Health Care Organizational Ethics

Nicholas Kristof on "Unhealthy America" - One Grand Slam and One Stikeout

2009-11-07T14:22:00.020-05:00

I greatly admire New York Times columnist Nicholas Kristof's reportorial thoroughness and passion for social justice. So I wasn't surprised that I agreed with the opening passage in his November 5 column on "Unhealthy America":

The moment of truth for health care is at hand, and the distortion that perhaps gets the most traction is this:

We have the greatest health care system in the world. Sure, it has flaws, but it saves lives in ways that other countries can only dream of. Abroad, people sit on waiting lists for months, so why should we squander billions of dollars to mess with a system that is the envy of the world? As Senator Richard Shelby of Alabama puts it, President Obama’s plans amount to “the first step in destroying the best health care system the world has ever known.”

That self-aggrandizing delusion may be the single greatest myth in the health care debate...

Kristof goes on to cite multiple studies that show just how mediocre our overall "system" is. This is educative journalism at its best.

Then he stumbled:

I regularly receive heartbreaking e-mails from readers simultaneously combating the predations of disease and insurers. One correspondent, Linda, told me how she had been diagnosed earlier this year with abdominal and bladder cancer — leading to battles with her insurance company.

“I will never forget standing outside the chemo treatment room knowing that the medication needed to save my life was only a few feet away, but that because I had private insurance it wasn’t available to me,” Linda wrote. “I read a comment from someone saying that they didn’t want a faceless government bureaucrat deciding if they would or would not get treatment. Well, a faceless bureaucrat from my private insurance made the decision that I wouldn’t get treatment and that I wasn’t worth saving.”

The flow of Kristof's article makes it clear that he is presenting Linda's painful story as an indictment of the inurer. But there are three basic possibilities for understanding Linda's tragic situation, only one of which is malfeasance. Kristof invites readers to see the insurer as guilty as charged, just one more example of insurer "villainy."

This is bad journalism, especially coming from a brilliant and ordinarily trustworthy reporter like Kristof. He missed an opportunity to educate his readers by making these important distinctions:

The medication Linda wants is a validated, "evidence-based" form of chemotherapy and the insurer knows this, but chooses not to cover it, duplicitously claiming that it is not "medically necessary." A court that found an insurer guilty of doing this would, and should, levy hefty punitive damages.
There are new findings about the medication or about Linda's particular condition that the insurer has not given proper weight to. In this situation, an appeal that documents the rationale for why the medication should be seen as effective should succeed. I have been part of an insurance appeals process and have seen numerous situations over the years in which decisions were seen in a new light when new information was introduced.
The medication Linda wants is ineffective, but an uninformed or overzealous physician has told her it's what she needs. In the 1990s, bone marrow transplant for advanced breast cancer was covered on the basis of faith and hope. Insurers who refused to cover it were sued. In a famous case (Fox v Healthnet) the plaintiff's family was awarded huge punitive damages. The treatment was ultimately found to be ineffective, but only after 30,00 women had received it, often with the result of increased suffering and shortened survival. (False Hope, by Richard Rettig and others describes the the painful saga in detail.) If this is the situation Linda should receive clear explanation and compassionate care, but not agreement that the insurer has committed a moral crime. And the physicians who are misleading her should receive a combination of reeducation and chastisement for giving such bad advice.

The fact that one of our best journalists is contributing to our national failure to understand the need for clinically informed, ethically justifiable limits says a lot about how difficult the learning curve will be. As I've often said in this blog, even if Mother Theresa was in charge of an insurance plan, she would not cover every cancer chemotherapy that we petition for.

(Norman Daniels and I discuss these issues in detail in Setting Limits Fairly.)

Should Health Insurance Pay for Prayers for Healing?

2009-11-03T20:27:00.006-05:00

If the Los Angeles Times is to be believed, the Senate health reform bill requires insurers to consider covering prayer "treatments" as medical expenses. The provision was inserted by Senator Hatch from Utah, with support from my own two Senators - Kennedy and Kerry! The Christian Science Church, which has substantial wealth, is based in Massachusetts. This probably explains why two ordinarily thoughtful liberal Senators supported such an absurdity.

In my clinical practice I often encouraged patients to use prayer as part of their "management strategy" for handling their conditions. And when patients with serious ailments asked me to remember them in my prayers I said I would, even though I do not do petitionary prayer. (I generally interpreted the request to be about concern for their well being and commitment to them, which is why I felt comfortable saying "yes" to the request.) But when prayer for patients by others has been subjected to experimental study it has not been effective. Mandating ineffective treatments is exactly what legislatures should not do.

The article quotes Erwin Chemerinsky, dean of the UC Irvine School of Law, as saying the provision raises serious questions about government support of religion: "I think when Congress mandates that health companies provide coverage for prayer, it has the effect of the government advancing religion." I disagree.

If prayer were shown to be effective in curing disease (and it hasn't been) it would seem just as reasonable for insurance to cover it as to cover acupuncture or hypnosis. For insurers to say "we will cover Christian prayer, but not Muslim prayer" or vice versa, would appear to be government endorsement of a particular religion. But endorsing a practice (prayer) doesn't require endorsing a belief (in a supreme being).

The reason for opposing the provision for covering prayer under insurance is that interventions that have been tested and found to be ineffective should not be paid for by communal funds. That should be a no-brainer in a rationally governed health system. But rational governance is not a covered benefit in the U.S. health "system"!

A Moral Conundrum in Massachusetts Health Reform

2009-11-01T21:07:00.018-05:00

The Massachusetts legislature is beginning to deliberate about the Special Commission on the Health Care Payment System's recommendation that the state phase out fee-for-service payment and replace it with global payments to "Accountable Care Organizations" (ACOs). At a conference this past Friday, Representative Harriet Stanley, Chair of the Massachusetts House Committee on Health Care Financing, told the audience that “cost containment is absolutely essential,” that she and other legislators want to see short term (1-2 years) cost savings, and that legislative action is likely before next summer.

Most reports sit on the shelf until they die of old age. That's not likely to happen with the report from the Special Commission. It, and the state, deserve, and will probably get, a lot of attention, as Massachusetts locks horns with the problem of costs! Massachusetts health reform will continue to be an important laboratory for federal policy developments.

Here's the moral conundrum the state will have to grapple with:

ACOs (combinations of hospital(s), groups of physicians, and other providers) will be responsible for caring for a population within a budget. To do this, and to promote integrated care, they will want to provide maximum care from within the ACO's own network.

But the Special Commission wasn't naive - it understood that in the era of capitation, consumers demanded free choice and rebelled against staying within networks. Here's what the report says - "While payments to ACOs will follow the enrollee’s choice of a primary care physician, patients will not be restricted (unless as a condition of their insurance contract) to providers in their primary care physician’s ACO" (p 57).

#1 and #2 point in opposite directions - #1 implies physician-guided treatment within the ACO while #2 implies patient-guided treatment within the entire community of clinicians (not necessarily restricted to Massachusetts).

I've had an opportunity to pose this conundrum to a member of the state legislature. The legislator gave a two part answer. Here's Part I of the answer - "If a patient wants a 'branded' service and equally good alternatives are available within the ACO, it's OK to be kept within the ACO. But if patients can't get the services they need within the ACO, that's a different story."

If our measurement of quality was precise enough and showed that surgeon A/hospital B (within the ACO) got results that were just as good as surgeon C/hospital D (outside the ACO), this principle would work well. It would be clear that the patient's wish reflected "preference," not "need." Saying "no" could readily be justified as a fair, evidence-based decision.

Unfortunately, we almost never have this information! I asked the legislator what happens then. Part II of the answer was - "we're thinking about this all the time - my staff would be interested in talking about it with you..."
I was glad to hear that the legislature is fretting over the question of how to adjudicate among the values of choice ("liberty"), efficiency, and integration of care (quality). Better information will make the tension among these values easier to address, but I don't see any way of avoiding some tough choices.

If Massachusetts is going to get a grip on its very high medical cost structure the state - probably starting with the Governor - will have to address the conundrum of "choice versus efficiency." We'll try to wiggle out of confronting the conflict between core values, but I don't think we'll be able to. This will be a real test of leadership!

Are Health Insurers Villains?

2009-10-27T07:30:00.004-04:00

Since I direct the ethics program at a health insurer (Harvard Pilgrim Health Care - a regional non profit company serving 1.1 million members in Massachusetts, New Hampshire and Maine), I've thought a lot about our national assault on insurers as "villains."

I've come to see the dissing of insurers as arising from five sources: (1) incidents of real "villainy"; (2) a critical view of the U.S. "system" of competing insurers; (3) lack of public acceptance of the need for stewardship; (4) societal PTSD from the managed care era; and, (5) politicians' need for a scapegoat.

The biblical story about Lucifer indicates that even angels commit evil deeds. If angels can't avoid sin, it's not surprising that virtually every human enterprise includes "villainy." Large organizations, such as insurers, are especially vulnerable to flying at 30,000 feet and not seeing the impact of what they do on the individuals they deal with. And, having many employees increases the risk that an individual employee will be inept in ways that cause harm or deliberately roguish. This risk is just as true for churches, hospitals, schools and other organizations. There's no reason to think that health insurers are cut from a different cloth than the rest of us. But because health care is a sacred calling, examples of bad behavior outrage us.
A substantial number of Americans regard the current structure of the U.S. health "system" itself as unethical. I agree. For many, that view leads to blaming health insurers for the rules of the game they are playing in. It's as if a pacifist blamed football teams for tackling each other when their real critique is of the game itself. The system we're currently in requires insurers who want to remain solvent to screen people who enroll as individuals for preexisting conditions. If Mother Theresa were made CEO of an insurer in the U.S. she could not discontinue the practice. (Because the "system" requires practices of that kind she would turn down the job and stay in Calcutta!)
I've written many times about our national failure to understand that containing health care costs is a ethical requirement, not a moral abomination. For the public, caring about patients ("fidelity") is "good," while managing costs ("stewardship") is "evil." We confuse the aphorism "life is priceless" with economic truth. Much political rhetoric asserts that what the physician prescribes is ipso facto "medically necessary" and therefore should not be questioned. Since provider behavior drives the cost of insurance this puts insurers an the unenviable position - the only positive role for them is to pay for what the physician or hospital recommends.
In the 1980s/1990s U.S. social policy asked insurers to manage care. Except for organizations like Kaiser Permanente and Group Health Cooperative this split caring for patients ("fidelity") and responsibility for health care funds ("stewardship") into opposing camps. The public, and physicians in fee for service practice, believed that physicians cared about patients and were "good," while insurers cared about money and were "bad." This was especially true with for profit insurers, but all health insurers are still tarred by the managed care brush.
Politics proceeds via sound bites designed to arouse emotion. Politicians need enemies. For the conservatives it's "socialized medicine" and "takeover by government." For the administration it's "greedy health insurance villains." These simplified, reflexive positions fire up the political base but create a major obstacle to thoughtful political discourse. We saw this process in clearest form in the mindless conservative rants about "death panels," but the global vilification of health insurers as "villains" is equally mindless.

Much of the journalism I've read in venues like the Boston Globe, Los Angeles Times, New York Times and Washington Post has been thoughtful and sophisticated. What's not yet clear is how much we - the public - have learned thus far from the health reform process. My pessimistic self says we're stuck in sound bite mud. But my optimistic self says we're inching forward in our understanding of the ethics of our health system.

The answer isn't yet in!

Insurers and Health Care Costs

2009-10-24T16:30:00.002-04:00

In a recent interview, Senator Olympia Snowe commented - "We need a lever to force the [insurance] industry to drive down prices." This is a common view. Unfortunately, it's a view that contributes to public misunderstanding of the drivers of health care costs.

Single payer advocates point to insurance-driven administrative overhead - within insurance companies themselves and at provider sites to cope with the complexities of billing - as the source of runaway costs and the key potential source of savings. Single payer advocates anticipate savings from eliminating insurance companies. But these aren't the savings Senator Snowe is talking about. She, along with many other legislators, are counting on market mechanisms and competition between insurers to drive expenditures down more than on administrative savings.

Here's where the problem comes in. Insurers can only achieve non-administrative savings in two ways. Decrease the volume of services or decrease provider prices. But by putting insurers in the doghouse we've made it next to impossible for them to get a grip on either volume or prices.

We clinicians know that the U.S. buys much more medical care than than we need. As individual clinicians we may believe our own care patterns are fine, and the problem is with our colleagues. But I've never met a clinician who didn't see lots of opportunity to reduce the volume of interventions we provide, without any loss of health. But the time between any proposal to reduce the scope of what we offer and an eruption of death panel nonsense would be nanoseconds! And since insurers have been so vigorously portrayed as "villains," they can't expect much support if they try to reduce Dr. Kildare's charges.

Portraying "health reform" as "health insurance reform" may be effective politics, but we can't expect "villainous" insurers to deal effectively with our bloated care system. For the moment we've created a no-win situation with regard to cost containment. We reject reject the single payer alternative, vilify insurance companies, and then expect those "villainous" companies to carry out the delicate function of reforming the U.S. delivery system. Locking horns with providers and convincing the public that we currently purchase vast quantities of unnecessary, and often harmful, care, requires trust. And we've systematically portrayed insurers as untrustworthy.

I don't expect this impasse to be solved in the current legislative process. We've barely mentioned delivery system reform in a way the public understands. Policy wonks understand the importance of the Dartmouth Atlas and recognize that high quality systems like Geisinger, Kaiser Permanente, Mayo Clinic and Harvard Vanguard can provide better care at a lower cost. But the public doesn't get it yet, and won't until there has been a substantial educative process.

The real work of health reform will happen after whatever legislation emerges from the Congressional struggles we're still in the midst of.

Is Ethics Relevant for Health Reform?

2009-10-19T17:30:00.041-04:00

As I sat down to prepare a talk on health reform and ethics I'll be giving soon, a Tina Turner song started to play in my head - but with "ethics" substituted for "love":

"What's ethics got to do, got to do with it?
What's ethics but a second hand emotion?"

Given the mind-numbing daily stories about twists and turns in Washington and the daft Republican rhetoric about "socialized medicine" and "death panels," an observer might conclude - "health reform is only about politics and special interests - ethics is an irrelevant second hand emotion!"

I've had that thought myself. But I think it's wrong.

There's no doubt that partisan politics and special interests are leading players in the reform process. (As an example, see here 'for an audio of Senator Jim DeMint's excitement about "breaking" President Obama and creating his "Waterloo" by defeating health reform.) But in addition to the impact of PAC money bribes and armies of lobbyists, politicians and special interests try to get their way by playing on the public's strongly held but unexamined values. From the political perspective this is "stealth ethics." From the philosophical perspective we might call it "pseudo ethics."

President Obama reported receiving a letter saying (see here for a videoclip of the President telling the story):

"I don't want government-run health care. I don't want socialized medicine. And don't touch my Medicare."

This story got a big laugh from the President's AARP audience. But it makes a deeper point about ethics and health reform. Ethical reflection isn't just a matter of asserting values. It requires bringing our values to bear on the world of facts, and, reciprocally, modifying our values as the facts may require. The joke here is that the anti-government, libertarian letter writer made the facts fit the values. Since she (it was a woman) liked Medicare, Medicare couldn't possibly be a government program!

Muddled "pseudo ethics" are stirring the reform pot in several ways. Here are two examples:

Health insurers are "villains." There's lots to criticize in the conduct of insurance companies and in the way we've structured our health "system" around competing insurers. But even if Mother Theresa were in charge of U.S. health care we'd need an insurance function to oversee the way we spend our funds and to seek value for money. The global condemnation of insurers abets the public fantasy that if we get rid of the villains we'll be in a paradise that requires no difficult choices.
From a moral perspective the aphorism "life is priceless" conveys what Albert Schweizer called "reverence for life." But as a piece of economic guidance the aphorism is psychotic. It implies that any limit that threatens life is evil. In actuality we constantly make choices that involve weighing life against other values - how much to spend on auto safety, whether to put defibrillators on every street corner, or whether the convenience of texting while driving is worth the risk to mortality (ours and others) it poses. By not distinguishing between the metaphoric meaning of "priceless" as applied to whether life should be revered and the need to use funds wisely, we again invite the body politic to remain ignorant about our ethical obligation to set limits in health care.

So ethics does have something "to do with it" - it's not just "a second hand emotion." But what's required is not shouting about values - that's easy, and accomplishes nothing. What's really needed is the much more difficult task of shuttling between values and facts - looking at the facts in light of our values, modifying those values as needed, as when the anti-government libertarian contemplates the fact that Medicare is a 44 year old government program, and developing options that serve important values to the greatest extent possible.

If the democratic process works as the founding fathers hoped it would, this is what the legislative process should strive to do with the bills that have been developed in the House and the Senate.

Why Comparative Effectiveness Research is so Important

2009-10-15T08:45:00.013-04:00

I'm on the road now, and yesterday gave the talk I wrote about (here) last week. (I'm not writing about the venue of the talk since it was an internal meeting, not a public session.)

I came away from the event convinced more than ever that a robust program of comparative effectiveness research (CER) is the crucial next baby step for improving the value of what we in the U.S. health "system" do in health care and making the topic of health care costs less toxic. Sadly, the challenge for us in the U.S. is to begin to deal with runaway costs in a serious fashion rather than waiting for the tooth fairy or the Wizard of Oz to make the problem go away. (See "Cost Control: How Incapacitated are We?" by Paul Menzel on the Hastings Center Health Care Cost Monitor for an analysis of the almost total collapse of meaningful cost containment in the health reform process.)

CER studies compare alternative approaches to treating the same condition. It's most straightforward when the comparison is between drug A and drug B, but in principle we can compare a drug to, say, meditation or exercise, as well. The legislation that is moving through Congress is careful to insist that CER cannot be used to manage care or drive insurance coverage. Drug companies are terrified at the prospect that CER will deflate their claims about "me too" drugs. Medical specialists fear that a sham treatment may equal or outperfom their favorite procedures, as has happened in prior research on surgery. It's a fairly safe prediction that the first thing that will happen from CER is....very little.

CER dramatizes the fact that much of what we do in health care is based on faith, not evidence. It treats our beliefs as hypotheses which may be correct but could be off the mark. For healing to occur we must have faith in our doctors. The more evidence our doctors have about what works best the more that faith is warranted and will be rewarded.

Because it's so obvious that when two approaches are equivalent there has to be a VERY good reason for not choosing the less costly alternative, CER will gradually shake us out of the reflexive U.S. attitude that costs should not be considered in delivering care. It's best to see the health reform process as a first step, not a "solution." If Congress can fashion a bill that the President can sign we'll have demonstrated that our fractious and wildly irrational political process can engage with health care. It seems certain that whatever emerges will be profoundly imperfect. But if the body politic and the legislature comes away from the reform process with more confidence about tackling health care, we'll be in a better position to learn from the flaws in what emerges and to take some wiser next steps.

That's where CER comes in. It enacts a scientific approach to a realm that is increasingly dominated by advertising and economic interests. The first useful impact will be when insured folks say "let's bring premiums down by doing what works best at the lowest cost" and taxpayers say "let's put some teeth into Medicare by using the results of CER." Vested interests have blocked these steps in the legislative process so far. But if the public, and our political leaders, see more facts emerging from CER, it will be harder for PAC contributions and advertising flim flam to drive health care.

Can we Discuss "How Much is Life Worth" without going ballistic?

2009-10-08T11:36:00.011-04:00

I've been invited to speak next week at a conference based on the article by Tito Fojo and Christine Grady ("How Much is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question") that I wrote a post about three weeks ago. The opportunity has led me to a clearer perspective on the currently undiscussable topic of health care rationing.

Fojo and Grady's central argument - that we in the U.S. should rein in our expenditures on interventions that produce small benefits at enormous cost is so obviously correct that the question to ask is not "are they right?" but rather "what's preventing us from doing what we so obviously need to do?"

I've thought about that question in light of the decision process that NICE (National Institute for Health and Clinical Excellence) uses for the guidance it provides to the National Health Service. NICE has created an elegant approach to setting limits. The logic of NICE's process is simple. (1) The National Health Service has a budget. (2) Every expenditure has an an opportunity cost and should be compared to alternative uses of the funds. (3) For selected new interventions, NICE reviews the evidence about its clinical effectiveness. (4) If the intervention offers clinical benefit NICE asks how much those benefits cost, defined as cost/QALY (Quality Adjusted Life Year). (5) NICE applies a template of social value judgments to the facts that emerge from its analysis. (6) The template includes a threshold range (20-30 thousand pounds/QALY) to guide decisions and a framework for deciding when and how to make exceptions to the threshold. (7) The entire process is conducted in a public manner, with opportunities to see the reasoning behind the conclusions and to raise challenges.

NICE fine tunes its approach over time, but its fundamental logic is sound. The impediment to us in the U.S. doing what Fojo and Grady urge us to do is not the absence of a method for deciding about the worth of marginal benefit. Any country ready to tackle rationing could take NICE's procedures off the shelf, study them, and adapt the process to its own culture and institutions.

The key word here is "ready." And, as Hamlet told us, "readiness is all!"

Experienced psychotherapists teach that the hardest job in treatment is dealing with the resistances to change. Once these impediments have been worked with well enough change almost takes care of itself. That model applies at the level of social process as well.

In my talk I'll take Fojo and Grady's argument as the starting point. They're obviously right. The folks at the conference are predisposed to agree - that's why they invited me. I'm going to suggest that making decisions about marginal benefit is, at heart, not all that difficult. NICE shows us how to do it. The task for all those who agree with Fojo and Grady is not to persuade others to see the same truth, but to chip away at the impediments to seeing the obvious. I'll write more about chipping away impediments in future postings.

(See here for NICE's Social Values Judgments report and here for reports from the Citizens Council.)

Rebellion Against the Individual Insurance Mandate

2009-09-29T18:00:00.003-04:00

This morning's New York Times reports that legislators in a dozen states are launching a rebellion against the possibility of a mandate that individuals must buy health insurance or pay a penalty. The legislators hope to amend their state constitutions to prohibit any federal requirement that individuals (or employers) must "play or pay."

In 2008 Arizona, a hotbed of radical anti-government sentiment, the electorate almost passed Proposition 101, "The Freedom of Choice in Health Care Act," that would have put the following into the Arizona constitution:

Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan.

The vote could hardly have been closer - 920,341 (49.8%) for and 928,452 (50.2%) against. A tweaked version of Proposition 101 will be on the 2010 ballot and may well win this time.

The brain trust behind the rebellion is the American Legislative Exchange Council (ALEC), a 30+ year old organization of conservative state legislators and policy analysts. ALEC's model legislative proposal is only available to members, but the gist of the proposal is can be seen here:

When consumers control the dollars, they make the decisions. On the other hand, a single-payer health system—which forces patients to enroll in a one-size-fits-all plan with rich benefits and weak cost-sharing—will cause spending to skyrocket and policymakers to ration care as a cost-containment measure...Under a socialized medicine scheme, many patients will suffer, and some will die on a waiting list...ALEC's Freedom of Choice in Health Care Act ensures a person's right to pay directly for medical care.

ALEC pushes all of the conservative buttons - "one-size-fits-all," "ration care" and "socialized medicine."

ALEC and the legislators in the twelve mandate-fighting states appear to favor the "consumer-driven" approach to health insurance, in which individuals are asked to do their own rationing by having to spend their own money on health services. I don't know how ALEC proposes to achieve universal coverage without a mandate. The alternative funding mechanism is to tax the better off to pay for the worse off, not a popular conservative approach.

When I first joined the practice at Harvard Community Health Plan, a non profit HMO, in 1975, "community rating" applied, and all employers were charged the same per-worker premium. Over time the payment system shifted to "experience rating," in which employers were charged in accord with the actual cost of providing care for their employees. This meant that employers were penalized for having older workers who were likely to cost more, and for making it possible for workers with chronic illnesses to hold jobs. Now conservative groups like ALEC want to disaggregate the community down to the level of individuals having the "right" to pay for their own care.

Even if a robust federal health law is passed states will continue to be crucial laboratories for reform initiatives. I'm at the opposite end of the political spectrum from ALEC and favor communitarian approaches to managing the health system. But I'd be happy to see an ethically guided state experiment that (a) achieved universal coverage, (b) tracked its results and allowed independent researchers to assess the state's performance, while (c) putting conservative principles into practice. My guess is that the rebellious legislators are better at shouting "fire" (or rather, "socialized medicine") than solving problems on the ground, but rather than trade sound bites it would be better to see if they can make their ideas work in a clinically sound and socially responsible manner.

Conservative critics of health reform emanate sound bites brilliantly. It's time to see if they can walk their talk!

(An op-ed supporting Arizona Proposition 101 by George Will is here. The Resolution that will be on the Arizona ballot in 2010 is here.)

Should Therapists Snoop in Their Patient's Facebook Site?

2009-09-28T21:32:00.012-04:00

A colleague recently asked me this question:

What do you think about therapists going to a patient's Facebook site if that site is open to the public, not just to people who the patient has friended? My younger colleagues think it's OK - like reading about your patient in the newspaper. It doesn't feel right to me but I'm not sure why?

What a terrific question!

From the perspective of privacy ethics there's nothing wrong with going to the Facebook site. After all - the patient has structured it so that anybody can come to the site to see what's there. In that limited way the younger colleagues are right - it isn't a violation of privacy.

But it matters what kind of a clinician we're talking about here. If a primary care physician was working with a patient on a self-management problem like difficulty sleeping or weight loss and was getting nowhere, I wouldn't fault her for going to the Facebook site as long as she was prepared to tell the patient about it, as in:

I've been troubled about why we're not making any progress in what we're working on - I just don't get it. So instead of running more tests I went onto your Facebook site. I think I can see what our problem is...

But what about a psychotherapist doing the same thing? Here I think the younger colleagues are missing the boat. Psychotherapy isn't just a matter of gathering information as part of the effort to solve a problem. The relationship itself is at the heart of the effort. The commitment on both sides is to use the experience of the relationship on behalf of the treatment goals. It wouldn't be surprising for the patient to see if the therapist has a Facebook site, but it would be important for the patient to bring the fact of the search into the therapy. What did the patient's curiosity focus on? What did what he found mean to him? What feelings were associated with the process?

If the therapist and patient were talking about the patient's self-presentation on Facebook it would be fine for the therapist to say - "would it be OK for us to look at it together right now?" That would lead to collaborative inquiry. But it wouldn't be OK for the therapist to go to the site covertly. What was the therapist looking for? Why didn't he bring up whatever the question was with the patient? If the therapist has a question he should ask it. If he goes to Facebook instead it suggests that he feels an impediment to direct work with his patient. That's what's key - not the information on the Facebook site.

Health Care Organizational Ethics Blog Cited

2009-09-27T16:55:00.005-04:00

Medicine 3.0 recently cited this blog as one of the top 50 health policy blogs. I appreciated the honor, and also appreciated learning about a number of interesting blogs I had not been aware of. I encourage readers to check out the site (see here).

Last November, the blog Online Universities cited Health Care Organizational Ethics as one of the "100 blogs that will make you smarter." The list is worth perusing.

The Art of Dying

2009-09-23T21:42:00.014-04:00

In the July/August issue of the Hastings Center Report, John Hardwig, professor of philosophy at the University of Tennessee, offers guidance on "the art of dying." Hardwig encourages us to think deeply about what we want for the end game of our lives and to create the groundwork for life to end the way we want it to.

Here's how Hardwig sets the context:

When the sensible fear is that death will come too soon, the reasonable course is to flee it - try to postpone it or put it off...

However, many of us now worry that death will come too late - long after life has lost its usefulness and its savor, long after we have ceased to have a 'life,' perhaps long after we even are ourselves. When the more sensible fear is that death will come too late, the reasonable course is to make death come sooner - to seek it out. Learning how to go to meet death is, I believe, one of the basic tasks of our time.

In Hardwig's view, and I agree, "our institutions - our law, our medicine, our customs and traditions, our ethics, our religions - are all designed to respond to the older kinds of death [deaths that came too soon]." He tells us that he is 69, and he envisions a generation that will have to grapple with the question of life's end game without much help from others. Insofar as he's right, what a sad situation!

I'm part of Hardwig's generation, but I wouldn't have had the guts to speak as directly as he does prior to reading his essay. Consider this:

At my age I should be ready to die...I should realize that I have already had a full life...If I am not yet ready to die, something is deeply amiss in my outlook on life. My basic beliefs and values need revision.

Hardwig warns about the danger of waiting for an exact point at which one wants death to come. We can't count on having that kind of control. Probably most of us mid-life or older know people who found themselves imprisoned in a prolonged end of life that they dearly wanted to avoid. He discusses refusing life-sustaining treatment, cessation of eating, and active suicide. It's my impression that many, perhaps most, people in their 60s and beyond mull over these questions, but that relatively few discuss the issues in depth with those they are close to.

Before I decided to go into medicine and psychiatry my alternative career plan was to become a philosopher. Had I done that (I decided I wasn't scholarly enough to take to a full time academic career) I would have hoped to do Hardwig's kind of writing - disciplined, well argued, and fully engaged with questions of personal meaning.

The Hastings Center Report article isn't addressed to physicians. I was pained by Hardwig's view that my profession is not ready to partner with patients in the kind of thinking he presents. I'd like to think that he's underestimating the capacity of the profession - that if doctors felt they had permission to help their patients think about - and talk about - "the art of dying," most would be ready to do so. When I was a medical intern at UCLA in 1964 my first outpatient undertook to teach me about Hardwig's topic. I was 25. He was 50, with a lymphoma that wasn't curable. At our first appointment he asked me to renew his sleeping pills. He told me that when the time came he would use them to end his life. Even though he didn't know I was going into psychiatry he gave an important lesson in succinct form - "I'm not depressed - I enjoy my life - but I'm realistic, and I know what I want." I renewed the pills. He was still alive when I ended the year of medicine and returned to Boston to do my residency in psychiatry. If his spirit has access to the Hastings Center Report I expect that he's saying "right on John Hardwig!"

(The July/August Hastings Center Article is not yet available online, but many of Hardwig's earlier articles, including his important essay "Is There a Duty to Die?" are available at his website.)

Shamans, Placebos and Multicultural Ethics

2009-09-20T09:08:00.023-04:00

Over coffee I read in this morning's New York Times about how Mercy Medical Center, an acute care hospital in Merced, California, allows Shamans to participate in the treatment of Hmong patients from Laos.

The Merced area has a large Hmong population (from Northern Laos), beautifully described in Anne Fadiman's superb book "The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and The Collision of Two Cultures." What's especially interesting is that Mercy Medical Center is part of Catholic Healthcare West, a faith-based system "committed to furthering the healing ministry of Jesus," as well as "to providing high-quality, affordable healthcare to the communities we serve."

It's easier for our scientifically-minded U.S. culture to recognize the importance of religion and magic in dealing with "foreign" cultures than with our own. In my own experience as a psychiatrist, and in my relatively limited interaction with other doctors as a patient, I've been aware of how much of what we do is anthropologically similar to what Shamans do.

When patients ask "so I have a chemical imbalance, right?" and I agree, our exchange has much in common with what is happening when a Hmong patient asks "so a spirit is causing my pain, right?" and the Shaman agrees. Whether or not a chemical imbalance or a spirit is responsible for the clinical state, applying a cognitive model the patient trusts in concert with a trusted healer can have a powerful impact.

In 1986 I made my first and thus-far only trip to China. On a train I conversed with a man who spoke English. I asked how he used "western" medicine compared to traditional Chinese medicine. His answer made excellent sense. "If I have a headache or pain in my back I go to a traditional Chinese healer. If I have pneumonia I go to a 'western' medicine doctor and get an antibiotic."

On returning to the U.S. I was referred a man who had recently arrived from Southeast Asia but who was ethnically Chinese. He had classical symptoms of major depression - depressed mood, suicidal thoughts, weight loss and sleep disturbance - for which antidepressant medication was (and is) the standard treatment in the U.S. He was dubious about trying the medication, so I wrote out my thoughts and encouraged him to discuss the treatment with his herbalist. The herbalist approved of my suggestion and in some weeks the depression was gone, presumably (but not necessarily) due to the medication.

A year later my patient returned and described what sounded like symptoms of erectile dysfunction. I began to ask the kinds of questions I would typically ask in that circumstance. My patient looked horrified at the direction the conversation was going, at which point I encouraged him to see his herbalist for the problem. A few years later I met him at the clinic carrying a baby. Presumably the herbs did the job!

Mercy Medical Center and Catholic Healthcare West are practicing admirable small 'c' Catholicism (in my dictionary "broad and comprehensive in interests, sympathies; liberal"). U.S. medicine needs to extend the same cultural sensitivity and anthropological sophistication to our own practices. We tend to use the term "placebo effect" disparagingly - "the Shaman's ritual is just a placebo effect." Each group takes its own beliefs as literally true and, ideally, acts like Mercy Medical Center with regard to the different beliefs held by others.

If we were more attuned to how much "evidence based" medical practice depends on the power of faith, magic, and the lowly placebo effect, we would be less inclined to flog patients with excessive technical interventions and readier to minister to them in a truly healing manner. When religious fundamentalists persist in using prayer as the only treatment for children with curable cancers we take them to court. But when medical fundamentalists persist in using one technical intervention after another rather than acknowledging that cure is not in the cards our insurance pays their fees.

Years ago a dear friend had come to the end of the available treatments for multiple myeloma and the disease was progressing. When she visited with her oncologist - a leader in technical medicine - he said "the best thing I can do for you now is to give you a hug," which he gave. I've used that as an example of ideal care with medical students.

Our health system can learn a useful lesson from my friend's oncologist and from Mercy Medical Center and Catholic Healthcare West!

How Much is Life Worth? - An Oncologist's Call to Arms.

2009-09-18T13:23:00.022-04:00

Between 1997 and 2004, Medicare spending on cancer drugs rose by 267% compared to an overall rise in Medicare spending of 47%. With an aging population, the cost of cancer drugs will become a progressively greater problem for the U.S. health "system."

A recent issue of the Journal of the National Cancer Institute has a very important article by Tito Fojo, an oncologist at the NCI Center for Cancer Research, and Christine Grady, an ethicist with the NIH Department of Bioethics. "How Much is Life Worth: Cetuximab, Non-Small Cell Lung Cancer, and the $440 Billion Question" calls for a fundamental change in research, the drug approval process, drug pricing, and clinical practice. The analysis and argument will be familiar to ethicists and policy wonks. What's especially important about the article is that Dr. Fojo speaks as a distinguished cancer researcher and addresses his recommendations to fellow oncologists.

Drs. Fojo and Grady don't flinch from using the "c" word - cost:

In some sense, every life is of infinite value, and we naturally avoid confronting the tension between not wanting to put a value on a life and having limited resources. But the spiraling cost of cancer care in particular makes this dilemma inescapable. We, the oncology community, cannot continue to ignore it.

The main example in the article is Cetuximab (Erbitux). Erbitux adds 36 days of life for patients with non-small cell lung cancer, but also adds a number of significant side effects. Conveniently, the study that demonstrated the 36 day extension of survival did not include quality of life measures. At its present cost, adding an average of 36 days of life is the equivalent of $800,000 per non-quality adjusted year of life. Fojo and Grady argue that this is far too much cost for far too little benefit.

The authors urge oncologists to act as true professionals who consider wider societal concerns like the uninsured or the U.S. economy going down the tubes. They don't use the word "narcissistic," but their analysis suggests that a profession that considers only its own perspective is just that. They make six specific recommendations for practice and policy:

1. "Research studies that are powered to detect a survival advantage of 2 months or less should only test interventions that can be marketed at a cost of less that $20,000 for a course of treatment." Here they are using the standard of one quality adjusted year of life for patients treated with dialysis ($129,090) as their standard.

2. Drugs should be priced accordingly.

3. "Drugs shown to be active in one subset of patients should be advocated, approved, and prescribed for that subset only. The marginal benefit, if any, which may be achieved in other patients should not be an excuse to administer a therapy even if it is decided that there is nothing further to be done."

4. FDA approved indications should be strictly adhered to.

5. "The all too common practice of administering a new, marginally beneficial drug to a patient with advanced cancer should be strongly discouraged. In cases where there are no further treatment options, emphasis should be first on quality of life and then cost."

6. "For therapies with marginal benefits, toxic effects should receive greater scrutiny."

Having exposed the chemotherapeutic emperor's new clothes for what they are, Drs. Fojo and Grady conclude:

We must deal with the escalating price of cancer therapy now. If we allow a survival advantage of 1.2 months to be worth $80 000, and by extrapolation survival of 1 year to be valued at $800 000, we would need $440 billion annually — an amount nearly 100 times the budget of the National Cancer Institute — to extend by 1 year the life of the 550 000 Americans who die of cancer annually. And no one would be cured.

The current situation cannot continue. We cannot ignore the cumulative costs of the tests and treatments we recommend and prescribe. As the agents of change, professional societies, including their academic and practicing oncologist members, must lead the way. The time to start is now.

Drs. Fojo and Grady have issued a courageous and compassionate challenge to their fellow medical professionals. It deserves wide attention!

(The article is not yet available without charge, but a summary and paid access to the full text are available here. For Dr. Fojo's web page see here.)

Massacusetts Insurance Costs and Federal Health Reform

2009-09-16T08:00:00.006-04:00

Our national approach to health reform is likely to draw on the reform process Massachusetts launched in 2006.

By the measuring rod of coverage, Massachusetts is doing significantly better than the other 49 states. "Only" 2.6% were uninsured in 2008, compared to a national average of 15%.

But by the measuring rod of cost containment, Massachusetts is - so far - a flop. Today the Boston Globe reported that the state's major health insurers plan to raise rates next year by approximately 10%, double the projected national average of 5%. (For the Boston Globe article, see here.)

Massachusetts is pursuing a high risk/high gain approach to health reform. Many political folks say "let's control costs first and then extend coverage." Given our pathetic national passivity about getting serious about health costs this approach is as likely to lead to real action as the sinner's promise to change his ways as soon as the Messiah approaches. Massachusetts' strategy has been to extend coverage first, hoping recognition that the accomplishment will go down the tubes unless costs can be controlled will act as a kind of Viagra for policy that catalyzes ability to overcome our national cost-containment impotence.

Massachusetts has proved that a combination of (1) requiring individuals to have health insurance (or pay a "fine"), (2) subsidizing insurance access for low income folks, and (3) requiring insurers to "pay or play," will (4) substantially lower the number of uninsured. But these accomplishments won't be sustainable unless (5) the state gets a grip on health care costs.

In 2008 Massachusetts created a Special Commission on the Health Care Payment System to "investigate reforming and restructuring the system to provide incentives for efficient and effective patient-centered care and to reduce variations in the quality and cost of care." (The key word is "efficient," a politically correct way of referring to cost containment.) The Commission issued its report in July. The state also contracted with the RAND corporation to develop a menu of cost containment strategies and to determine their potential impact on the health care system in Massachusetts.

Now the really important aspect of health reform in Massachusetts gets underway. The Special Commission and RAND have both recommended radical payment reform - moving from a predominantly fee-for-service system to a system of global payments. The Commission envisions "Accountable Care Organizations" of clinicians and hospitals caring for populations under a budget. The Commission understands that getting from here to there will take time and allows for a transition period of 5 years.

Our way of budgeting for health care in the U.S. is a farce. Rather than deciding what we want to spend we put our finger to the wind, ask what the system is likely to charge, and then create next year's "budget" based on our prediction. In the 1990s we asked health insurers to manage the system actively. For a time that worked - the trend slowed. But a system in which insurers put reins onto providers can't work - there's too much distrust of insurers, and it's too easy to vilify them as uncaring bureaucrats.

What we need is a system in which clinicians and their patients collaborate to manage care. I know first hand that this approach can work well from decades of practice in the Harvard Community Health Plan HMO, a non profit program that cared for a population within a budget. (Norman Daniels and I have described how doctors, patients, and other stakeholders can collaborate this way in "Setting Limits Fairly: Learning to Share Resources for Health.")

In 1630 John Winthrop gave a sermon to the Puritans who were about to found the Massachusetts Bay Colony:

For we must consider that we shall be as a city upon a hill. The eyes of all people are upon us. So that if we shall deal falsely with our God in this work we have undertaken... we shall be made a story and a by-word throughout the world. We shall open the mouths of enemies to speak evil of the ways of God... We shall shame the faces of many of God's worthy servants, and cause their prayers to be turned into curses upon us til we be consumed out of the good land whither we are a-going

If Massachusetts steps up to the plate and implements what the Special Commission and the RAND consultants have recommended it will become a learning laboratory for the U.S. system. If it succeeds in doing the job right the state will be a city upon a hill!

For those who are interested here are the principles the Special Commission recommended to the state:

1. As currently implemented, fee-for-service payment rewards service volume rather than outcomes and efficiency, and therefore other models should be considered.

2. Health care payments should cover the cost of efficiently provided care, support investments in system infrastructure, and ensure timely access to high quality, patient-centered care. Additional payment should reward and promote the delivery of coordinated, patient-centered, high quality health care that aligns with evidence-based guidelines where available, and produces superior outcomes and improved health status. Performance measurement should rely on reliable information and utilize uniform, nationally accepted quality measures.

3. Provider payment systems should balance payments for cognitive, preventive, behavioral, chronic and interventional care; support the development and maintenance of an adequate supply of primary care practitioners; and respond to the cross-subsidization occurring within provider organizations as a result of the current lack of balance in payment levels by service.

4. Differences in health care payments should reflect measurable differences in value (cost and quality). Payments should be adjusted for clinical risk and socio-economic status wherever technically possible, and should promote greater equity of payments across payers and providers, to the extent that this is financially feasible.
a. Differences in health care payments should be transparent, including across different payers.
b. Costs associated with desired investments in teaching and research should be paid outside of base payments, and should require provider accountability for how such payments are spent.
c. Costs associated with desired investment in special “stand by” capacity should be accounted for in the payment system.

5. The health care payment system should be structured in such a way as to minimize provider, payer and patient administrative costs that do not add value.

6. Payment reform must consider how:
a. Some payment methods may require certain organization of the service delivery system, and
b. Health benefit designs either support or limit payment reform.

7. Health care per capita costs and cost growth should be reduced, and providers, payers, private and public purchasers and patients should all share in the savings arising from payment reform.

8. The health care payment system should be transparent so that patients, providers and purchasers understand how providers are paid, and what incentives the payment system creates for providers.

9. It will be necessary to consider the diversity of populations, geography and providers across the Commonwealth when designing payment reform to ensure high quality, patient-centered care to all populations and geographic regions in the Commonwealth.

10. Implementation should be phased over time with:
a. Clear and attainable deadlines;
b. Planned evaluation for intended and unintended consequences; and
c. Mid-course corrections.

(See here for the RAND study, and here for the Special Commission on the Health Care Payment System report.)

Obama's Speech - Good Ethics and Good Politics

2009-09-10T04:22:00.024-04:00

President Obama hit a home run last night. His speech brought together the three roles we need our president to take in the health reform process - educator, ethicist, and tough politician.

President as educator. As a public we've been clueless about health care. How many times have we heard "the U.S. has the best health care in the world!" Many of our local settings are superb. President Obama mentioned two - Intermountain Healthcare in Utah and Geisinger in Pennsylvania. These were the right kinds of examples to give - integrated systems with strong primary care and careful attention to efficiency and cost management. We were spared from hearing another worshipful invocation of a once in a lifetime high-tech miracle as the definer of what we do best.

President as ethicist. The cancer of the U.S. health system is our rampant narcissism and neglect of our common interests. Individuals are being cheated unless they receive whatever they want. Physicians are being mistreated if each individual isn't allowed to command whatever resources he believes are called for without being questioned.

I like to use the metaphor of cancer for our health system - by letting costs explode we let health care invade and destroy so much of our capacity for creative action. President Obama used the deficit, and the specter of the depression we almost fell into - "our health care problem is our deficit problem - nothing else comes close." In other words - we choose between our thoughtless commitment to a wasteful system that produces mediocre results and a parched, deficit-ridden public life.

Sadly, Ted Kennedy can no longer be part of the end game in health reform, but happily the president channeled him to bring out the moral imperative behind the insistence on universal coverage. Reading from Senator Kennedy's letter was a proto-religious act - a message from a loving person sent from the other world.

President as tough politician. Channeling Ted Kennedy was a rhetorical triumph, but to go from rhetoric to a meaningful piece of legislation, Obama must channel Lyndon Johnson as well. He came close to naming names in his reference to "liars" with regard to the cynical efforts to manipulate the public by shouting"death panel," "government takeover" and "socialism." In the speech he evoked the persona of a don't-mess-with-me Chicago politician in an effective manner, but he'll have to emulate Johnson's combination of one-by-one persuasion and bludgeoning to move the legislature to create and pass of a bill.

It's too early to evaluate what the principles Obama laid out will look like when they take on legislative flesh. The angels and devils will be in the details of how the exchange(s) and public option are structured. I was especially interested in the president's vague reference to a commission of physicians and other experts who would identify areas of waste in our bloated system. That could mean managed care, which to me - if done well - has always seemed like the right way for a health system to go.

Wendell Potter on For-Profit Health Insurance

2009-09-08T23:00:00.012-04:00

Wendell Potter, who retired last April from his job as head of communications for the CIGNA health insurance company, has been in the news since then as a whistle-blowing critic of the insurance industry. Today I belatedly read his June 24 testimony to the U.S. Senate Committee on Commerce, Science and Transportation (see here) watched his July 10 interview with Bill Moyers (see here).

Potter is especially clear about the way short term considerations drive the behavior of for-profit insurers:

The top priority of for-profit companies is to drive up the value of their stock. Stocks fluctuate based on companies’ quarterly reports, which are discussed every three months in conference calls with investors and analysts. On these calls, Wall Street investors and analysts look for two key figures: earnings per share and the "medical-loss" ratio - the ratio between what the company actually pays out in claims and what it has left over to cover sales, marketing, underwriting and other administrative expenses and, of course, profits.

To win the favor of powerful analysts, for-profit insurers must prove that they made more money during the previous quarter than a year earlier and that the portion of the premium going to medical costs is falling. Even very profitable companies can see sharp declines in stock prices moments after admitting they’ve failed to trim medical costs. I have seen an insurer’s stock price fall 20 percent or more in a single day after executives disclosed that the company had to spend a slightly higher percentage of premiums on medical claims during the quarter than it did during a previous period. The smoking gun was the company’s first-quarter medical loss ratio, which had increased from 77.9% to 79.4% a year later. (slightly edited)

The problem with investor ownership and for-profit insurance isn't the people. Over the years I've studied a number of for-profit companies. The people I dealt with and observed seemed just as caring and idealistic as their counterparts in the not-for-profit world.

And the problem isn't profit per se. Although in most of my years of clinical practice I was paid as a salaried member of a not-for-profit group, I did ten years of fee-for-service practice. As a solo psychiatrist I typed my own bills and gave them to my patients each month. They brought a check to a subsequent appointment and handed it to me. This ritual made it crystal clear that I was running a for-profit enterprise, albeit a tiny one.

I was entirely comfortable with the ethics of my for-profit practice. I set my fees and could lower them if I chose to do so. When discussing fees I said "the aim is to make an arrangement that is fair to both of us." The owner of the enterprise (me) and the investor/purchaser (my patient) could look each other in the eye. Parsing what mutual fairness entailed was often part of the therapeutic process.

Public companies are large, impersonal structures. In particular, the equity owners are investors guided by economic rather than caretaking values. They're not challenged by looking the patient directly in the eye and having to see and take responsibility for the impact of corporate decisions.

I run the ethics program at a not-for-profit health insurance company. Like all other participants in the U.S. system we're subject to market pressures for efficiency. I think that's a useful pressure, just as the pressure to make treatment affordable for my fee-for-service patients was. But we're not subject to quarterly conferences with investors whose only concern is with financial performance.

If you look at the video you'll see that Potter looks "corporate" and speaks calmly. His clear discussion of the structural impact of equity ownership on the health system is a valuable contribution. I hope we hear reverberations of his analysis in President Obama's speech tomorrow night!

The Paranoid Style in American Politics

2009-09-02T21:40:00.022-04:00

In the course of trying to understand the eruption of rage against the non-existent "death panels" in the emerging health reform bills I went back to historian Richard Hofstadter's 1964 essay in Harper's Magazine - "The Paranoid Style in American Politics." The opening sentence reads "American politics has often been an arena for angry minds." How true!

Here's the essence of Hofstadter's argument:

I believe there is a style of mind that is far from new and that is not necessarily right wing. I call it the paranoid style simply because no other word adequately evokes the sense of heated exaggeration, suspiciousness, and conspiratorial fantasy I have in mind. I am not speaking in a clinical sense...It is the use of paranoid modes of expression by more or less normal people that makes the phenomenon significant.

Hofstadter cites examples in U.S. history going back to a wave of fear in the late 18th century that the Bavarian Illuminati - a group that espoused Enlightenment rationalism "spiced with the anticlerical atmosphere of eighteenth-century Bavaria" - were plotting to overthrow Christianity. Other examples include the anti-Masonic movement, anti-Catholic and anti-Mormon movements, late 19th century beliefs about a conspiracy of international bankers, and of course the fulminations of Senator McCarthy.

While Hofstadter emphasized that the paranoid style was not exclusively right wing he discerned a continuing belief in a "sustained conspiracy, running over more of a generation, and reaching its climax in Roosevelt's New Deal, to undermine free capitalism, to bring the economy under the direction of the federal government, and to pave the way for socialism or communism." Hofstadter's words in 1964 could be applied unchanged to what was being shouted at town meetings and broadcast on Fox in August.

Hofstadter's analysis offers an explanation for the intractability of public and political debate we are seeing in the health reform process:

As a member of the avant-garde who is capable of perceiving the conspiracy before it is fully obvious to an as yet unaroused public, the paranoid is a militant leader. He does not see social conflict as something to be mediated and compromised, in the manner of the working politician. Since what is at stake is always a conflict between absolute good and absolute evil, what is necessary is not compromise but the will to fight things out to a finish. Since the enemy is thought of as being totally evil and totally unappeasable, he must be totally eliminated—if not from the world, at least from the theatre of operations to which the paranoid directs his attention.

Hofstadter acknowledged that the term he chose to use for the style of mind he was describing was judgmental: "Of course this term is pejorative, and it is meant to be: the paranoid style has a greater affinity for bad causes than good." I'm not sure that he's right on this. Many people (like Hofstadter) on the liberal-left would admire whistleblowers like Ralph Nader, to whom the term "paranoid style" could certainly be applied.

In my clinical practice I thought of paranoid style as an accentuated version of the vigilance regarding external threats that has been hard wired into our nervous systems over millions of years. I sometimes said to patients - "when our ancestors in the forest hundreds of thousands of years ago heard a rustling sound, some probably paid no attention and went about their business, and others thought 'that's a tiger' and climbed a tree...if it was a tiger we know who natural selection favored..."

I don't know whether the likes of Newt Gingrich, Charles Grassley and Sarah Palin believe the nonsense they've spouted about death panels (paranoid style) or are cynically appealing to their political base's hatred of government (duplicitous manipulation). I'd guess that it varies from person to person. In retrospect the administration should have read Hofstadter's essay and conducted a series of political "war games" in which they tried to anticipate and innoculate against the full range of fears that could be triggered by the health reform debate.

Demonizing the paranoid style only makes things worse. Sometimes the rustling in the forest was just the wind, but sometimes it was a tiger. Too much trust is just as dangerous as too much vigilance. I, like many others, was inspired by the President's wish for a "different kind of politics," but that aim should not lead to the delusion that the entire political spectrum can be drawn into deliberative discussion!

(If you want to see Hofstadter's full essay, it's here.)

Immigrant Health and Heart Transplants

2009-09-01T04:30:00.021-04:00

I'm still jet lagged from 2 1/2 weeks in Europe, so when I woke up in the dark this morning I sought out the online New York Times for solace. Two articles yielded a larger story about health reform.

Eric De La Cruz was a student and part time disc jockey and graphic designer in Las Vegas in his early 20s when the symptoms of progressive cardiomyopathy - weakness of the heart muscle - began to cause symptoms of heart failure. The condition steadily got worse, and it became clear that the only hope for Eric would be a heart transplant. But neither of his employers provided health insurance. And, surprisingly, when he applied for Social Security disability benefits, which would have made him eligible for Medicare, he was turned down.

Eric did qualify for Medicaid, but in Nevada Medicaid covers heart transplants only up to age 20. At this point his sister began a Twitter-based effort to raise money, and within two weeks $1 million had been offered! Eric went to the University of Southern California for evaluation, but his condition was too far advanced, and he died on July 4.

The second article was from Massachusetts. The recession-driven shortfall in revenues and the requirement that the state stay within its budget necessitated cutbacks in the state's health reform program. (The program has led to the lowest uninsured rate in the U.S. - 2.6% compared to a national average of 15%.) The legislature decided to cut most of the $130 million dedicated to 31,000 legal immigrants. But by scrounging up some additional funding and developing a stripped down set of benefits, a relatively comprehensive insurance package will still be available to the legal immigrant group. It won't cover dental, hospice, or skilled nursing care, and will require higher copayments for non-generic drugs, but it would have covered a heart transplant for someone with Eric Cruz's condition.

After his death, Eric's sister Veronica De La Cruz said:

If my brother had been able to buy health insurance, he would never have been in this situation. No one should ever have to go through what we’ve been through. Eric should still be alive.

Veronica is half right. In a wealthy country like the U.S., a healthy young person like Eric should be eligible for a heart transplant. A heart might not be available, but that would be a tragedy, not an injustice.

Ben Kieckhefer, a spokesman for the Nevada Department of Health and Human Services, described the the state's policy clearly and honestly:

All insurance plans decide what things they are going to cover and what things they are not going to cover. Everyone in the state Medicaid program recognized the difficult situation the family was in, but we can’t just start covering something for one individual case.

Unless there is some form of universal or near-universal coverage, as through a single payer system or a requirement that individuals purchase insurance (as in Massachusetts) Eric would not - and should not - have been able to buy insurance. If we allow ourselves to wait until a need appears before we get insured, free-riding would be the rational choice for the individual to make, and insurance costs would be stratospheric in no time.

Affordable insurance depends on social solidarity, with the healthy contributing more than they receive and the sick receiving more than they contribute. In the U.S., however, talking about "solidarity" invokes fear of the other dreaded "S" word - "socialism."

And as the stories from Massachusetts and Nevada show, viable insurance also entails the equally dreaded "R" word - "rationing." Health systems must set limits. A society (like the U.S.) that refuses to ration in a thoughtful, ethically-guided manner, will (like the U.S.) end up rationing in a thoughtless, unethical manner. Whether a society prefers to limit high cost/high tech interventions as Nevada has done, or more mundane but nevertheless valuable services as Massachusetts chose to do, is the kind of policy decision that requires thoughtful democratic deliberation. Sadly, thoughtful deliberation is currently being drowned out by strident advocacy, pervasive misunderstanding, and lies.

(To read more about Eric De La Cruz see here. For the Massachusetts story, see here.)

Outing the Rorschach Inkblots (2)

2009-08-30T13:42:00.012-04:00

A few weeks ago I wrote about the controversy surrounding the publication in Wikipedia of the ten Rorschach inkblots accompanied by the most common responses. (See the original post here.) Now two psychologists have filed complaints with the Saskatchewan Medical Society against Dr. James Heilman, the emergency room physician who posted the images.

Here's the gist of the complaints (see here for more details):

One of them, Andrea Kowaz of the College of Psychologists of British Columbia, complained that by including the inkblots on Wikipedia, Dr. Heilman was violating the test’s secrecy and that if he were a psychologist his behavior would be “viewed as serious misconduct.”

The other letter, from Laurene J. Wilson, a psychologist at Royal University Hospital in Saskatoon, echoed the concern about the test’s security but added that Dr. Heilman “shows disrespect to his professional colleagues in psychology and disparages them in the eyes of the public.”

Dr. Wilson said she had read interviews with Dr. Heilman in which he “refers to psychologists as undertaking practices akin to a magic show with smoke and mirrors.”

I side with Dr. Heilman.

Dr. Kowar accuses Dr. Heilman of "violating the test's secrecy." But the test is just a series of inkblots and an interpretive system. Secrecy is a commitment psychologists make about the test and an aspiration they hold for it. The commitment is a piece of professional self-regulation and isn't binding on others. And a visit to Amazon will show that the secrecy cat is long since out of the bag. All the major texts on Rorschach interpretation are readily available. The idea that the images and the theories about how to interpret responses are secret is a naive fantasy, and the claim that a professional society's code of ethics applies to people outside of the profession is muddled thinking.

Dr. Wilson raises a more vexing question - what do professionals owe to each other in terms of public respect or disrespect? Putting aside the fact that psychology and medicine are different professions, professional etiquette has long demanded that physicians speak of each other respectfully in public. At best this expectation avoids undermining patient respect for doctors who deserve to be respected. At worst it protects colleagues from justified criticism and prevents action to protect patients from harm.

I don't agree that competent psychologists are conducting "practices akin to a magic show with smoke and mirrors" any more than I see emergency room doctors as butchers, even though some psychologists are presumably smoke and mirror charlatans and some ER doctors are probably dangerous butchers. If Dr. Heilman spoke this way and I were part of the Saskatchewan Medical Society I would point out that public trust is crucial for the health professions. He should be free to make reasoned and evidence-based critiques of medical (including psychological) practices, but name calling is demeaning to him as well as to those the names are aimed at. Respectful debate can improve practice and will enhance public trust that the health professions are doing their best to get things right. Name calling does nothing for quality and makes professionals look like children squabbling in a sandbox.

This, however, does not rise to the level of being an ethical violation. I'll be surprised if the Saskatchewan Medical Society concludes otherwise. The Society usually responds within 60 days, so stay tuned!

American Values and Health Reform (3): Medical Progress

2009-08-23T20:00:00.027-04:00

This is the third in a series of posts based on “Connecting American Values with Health Reform,” a publication of eleven short essays from The Hastings Center. The aim of the project was to consider what we want health reform to accomplish and to suggest what values our institutions and practices should be built upon, based on the belief that more clarity about underlying values would allow legislators and the public to handle reform more effectively. (See here and here for the two previous posts)

I hope legislators and media folks read Dan Callhan's essay on "Medical Progress: Unintended Consequences." The content will be familiar to those who have followed Callahan's work, but the short piece is provocative, clear, and easy to follow. It provides an ideal basis for a book club type discussion.

Callahan takes off from the observation that "a powerful faith in science as a basic human value, matched by an equally strong belief in medical progress, has been a central feature of American culture from the start." He acknowledges that we are "healthier and more prosperous because of it," but notes that the intensity of our faith in medical progress has put it off limits for ethical inquiry.

With that background Callahan lays out a series of concerns about the policy implications of our unquestioned faith in the value of medical progress:

New technologies or intensified use of older ones account for 50% of our annual health care cost increases. "Our technological benefit is turning into our economic bane." Callahan argues that we should do more assessment of cost-benefit ratios and make choices about what we want to pay for.
Much of the improvement we have achieved in health and longevity comes from improvements in socioeconomic factors - perhaps 60%. Callahan argues that "one could make a good case that improvements in education and job creation could be a better use of limited funds than better medical care."
Given his view that "throwing technology at illness in the name of progress is an increasingly expensive and economically destructive way to go," Callahan urges us "to aim for a better balance between cure-oriented and care-oriented medicine."
With regard to prevention, Callahan takes a very tough stand: "the only way to assure a good outcome for prevention programs is to make clear to the public that high cost technologies will be severely limited when the final illness comes. The carrot is that prevention will give us a longer life with a higher quality. The stick will be the message that you should take care of yourself and not expect medicine to save you when your time runs out."
As an extension of his comments about prevention, Callahan engages directly with longevity and mortality: "Americans already live, on average, a long life of seventy-seven years. There is no need to go out of our way to chase life extension, or the denial of death, as the sine qua non of medical progress. We need progress in removing the health disparities that keep millions from reaching seventy-seven..." Coming from a younger person this perspective would elicit a torrent of ageism accusations. Coming, however, from someone who, if online information is to be believed, will be 80 next July, Callahan's view may receive the thoughtful and respectful attention it deserves.

Callahan's tone is moderate, but his conclusions are radical:

Serious progress would mean turning back the clock: learning to take care of ourselves, to tolerate some degree of discomfort, to accept the reality of aging and death, and to see our personal doctor as someone as likely to talk with us as to have us scanned. That cluster of backward-looking ideas is what I think of as common sense, affordable progress.

I think most people who have given serious thought to the health system, including conservatives and people of faith, will agree with much of what Callahan says. But in the frenzy of anti-government sentiment that Republicans are fomenting, Callahan's views may elicit an "Aha - they really are planning for euthanasia" reaction from the Rush Limbaugh crowd. The level of political hysteria and public paranoia is so high that even a great communicator like the President would have a lot of difficulty working with Callahan's wise perspective.

American Values and Health Reform (2): Liberty

2009-08-16T20:00:00.026-04:00

As I noted in a post last week, The Hastings Center has published eleven short essays as a small booklet – “Connecting American Values with Health Reform.” The aim of the project was to consider what we want health reform to accomplish and what values our institutions and practices should be built upon, based on the belief that more clarity about underlying values would allow legislators and the public to handle reform more effectively. This post is the second of three I plan to do based on The Hastings Center project.

Bruce Jennings, senior consultant at The Hastings Center, wrote about "liberty." In the context of the orchestrated hooliganism that is disrupting town meetings and the stunningly confused public fear that government involvement means euthanasia, Jennings's comments are remarkably prescient:

Values so ubiquitous [like liberty] are often taken for granted and not sufficiently scrutinized. They therefore have great political power yet are vulnerable to cynical misuse and manipulation...The health reform conversation has to be reframed at the grass roots level so that a new way of seeing what liberty is and what it requires will grow out of that conversation. (emphasis added)

The reframing of liberty that Jennings wants to encourage is to see liberty as freedom to, not simply freedom from:

Health care is not simply about preserving you from the 'outside' interference of others or of disease; it is also about obtaining the active assistance of others so as to enhance the types of activities you can pursue and the kinds of relationships you can have. Thus, health care is as much about positive liberty as it is about negative liberty.

The fundamental American skepticism about claims made by government and other authorities has largely been a force for the good. But as Jennings suggested, our attachment to liberty from external control is vulnerable to "cynical misuse and manipulation." That's what we're seeing now, as in this statement by Newt Gingrich about the allegation by Sarah Palin and others that the House health reform bill promotes euthanasia:

I think people are very concerned, when you start talking about cost controls, that...you're asking us to trust the government. Now, I'm not talking about the Obama administration. I'm talking about the government...We know people who have said routinely, well, you're going to have to make decisions. You're going to have to decide. Communal standards historically is a very dangerous concept...You're asking us to trust turning power over to the government, when there clearly are people in America who believe in -- in establishing euthanasia, including selective standards.

The President has tried to mobilize a sense of crisis about health reform, but thus far the true danger that runaway health costs will euthanize American prosperity does not measure up to the false claim that health reform threatens the lives of our citizens. A subset of the population that appears to hold a monolithic commitment to negative liberty - freedom from -is prepared to believe the Republican lie that an administration led by a "foreigner" is covertly preparing to kill its citizens.

Words like "insane" and "paranoid" are being used too casually. While there probably are a few clinically paranoid people among the hooligan protesters, my guess is that most are folks who would (a) get a "D" in a college ethics class because (b) they are unable or unwilling to see complexity among values but who (c) unlike lazy students are (d) prepared to be mobilized into a fascist gang disrupting public meetings.

Jennings's essential argument is powerful:

One tenet of [health reform] should be that equity in access to health care, reduction in group disparities in health status, and greater attention to the social determinants of the health of populations and individuals are all policy goals through which liberty will be enhanced, not diminished...we must see that health reform involves equitable access to the social preconditions of health, as well as to health care...that when anyone lacks such access the liberty of all is compromised.

His vision, however, won't silence the hooligan disrupters, especially as their fears are stoked by cynical politicians of the Gingrich/Palin ilk. But his analysis, and others, may help legislators and members of the public understand the otherwise perplexing frenzy we are currently seeing and turn against it.

Mandating Health Benefits in Massachusetts

2009-08-11T20:00:00.000-04:00

The Boston Globe recently reported that 70 bills requiring insurers to cover specific health services are pending in the Massachusetts legislature. Many of the proposed services are clearly desirable - such as hearing aids for children and treatments for cleft palate.

At the same time that 70 proposals to require new services are pending, the Massachusetts health care reform program is staggering under its burden of cost, and is considering cutbacks on coverage and services. What's going on?

The answer is - business as usual!

We currently make choice the top value for our health system - individual patient choice of physicians and hospitals, individual physician choice of treatments, and individual legislator choice of what to lobby for. Fear of losing choices is the biggest roadblock for national health care reform.

Virtually all of my clinical practice life has been in systems that (a) had overall budgets which (b) were allocated by a combination of expert leadership and patient involvement, with (c) processes that allowed appeal - by physicians or patients - when limits were encountered. But in the last 20 years we've had a big pendulum swing against this kind of managed approach.

I hope we in Massachusetts can come to our senses about the downsides of our choice mania. Runaway cost is the most obvious negative. But governing a health system by the sum of a billion individual choices is like trying to build a house without an plan for the foundation and how the parts will fit together. We haven't yet come to a public understanding of how much quality of care suffers from our lack of coordination.

Legislators who are lobbying for new benefits are focused on a particular choice, but without a sense of how that choice, which might be good in itself, impacts on the system it would play out in. What we're seeing in Massachusetts provides an argument for expert health boards that would be insulated from the kind of immediate public pressure that legislatures are subject to.

My work in ethics involves reflecting about what appears to be the best course of action and the right way to do things. What we're seeing now in the health reform process is the transition from ethics to politics. Our system of (a) relatively unfettered choice combined with (b) third party financing of those choices results in (c) superb market opportunities for the providers of services and, as the public is beginning to recognize (d) runaway costs which (e) undermine wages and national competitiveness. Enormous lobbying funds are fanning fear of "loss of choice to government bureaucrats."

If I were the czar of the health system I would decree dissemination of "accountable health organizations" modelled on Kaiser Permanente, Mayo Clinic, Geisinger, Harvard Vanguard, and other excellent managed clinical programs, in which patients and clinicians collaborate to make collective choices within budgets.

But organizations of this kind limit individual choice. The only alternative to collective self governance is individual risk for the cost of the choices we make. In Massachusetts our legislature is playing both sides of the coin at once - holding health care reform to a budget, but fracturing that budget by proposing 70 new choices. But unlike the federal government, the states can't run deficits, and can't as readily avoid the implcations of their choices. We need to learn to say "no" to ourselves. That's not likely to happen on the national level anytime soon. If we can't learn how to accept and manage limits at the state level we might as well toss in the health care towel.

American Values and Health Reform (1): Responsibility

2009-08-09T20:39:00.003-04:00

This spring the Hastings Center published eleven short essays as a small booklet – “Connecting American Values with Health Reform.” The aim of the project was to go beyond the dizzying area of sound bites and legislation in progress to consider what we want health reform to accomplish and what values our institutions and practices should be built upon. In my view the publication (which I contributed to) can be useful to the health reform process. This post is the first of three I’ll do based on the Hastings Center project.

My assignment was to discuss how the value of “responsibility” relates to the health reform debate. As I sat down to write the piece my mind drifted to a movie I hadn’t seen for at least twenty years – “Shane.” I got a copy from the local library and brought it to my office, hoping colleagues and students wouldn’t discover me watching a cowboy film.

My association to “Shane” was on target. In the film little Joey Starrett is torn between two icons of responsibility – his father, Joe, the homesteader, and Shane, the mysterious cowboy gunslinger.

Joe and Shane embody the two poles of responsibility in U.S. moral discourse. Joe exemplifies responsibility as social solidarity – building a caring community that takes responsibility for the welfare of its members. For homesteaders like Joe, the emblem of responsibility is barn-raising, in which the community bands together to help individuals meet a basic need. Shane exemplifies responsibility as individual action. For cowboys like Shane, the emblem of responsibility is the six-gun and the knowledge of when and how to use it.

Our love affair with the myth of the heroic cowboy enhances the attractiveness of market-based health reform proposals. In place of the cowboy these proposals envision a heroically empowered “consumer,” motivated by “skin in the game” and armed with knowledge, who strides into the marketplace to make choices of high-quality, low-cost health care, in accord with their own values. The empowered consumer stands tall and takes orders from no one. This constellation of values is being used to whip up the frenzy of disruptions we’re currently seeing in town hall meetings around the country. The would-be Shanes shouting at their representatives and even threatening death represent the value of individual responsibility run amok.

Proposals that emphasize universal coverage – like the single payer plan and variants of the Massachusetts program – are enhanced by the myth of an Edenic, barn-raising frontier. The single payer plan envisions a society that pools its resources to minister to the health needs of each member of the community. The Massachusetts plan plays down the communitarian ethos of the single payer approach by (1) requiring each individual to buy insurance rather than requiring contribution via taxes and (2) gives the individual a range of insurance choices. (see here, here and here for discussions of the Massachusetts program.)

One reason the Massachusetts plan has attracted so much attention nationally is the way it addresses the deeply rooted American standoff between the proponents of individual responsibility (Shane) and societal responsibility (Joe Starett). The architects of the plan like to point out that it requires everyone to take responsibility. Individuals are required to purchase health insurance, but are free to choose among a large number of private ("nongovernmental") plans. Employers are required to contribute. The state is required to pay for those too poor to buy their own insurance. And if the state's recent recommendation goes through, providers will be required to form "accountable organizations" and work within budgets.

In his inauguration speech, President Obama invoked responsibility as a major theme - "What is required of us now is a new era of responsibility - a recognition, on the part of every American, that we have duties to ourselves, our nation and the world." It sounds as if the President wants to side with both Shane and Joe Starrett. Whatever emerges from the national health reform process will almost certainly have to find ways of integrating the virtues of Shane and Joe!

Attacking Insurers - Good Politics/Bad Ethics

2009-08-06T14:02:00.014-04:00

As you read this post, keep in mind that I direct the ethics program at a nonprofit health insurance company - Harvard Pilgrim Health Care.

The administration is feeling the heat from conservative fear mongering about health reform. The well orchestrated disruptions of Congressional town hall meetings are getting a lot of publicity. To get out of a no win defensive posture, the administration appears to have opted for an anti-insurer strategy.

This may turn out to be a good political move, since public trust of health insurers is low. And of course there's lots to criticize in our health insurance system. In the battle of sound bites, (1) turning public fears away from "ObmamaCare" onto the insurance industry and (2) pinning a "pro-insurance" label onto conservative critics, may be effective politics.

Unfortunately, the tactic also continues the process of disinformation, which has resulted in an extraordinarily low level of public understanding of the health system. Modern health systems need active management. This is true for the Canadian single payer system, the British National Health Service, and our own hodge podge of public and private payers. The driving forces for our out of control health expenditures are the way we provide care as clinicians and the expectations/demands we have as patients.

Health insurers are in the middle of our profligate provider system and our clueless consumer system. In the 1980s and 1990s U.S. public policy asked insurers to alter clinical practice and educate the insured population. There was tremendous pushback against insurer led managed care and insurers have largely backed off from that effort.

Even if a public program is part of what emerges from the reform process, it will have to decide what will and will not be covered, how to apply comparative effectiveness findings, and when marginally beneficial care is too expensive to include. And if accountable medical organizations are asked to take over insurance functions by being given a budgets to care for populations, they will have to carry out these same activities.

As I said in a recent post, my candidate for the demon the administration needs is conservative rhetoric itself. If the conservative attackers mean what they say, the logical extension of their sound bites is that Medicare should be abolished, since it is a government run, single payer program.

The administration isn't proposing a single payer insurance plan. So whatever comes out of the health reform process we will still have an insurance system. Demonizing the programs we'll be turning to for thoughtful guidance to providers and the public may make short term political sense, but it isn't a coherent long term strategy!