Archive for Ethics
by Fred Fortin
March 5, 2008 at 10:46 pm · Filed under Insurance, Public Purchasers, Health Plan/Payer CEOs, Policy Makers, Regulators, Universal Coverage, Business of Health, Value-based health care, Ethics
I’m attending the AHIP health policy conference in Washington, DC this week and getting an earful about the elections and healthcare reform. Some impressions:
First up on the podium was Chris Matthews, TV commentator of Hardball fame. Matthews is a good speaker and captures the audience right away. He believes anyone of the three presidential candidates could take the election. Yes, there is still a path for Hillary to get the nomination but a lot depends on what happens today at the polls in Texas, Ohio, Rhode Island and Vermont.
To Matthews, America is in a “rut”. The people want change, they want deliverance. And doing nothing is definitely “out”. Obama is different, not your typical politician and he believes that this election is really going to be “transformative”, the likes of which we have not seen for quite a while. While he did not address health care reform in a specific way, Matthews argues that real political change only comes from brilliant, dramatic, unpredictable and grand moves. So I don’t think health care incrementalism is in Matthews’ play book.
Donna Brazile, TV political commentator and Chair of the Democratic National Committee’s Voting Rights Institute, and super-delegate, also believes that voters are in a foul mood. There “will be blood in this election”, she says. The next president will inherit a divided country and healthcare will be right in the middle of it. In addition, the deterioration of the economy will make health care reform doubly difficult. Even so, Democrats will want to get something in healthcare reform on the table quickly after the election.
Michael Murphy, Republican Political Consultant, and TV Commentator, on this point, says a McCain presidency may, contrary to popular thinking, do more for healthcare reform since if it is proposed by Democrats, the Republicans will block it. Like Nixon going to China, you need a conservative to front this kind of liberal change.
Dan Crippen, former Director of the Congressional Budget Office, observes that many people think rising health care premiums are capricious acts; they go up by themselves and are unrelated to cost structure. He asks “How do we change the 30 year old question in healthcare from ‘who should pay’ to ‘what are we buying’.”
Ezekiel Emanuel, Chair of the Department of Clinical Bioethics, Warren G. Magnuson Clinical Center, National Institutes of Health, asks the question of how do we make sure that the process of healthcare reform is legitimate if we need to make sacrifices? What voices need to be heard? He also agrees with many of the other speakers that we need to better assess what we’re spending our money on in healthcare. We need a better strategy. In responding to those who say that cost should not be a consideration in delivering healthcare, he advocates, that cost is an essential ethical consideration in healthcare because cost has an impact on our ability to pay for other critical services and needs. And that fact alone makes it an ethical dimension worth weighing.
In a similar vein, Paul B. Ginsburg, President, Center for Studying Health System Change, provokes the audience on questions about the importance of equity in healthcare, and the public tolerance for administrative control of the distribution of health care services. Containing health care costs will be painful, he reminds us. There is no painless solution. Ginsburg warns that health care financing systems can fail, but that they fail slowly. This health care crisis has been with us for over a decade. However, the affordability problem is now invading the middle class, crowding out other important needs.
The final speaker of the day one was the notable Theodore R. Marmor, Professor Emeritus of Public Policy and Management, and Political Science, School of Management, Yale University. Marmor observes that the lack of consensus should not be surprising since with healthcare we have five Americas: The British model embodied in the Veterans Administration system; the German social insurance program model in Medicare; the 19th century poor laws model in Medicaid; the private health insurance system; and pure charity medicine.
His own criteria for judging health reform proposals are fairly simple: Does is include everyone as payers and recipients for care? Does it cover what ordinary people think is medical care? Does it contain fiscal restraints to prevent the raiding of either the public or personal funds? It is accountable for results? And is the protection portable?
Marmor would like to see a real national conversation about healthcare since right now he feels what Washington is saying up to this point is pure gibberish. How, he asks, can we avoid another mistake like that which was made by the Clintons without a real national dialogue and consensus? We cannot wait another decade for an answer.
US Senator Ron Wyden took the stage first thing the morning of day two of the conference. He’s a frequent speaker at this conference usually focusing on his ‘Healthy Americans Act’ as a step towards real healthcare reform. He says the first 100 days for the new president will be critical for healthcare. Democrats — if they win — will need to put something on the table quickly. Congress is getting ready to act and Wyden does not want a repeat of the now infamous Clinton failure of 1994. This time there is an opportunity to do healthcare reform right. He wants a system where everyone has a basic private portable health insurance plan.
Recent history shows states cannot fix healthcare by themselves because the big drivers are federal, such as Medicaid and Medicare. And if we don’t fix the private market, the country will go single payer. Wyden wants a new private health insurance market that breaks the dependence on employer-sponsored coverage. His plan would still offer a choice of an employer plan. But his ‘Healthy Americans Act’ now before Congress would provide for an alternative to both single payer, and an over-dependence on employer-sponsored healthcare.
But how will health insurers respond to these proposed new changes? Cajoling his audience of health plan representatives, he argues that his approach would be one way to stop playing the healthcare blame game, replete with its usual designated healthcare villain of the day being held responsible for all that is wrong in healthcare. Health plans have all too often shared this distinction.
Andy Stern, President of Service Employees International Union, started his talk with an all-too-familiar tragic story of a healthcare disaster that end bankrupting an American family. He then switched gears to share the changes his own union has had to undergo to confront the new global economy. Healthcare, he believes, has also not reacted well to this new global economy. What we have now is a healthcare sector; what we need to build is a healthcare system. “Change is inevitable but progress is optional,” he lamented.
If there is one truth about healthcare reform, Stern believes, it is that the longer you wait, the worse it gets. And the US employer-based healthcare system is not sustainable for the economy of the future. It is dead and it’s time for hard choices. We need to move on to a more competitive approach. But he doesn’t think the country is ready, willing or able to go for a single payer system. We have to build a broader coalition on healthcare and negotiate a new blend in order to move on.
Stern warned that there is a big target painted on health insurers and the bullets are getting closer. Health insurers will have to walk in a new direction. People are ready for change. But where is the solution? “Be the agents of change”, he charged, “not the assassins of change”.
Gail Wilensky, Senior Fellow, Project Hope and a former Medicare chief, observed that even when we have expanded access to healthcare — such as the recent addition of drug benefits to Medicare, we still have problems with cost and quality. Medicare’s cost is unsustainable and its population is becoming more politically forceful. The program’s provider financial incentives are perverse and its spending constraints are ineffective when it comes to value and quality. It will be an immense challenge to moderate the Medicare’s cost growth.
Bruce Vladeck, Senior Health Policy Advisor, Ernst & Young, and also a former Medicare chief noted that the healthcare reform proposals put forth by the presidential candidates rarely mention Medicare or Medicaid. Problems with Medicare are the problems with the healthcare system generally speaking. He argues that Medicare costs — even with new efficiencies — cannot be sustained without new money. Politicians need to be more open and explicit about this hard fact. And he adds, that we must stop confounding the problems having to do with improving the quality of healthcare, with the problems of moderating the cost of care. It is a fantasy, he says, that improved quality will save serious money in healthcare.
by Fred Fortin
January 1, 2008 at 8:21 pm · Filed under Policy Makers, Regulators, Transparency/Public Disclosure, International Health, Ethics
Health care privacy is part of the bigger picture of a society’s respect for human rights and individual persons. Balancing privacy, security as well as transparency and openness is a cultural and political challenge for any nation. Surveillance is the modern compromise for living in a dangerous world. But how much, who, where and when are choices and decision-points by authorities that affect us all. And consequently, the way we manage the tensions between privacy and legitimate surveillance generally, will impact the way we think about the privacy of medical information.
Privacy International has come out with their international privacy rankings and determinations of the world’ leading surveillance societies. The 2007 rankings indicate “an overall worsening of privacy protection across the world, reflecting an increase in surveillance and a declining performance of privacy safeguards.” One category the report is the surveillance of “medical and financial movement” in which countries like the U.S. and the U.K. (and others) are deemed countries with the worst records providing “weak protections of financial and medical privacy.”
A few weeks ago I attended the World Healthcare Innovation and Technology Conference (WHIT 3.0) where a different perspective was being advocated, namely that health care privacy laws were too strict and impeding progress in the implementation of information technologies and new media that’s needed to improve quality, access and constrain cost. Figures such as Adam Bosworth were unequivocal: Government is “trading off the deaths of hundreds of thousands of people to prevent the exposure of very few” with these laws against “possible and rare risks to privacy.” In that conference, no one contested his position. I could imagine a very different conference, say of privacy or health care activists, who would find Bosworth’s position an extreme one indeed.
I once visited a thriving hospital in Beijing where patients were lined up outside just to get services. Once inside the hospital physician’s office, they sat across the desk from the doctor along with the next few patients in the waiting line, who watched and even participated in an open door, open seating and open discussion of the patient’s problems. Certainly a surprise to westerners, but it is a normal practice at many of China’s public hospitals.
The point is, the struggle to find balance in this area is going to run up against a strong phalanx of opinion and cultural differences no matter where one sits. And it is by no means clear or self-evident, despite all manner of strong assertions to the contrary, where that balance point resides.
by Fred Fortin
December 23, 2007 at 8:56 pm · Filed under Policy Makers, Consumer Engagement, Transparency/Public Disclosure, Hospital Administration, International Health, Ethics
From a China Digital Times post translated from the China News Service:
China’s Ministry of Health and Chinese Medicine Administration have jointly issued a regulation that aims to set up a evaluation system to tally the medical ethics of doctors in various hospitals and other health care providers in the country. There are three components in the evaluation regime: self-assessment, departmental assessment and institutional assessment. A filing system will also be set up to store the records, in an effort to link the ethics scores with the doctor’s compensations and promotions. But there is one thing missing, as some commentaries point out: opinions from the patients and their families.
If I were a physician in China, this new initiative would make me extremely uncomfortable for a couple reasons. First, physicians working in a health care system characterized typically by a heavy top-down management style, and absent a strong peer advocacy group, are at a distinct disadvantage when it comes to disagreements about professional behavior. And second, political intolerance of dissent and social action is often framed as action against ethical misconduct. I do recognize that medical leaders and institutions do have responsibilities when it comes to the ethical behavior of those whom they oversee. But it is the cultural and political context that surrounds this new ranking approach that makes me uncomfortable.
As far as the absence of the public ranking of physicians in this new scheme, that, my friends, is simply a matter of time.
by Fred Fortin
October 1, 2007 at 2:07 am · Filed under Policy Makers, Health IT, Transparency/Public Disclosure, Business of Health, Hospital Administration, Electronic Medical Records, Ethics
Last week AT&T Inc. announced it is now selling “a complete portfolio of radio frequency identification (RFID) tracking offers for health care providers. The RFID solution will enhance visibility into the operations of hospitals and other health care facilities.”
“The company is offering the devices, infrastructure and systems needed for full-scale tracking applications — everything from tags and software to networks and data storage”. . .providing “a Wi-Fi-enabled location-based service to track equipment, devices and patients. . .”
In an interview with Tim Cunningham, Director of RFID development at AT&T, specific solutions for their customers would differ since “it all depends what is being tracked, and whether that includes patients or not,” he said. Intel’s Director of Research, Andrew Chien, speaking at the MIT’s Emerging Technologies Conference this week, talked about “terascale computing”. Chien is looking at how to use these future machines.
“One of the things we’re very focused on is this idea of inference and understanding the world. The big idea is all about this question of whether inference and sensors are really the missing piece to make ubiquitous computing come to fruition.”
Ubiquitous Computing (pervasive computing, physical computing, tangible media) or “Everyware”, as critical technology futurist Adam Greenfield describes it, is here. Today. And while the promoters of Health 2.0 feel there is gold in “them thar hills”, but are still looking around for a business model, ‘everyware’ developers are already mining the health care industry’s deep pockets who, in turn, are being driven by a number of more immediate concerns such as patient safety and cost.
So what is ‘everyware’ when it comes to health care? Well, let’s take something we are starting to get a handle on, Electronic Medical Records (EMR). We’ve already mentioned the evolution we see happening towards an intelligent EMR (see earlier post).We now think of the EMR as a snapshot of someone’s medical history and current status. What if the EMR was more of a movie instead: a continuous, real time flow of information from the source, the patient’s body, to an intelligent networked system geared to flag critical indicators and thresholds and whatever else, for that matter, that needs monitoring?
Medical vigilance technologies, for example, hook up the body’s formidable medical information production capabilities to wireless, networked and intelligent systems — whether you’re in the hospital, at home or on the go. Tracking technologies can also tell where you are, or have been, in each of those settings as well.
For hospitals, tracking applications, like that of AT&T, can both save lives and money. Beyond knowing instantly where emergency personnel and equipment are, for example, surgical teams can track things like sponges or instruments to ensure that nothing is left in places where they not ought to be.
For our growing population of elderly, wearable biometric devices, voice and gesture recognition interfaces, memory augmentation systems — all these may be essential (and cost-effective) tools in managing future complex health conditions while maintaining as much patient autonomy as possible.
Along with intelligent bathtubs, toilets, beds, refrigerators, rooms, and entire homes — literally anything that can be “colonized” by sensors, or “ambients”, which wirelessly port information over to an intelligent network — ‘everyware’ is slowly insinuating itself into what we can call “smart” health care.
The convergence of these technologies — RFID, ultra-wideband, and IPv6 (new internet protocol) — pointed at the needs of the health care industry, promises great advances in the convenience, cost and quality of care. But this promise also comes with great risks. Greenfield has pointed to many of these risks which can be easily transfered to what’s happening in health care. They include among other things:
- the exponential expansion of “surveillance” (including medical surveillance)
- the consequences of software/hardware failure
- the psychological impact of former latent, unmeasured information being made ‘public’
- the lack of awareness, or understanding, of being subject to these unannounced or invisible technologies
- the unpredictability of how these technologies will act — think HAL 2001 here — when all are interconnected
These technologies will come to us piece by piece, with the impact being a slow emerging boil, rather than a full and obvious onslaught of a total inter-connected system being thrust upon us. But the speed, storage, addressing, display, wireless, and technical standards for these systems already exists. That means ‘everyware’ is already a reality for some.
Yet thinking about these technologies holistically will be difficult. And according to Greenfield, it’s not sufficient simply to say “First, do no harm”. He advises that we take the time now to deliberate on the human consequences of all this and start to think through the social rules of the game. In that light he poses a few principles to be considered.
- Everyware must default to harmlessness
- Everyware must be self-disclosing
- Everyware must be conservative of face
- Everyware must be conservative of time
- Everyware must be deniable (opting out)
The recognition of these principles, along with educating ourselves on these new technologies is the starting position. The race will be long. The outcome will determine, as Greenfield observes, whether we’ll “develop an everyware that suits us, as opposed to the other way around.”
by Nick Jacobs
August 6, 2007 at 8:43 am · Filed under International Health, Ethics
This could have been a comment to Fred Fortin’s last blog post, but, since it’s so long, I decided to blog it.
This comment came from a wonderful, Chinese physician friend: “I have practiced in a half dozen different hospitals in China and can tell you definitively that the Red Package is absolutely true in China.” His very clear description of the life of a physician in China is that it is a very high risk profession. The majority of hospitals have no malpractice insurance. If the patient has a problem with the physician, there have been numerous cases where physicians are beaten, kidnapped and sometimes even killed. Most of the time, he explained that hospitals choose to take no action, and the police usually assume the same position.
Physicians in China earn just a little more than the average salary. The income does not match their education, requirements and talent, and according to my physician friend, respect for physicians is not very high.
Solutions? Well, because it is a third world, developing country, there are numerous challenges. A health insurance system for the people of China, support from the media, and, generally, protection for them provided by hospitals and law enforcement organizations would go a long way.
So, when the Red Package is discussed, it brings back memories of a conversation that I had with an accountant once said to me, “If you want to make an honest man dishonest, pay him too little and put him in a position where he is exposed to cash on a daily basis.” Red Package is a way of life in most developing countries.
While speaking at a World Health Organization conference in Africa, I noted that what we would give as a tip after service in the United States is given as encouragement to receive that service in Aftrica. Bribes by any other name may be considered TIPS, and, if it takes a TIP to save your mother-in-law, I’m sure you won’t think twice to do that!
Not too many years ago, in the United States, we had physicians taking vacation cruises paid for by pharmaceutical companies. These gifts were intended to encourage the use of their product. Was this payola or advertising? Bribes or Tips? Red Packages are actual income enhancements for service to be rendered in a society that does not recognize the true value of the medical profession. Ethical or unethical? Yes, it is.
