward.

I write about Optum and American Well on an ethics site becuse the fundamental step of trying to meet "constructive," "health promoting" patient preferences evinces an ethical focus on patient and public values. Even in my dark ages psychiatry practice I had patients who were VERY grateful for the opportunity to use email to monitor and manage the medications we were using, or to use email to discuss issues we had initially opened up in the office. And when email served my patients' needs it was a win/win tool, since I could access it from home at times that were convenient for me as well.

David Himmelstein is absolutely correct in noting the ways in which E-visits fall short of what an expert physician can transact in the office. But there is a segment of the public that places more value on convenience and timeliness than on a high quality in-person relationship. I have less of a sense of the pros and cons of E-visits for this segment, but it's an experiment worth conducting, on the hypothesis that E-access is better than no access!

(More information on the HMSA program is available from a Fortune article here and a Business Week article here.

Medical Culture and Costs at UCLA

An article about the cost of end-of-life care in this morning's New York Times focuses on the Ronald Reagan UCLA Medical Center. UCLA has a national reputation for high quality/high tech care, but also for high costs. According to the Dartmouth studies, Medicare pays UCLA $50,000 during the last 6 months of a patient's life compared to $25,000 at the Mayo Clinic.

The article quoted CEO David Feinberg as saying “If you come into this hospital, we’re not going to let you die”!

I have memories that shed light on the story.

From July 1964 to June 1965 I was a medical intern at UCLA, before returning to Boston to train in psychiatry. I don't remember any limits being set on the tests we ordered until the chief resident came to us in the spring to say "folks, we're running out of money for tests, so cut back where you can." He was apologetic for having to cramp our style. The question of when tests were medically important to do, when they were wasteful, and when the risk of false positive results or otherwise misleading findings was so great that doing the test would be, in medical jargon, "contraindicated," was never discussed. UCLA was probably not unusual in that era, but in retrospect it seems that a cost-unconscious ethos was already part of the culture.

The article in the Times also discussed UCLA's ethic of doing everything possible for patients - sometimes with extraordinarily beneficial results. I experienced this in a very positive way as an intern. During one of my ward rotations a young professor was admitted for a heart attack. He was stable, but the physician in charge had me sleep in the same room with him as an additional element of safety. My skills at cardiology were, to put it politely, "developing" at best. But the message of concern and caution embodied in my assignment made a strong impression on me. (I was also aware of the absence of equity - we didn't have interns sleeping in the rooms of our other heart attack patients.)

Dr. Feinberg, the CEO, is a child psychiatrist. Prior to becoming CEO of the UCLA hospitals he was medical director for the Neuropsychiatric Hospital there. Psychiatry has always been subject to limits in ways the rest of medicine hasn't. In addition to his medical training, Dr. Feinberg has an MBA. I trust that his comment about how UCLA is "not going to let you die" is a wry way of tweaking a culture that has been overly technology-driven and underattentive to the ethics of medical costs.

(See here for a profile of Dr. Feinberg, here for the New York Times story, and here for "Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care," a paper I wrote in 1994.)

Patient Safety, Ethics, and Psychiatry

This fall I was asked to discuss a case for the Agency for Healthcare Research and Quality Mortality and Morbidity Rounds - a web-based patient safety education site.

At first I thought they were writing to the wrong Dr. Sabin. Patient safety isn't an area of my expertise. But the case they asked me to discuss had major issues of ethics and psychiatry that arose in the care of a homeless man with a history of IV drug use, admitted to a hospital with a methicillin-resistant Staphylococcus aureus (MRSA) abscess near the spine. The patient left the hospital against medical advice (AMA) with bad aftereffects.

I won't recapitulate the case and my discussion here. The moral of the story in the case I discussed was that homeless IV drug users are more "foreign" to most hospital staff than patients from "foreign" countries. Caring for people who we may see as "other" calls for distinctive cultural competence skills. When an institution lacks those skills safety is jeopardized. Ethics and psychiatric consultation can often be helpful.

(I read a number of cases on the website and found them uniformly engaging and informative. The AHRQ site is well worth visiting.)

Crunch Time in Health Care Reform

We're in the end game of health care reform.

As I said in my last post, we're seeing real debate in the Senate, but - unfortunately - only among the Democrats, since the Republicans have united around their goal of preventing the Democrats from passing a bill.

Yesterday two of our best commentators - David Brooks and Paul Krugman - discussed whether Senators should support the bill. Brooks (here) agonizes over the choice, but ultimately concludes that he would vote no. Here's why:

"...if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach."

Krugman (here), I believe, would agree with Brook's analysis of the pluses and minuses in the bill. But he ends up encouraging a "yes" vote:

"With all its flaws, the Senate health bill would be the biggest expansion of the social safety net since Medicare, greatly improving the lives of millions. Getting this bill would be much, much better than watching health care reform fail...Bear in mind also the lessons of history: social insurance programs tend to start out highly imperfect and incomplete, but get better and more comprehensive as the years go by. Thus Social Security originally had huge gaps in coverage — and a majority of African-Americans, in particular, fell through those gaps. But it was improved over time, and it’s now the bedrock of retirement stability for the vast majority of Americans."

For three reasons I think Krugman got it right:

1. The perfect is the enemy of the good. No matter where one falls on the spectrum from single payer advocate to market hawk, the Senate bill is hard to love. The legislative sausage moving through the reform process won't satisfy anyone's dreams. But the right comparison is with the status quo, not the ideal. It's been 16 years since the last serious effort at health reform. Senators should ask - "would we rather tinker with the status quo for the next 16 years or work with the framework created by the bill?" Imagining a better bill isn't a reason for voting "no." We're not going to see a better bill. Only those who (a) genuinely believe that tinkering with the status quo is the better course to follow from 2009 to 2025 or (b) expect that when we go further into economic hell in our health system handbasket we'll be readier to pass a better bill should vote against the bill we have.
   
   


2. Wishful thinking won't control health care costs. The bill is rightly seen as doing little to contain costs. But many of those who make this attack are the same ones who shouted "evil rationing" and "death panel" when costs were dealt with more directly. We've made progress as a body politic in understanding that health care cost containment is a moral and economic necessity, but we haven't grown up enough yet to dig in to the cost problem openly, honestly and vigorously. In 1914 Freud introduced the concept of "working through" a "neurosis" - clarifying the elements of a conflict, identifying the basis of our resistances to change, and moving forward as best we can - as the pathway to change. It's a sloppy and slow process - "an arduous task for the subject of the analysis and a trial of patience for the analyst" - is how he described it. As it was with Freud's patients trying to cure neuroses in 1914, so it is with our population trying to cure the health system through political action in 2009. Alas, knowing that our system is profoundly wasteful and unjust doesn't create the will to to make bold choices any more than knowing the source of our neuroses erases our quirks. We have to take baby steps - working through!
   
   


3. It's time to retire Reagan's sound bite that "government is the problem." In his inaugural speech in 1980 President Reagan said "Government is not a solution to our problem, government is the problem." It's still the central tenet of Republican theology. (See here for a video clip of Reagan's speech.) Because of our pervasive distrust of government, proposals like single payer insurance or a "public option," which would be mainstream ideas in most other developed economies, are seen as "radical" and "socialist" in the U.S. Our readiness to believe that support for doctor-patient dialogue about appropriate care for the elderly meant "death panels" showed just how powerful the grip of the perspective Reagan articulated so forcefully is in our national psyche. (See here for a discussion of the "paranoid style" in American politics.)
   
   Atul Gawande's characteristically insightful article in the December 14 New Yorker draws an analogy between the federal government's creative role in catalyzing development of U.S. agriculture at the turn of the 20th century to the potential impact of the many pilot programs promoted in the Senate bill. His argument won't convince the right wing mullahs, but I think anyone with even a partly open mind will see the many ways public action could foster positive change.

The Senate bill, and whatever comes out of the Senate-House conference, is the best option for change we're likely to have before 2025. It will be VERY imperfect. There will be LOTS to criticize. But voting it down and endorsing the status quo would be the wrong course for the country to take.

Empty Republican Rhetoric on Health Reform

I've just read "Health Care Reform - A Republican View," by Iowa Senator Chuck Grassley, in today's online edition of the New England Journal of Medicine.

It's disgracefully empty rhetoric!

Senator Grassley is an intelligent person, ready to crusade for values he believes in. I've praised his advocacy for strong conflict of interest protections here and here. In that area he's been a real leader.

But his New England Journal screed is simply a rehash of Regan-era platitudes about the evils of government and threats to our freedom. It's the marching orders for the 40 Senate Republicans, who, unless Senator Snowe defects, are maintaining (a) remarkable unity and (b) stunning absence of positive ideas.

I do agree with Senator Grassley's emphasis on tort reform. Even though economic analysis suggests that malpractice reform will have limited financial impact, anyone who is close to medical practice knows how corrosive the threat of malpractice action has become. The system does not promote improved quality and does not take good care of those who have suffered. The Republicans are right on this issue.

We've actually had some thoughtful debate in the Senate, but it's all within the ranks of the Democrats. Since the Republicans appear to be united behind Senator Jim DeMint's campaign to "break" President Obama and create his "Waterloo" by defeating health reform, their role has simply been to say "no." They've left it to the Democrats to argue about alternatives.

Read the New England Journal piece and see what you think.

Facebook Friends, Judges, and Conflict of Interest

Florida's Judicial Ethics Advisory Committee was recently asked the following question:

Whether a judge may add lawyers who may appear before the judge as "friends" on a social networking site, and permit such lawyers to add the judge as their "friend."

The majority - correctly - said "no," in accord with the expectation that judges will not "convey or permit others to convey the impression that they are in a special position to influence the judge." The principle behind the majority's conclusion is this:

Irresponsible or improper conduct by judges erodes public confidence in the judiciary. A judge must avoid all impropriety and appearance of impropriety. A judge must expect to be the subject of constant public scrutiny. A judge must therefore accept restrictions on the judge's conduct that might be viewed as burdensome by the ordinary citizen and should do so freely and willingly.

What's most interesting about the advice is the minority view on the Committee:

The minority believes that the listing of lawyers who may appear before the judge as "friends" on a judge's social networking page does not reasonably convey to others the impression that these lawyers are in a special position to influence the judge. The minority concludes that social networking sites have become so ubiquitous that the term "friend" on these pages does not convey the same meaning that it did in the pre-internet age; that today, the term "friend" on social networking sites merely conveys the message that a person so identified is a contact or acquaintance; and that such an identification does not convey that a person is a "friend" in the traditional sense, i.e., a person attached to another person by feelings of affection or personal regard...the minority concludes that identification of a lawyer who may appear before a judge as a "friend" on a social networking site does not convey the impression that the person is in a position to influence the judge...

Two things stand out about the minority position:

First, there's a generation gap with regard to social networking, so that for some, a "Facebook friend" isn't necessarily a "real friend." But since some Facebook friends are indeed real friends, it seems to me that the minority is wrong. An observer would have to do a differential diagnosis of the term "friend." That process can't be counted on to protect public trust in the judge.

Second, both majority and minority were solidly focused on appearance. They don't ruminate about whether the judge is really friends with the lawyer and actually subject to influence. To maintain public trust judges don't simply scrutinize their motives - they have to start by scrutinizing how their conduct would appear to a skeptical observer.

We've not made that distinction at all well in medicine. Later this week I'll be writing about how failure to take appearance seriously is again undermining an important American Psychiatric Association initiative.

(The Florida Judicial Ethics Advisory Committee opinion is available here.)

Will Reducing Health Care Costs Kill Patients?

David Leonhardt, economics columnist for the New York Times, continues to do superb reporting and analysis of our health system. Print journalists don't have the reach of the right wing talk show blowhards, but a steady drum of thoughtful, informed voices like Leonhardt can chip away at the flood of disinformation we receive.

I just came upon his column from a couple of days ago and wanted to toot the horn for it. Here's an excerpt:

The House has shown little interest in cost control. President Obama and his administration have pushed aggressively for it, but they have limited leverage. Mr. Obama can’t credibly threaten to veto any of the health reform bills that now seem likely to emerge from Congress.

So after the 11 [Senate] freshmen announced their [cost-cutting] plan on Tuesday, I caught up with Mark Warner, the Virginia Democrat who is the group’s leader, underneath the Capitol building and asked him how he and his colleagues would deal with the inevitable scare stories still to come: How do you respond to a lobbyist who effectively accuses you of killing patients?

“I don’t know any other way than you take incremental steps,” Mr. Warner said, “and you hope you get to the tipping point where fear and misinformation don’t have an effect, because people see these things don’t do what they are accused of doing.”

That, obviously, is the long-term strategy. In coming weeks, we’ll see how well Mr. Warner and his colleagues deal with the immediate pressure. The Grim Reaper is a tough opponent.

I encourage readers - especially those from outside of the U.S. who are struggling to fathom what on earth is going on in our health reform process - to look at Leonhardt's full article. (And for a previous post on Leonhardt's discussion of rationing, see here.)