Specialty Hospitalists: what is best for the patient?

In a “Viewpoint” article in JAMA, April 25, 2012, John Nelson, Laurence Wellikson, and Robert Wachter discuss “Specialty hospitalists: analyzing an emerging phenomenon”.[1] They describe the progression of the hospitalist model – doctors who just care for patients in the hospital, rather than seeing them also in the office from general medical care to specialty care. They note that in recent years hospitals have hired physicians in a variety of specialties, including neurology, orthopedics, obstetrics/gynecology and others, to take care of patients, particularly at night or in emergency situations, so that other doctors to not have to come in to do so.

An argument in favor of this arrangement is that these physicians are present for urgent events (e.g., the neurology stroke specialist who is there right away to care for a person who comes to the emergency room with an acute stroke) and that they may have specialized knowledge that a more “general specialist” doesn’t. In a useful “box”, the authors summarize the criteria that might be applied to deciding if a specialty hospitalist is a good idea. These include the number of inpatients who might require their services, the urgency of the need for those services (is it a matter of minutes that may save a life?), whether the other specialists are so tied up in the operating room or office that they could not respond promptly, and if there so much “sub-specialization” that many doctors in that specialty would not be capable of addressing the needs that arise in the hospital.

I have previously written about “generalist” hospitalists, (Hospitalists, Dec 4, 2008) and expressed my concerns about this movement from the point of view of the patient. The advantage for hospitals and health systems that employ physicians is obvious – they can have some doctors that work in the ambulatory setting, and some that work in the hospital, and each can be most “productive” in that setting and not have to leave to go to the other, decreasing efficiency.  In theory, at least, the hospitalists are very good at managing the problems of people in the hospital, so quality may improve. And, to be sure, doctors often like it also – it makes their lives easier, or more controllable – they are only responsible for outpatient medicine, and don’t have to travel to the hospital to see their patients, or if they are hospitalists, don’t have to go to the office. While not one of those listed by Nelson et al. as a benefit of having hospitalists, this advantage for doctors is real.They can work set shifts, like many of the most popular specialties such as emergency medicine and anesthesiology and intensive care – and then be off.  

This, of course, leaves the patients. While hospitalized patients certainly want to be cared for by a physician or physicians who are skilled in addressing the problems that they have, it is also often a very scary time, and a good time to have the involvement of someone who knows you, who knew what you were like before you got so ill that you had to be hospitalized. Your primary care doctor, if you are lucky enough to have one. The technical skills of the hospitalist may be fine, but they do not know what you were like before, and will not be involved in your care after, your hospitalization. Plus the same attractions that lead to hospitalists in the first place now have led to a sub-species of hospitalist called “nocturnists”, and mean that you will not necessarily even have the same hospitalist making decisions about your care, even during the day, for the duration of your stay.

In addition, the skill sets of hospitalists vary. Dr. Wachter is one of the founders of the hospitalist movement and heads a long-standing hospitalist service at the University of California San Francisco (UCSF). His 1996 article, The emerging role of "hospitalists" in the American health care system,[2] written with Lee Goldman, is one of the seminal articles in the field. But the results that are achieved by teams of experienced career hospitalist groups such as his, in terms of both quality and cost, may well not be replicated by hospitalists who are just out of their residency training and spending a year working in this role prior to subspecialty fellowships in cardiology or gastroenterology. Nelson, et al., cite a study by Seiler et al. showing that patient satisfaction with hospitalist care is equal to that provided by primary care doctors,[3] but this doesn’t separate out the satisfaction of patients who have primary care doctors who are now not seeing them from those who do not.

That said, I do not have a problem with most specialty hospitalists. Specialists are not generalists, unlike primary care providers, we don’t think that every person should have one of each. The person who comes in to the Emergency Department with an acute stroke and benefits from having a stroke neurologist right there is not likely to have a general neurologist. The same can be said for orthopedics and otorhinolaryngology (ENT) and neurosurgery, among others, or for people who need emergency intervention for an acute heart attack. The case of “laborists” is somewhat different; the women having a baby (arguably the most common reason for people being glad to be in the hospital) who has been followed by an obstetrician or family doctor might well want and expect to be delivered by that doctor (a point acknowledged by Nelson). While many primary care doctors would like to provide this continuity to their patients, they may be unable to in the system they work in. And if it is not their “fault”, it is a pretty guilt-free way to enjoy the benefit.

If the hospitals and health systems make more money and operate more “efficiently” with separate hospitalist and “ambulists” (yes, this term is being used by some!), and if the doctors are happy with the arrangement because it makes their lives more controllable, the boat on generalist hospitalists and “laborists” has probably already sailed, at least in communities large enough for this to be feasible.

Anyone who has flown in and out of the Kansas City International Airport (KCI) knows what a pleasure it is compared to other airports in even relatively big cities. Built on only one level in 3 almost-circular terminals, there are only a few gates for each security checkpoint so the lines are relatively short (compared to, say, the nightmare at Denver International). Once you come in you get off your plane, walk right out into the hall where your baggage carousel is nearby, and then you walk right out to the street (even sooner if you have no checked bag), where you can be picked up or go to your car in the garage right there. It is a true pleasure for the traveler.

But it is not so desirable for the airport and airlines. I have heard that this setup requires more security people than any airport except Heathrow. There are rumblings about redesigning, maybe rebuilding, the airport to make it more “efficient”. Sure, it will be worse for the traveler, but that’s the way it goes.

So maybe you want to ask your doctor if s/he will see you in the hospital. And let the hospital and health system know that you think it is important, too. It is unreasonable to ask your primary care doctor to work a full day in the office and also care for patients in the hospital; that time needs to be built into their schedules by their employers. It could work; you never know. What’s good for people sometimes actually happens.

And if you haven’t flown in and out of KCI, you should do it soon before it becomes Denver. 

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[1] Nelson JR, Wellikson L, Wachter RM. Specialty hospitalists: analyzing an emerging phenomenon. JAMA. 2012 Apr 25;307(16):1699-700.

[2] Wachter RM, Goldman L., The emerging role of "hospitalists" in the American health care system, N Engl J Med. 1996 Aug 15;335(7):514-7.

[3] Seiler A, Visintainer P, Brzostek R, et al. Patient satisfaction with hospital care provided by hospitalists and primary care physicians. J Hosp Med. 2012;7(2):131–136, pmid:22042532.

Value-based purchasing: whose values?

In October, hospitals around the country will begin having their payments from Medicare affected by the Value-Based Purchasing Program (VBP). The plan is that a portion of the money that hospitals would have received (beginning at 1% and rising gradually to 2% by 2017) will be withheld and then re-distributed based on a variety of performance measures, with low-performing hospitals losing money and high-performing hospitals getting bonuses. The measures that will be used in federal FY 2013 (which starts in October 2012) are “clinical process” and “patient satisfaction” indicators; they will be expanded the next year to include also patient mortality, hospital-acquired conditions, and patient safety measures. These are succinctly portrayed in a helpful “box” within the short Perspective “Making the best of hospital pay for performance” by Andrew Ryan and Jan Blustein in the New England Journal of Medicine, April 26, 2012.

Ryan and Blustein review the history of previous “pay for performance” efforts by Medicare, noting that a demonstration project begun in 2004 that required hospitals to report their quality data and paid money to those hospitals that did well had initial success. However, this success was not replicated in the second phase of the project beginning in 2006; while there was “…an increase of nearly 50% in the total amount of incentives paid out…these changes did not catalyze additional quality improvement…improvement relative to comparison hospitals actually declined.” Moreover, a similar “…program implemented by Medicaid in Massachusetts with incentives approximately 5 times the size…also showed that pay for performance had no effect on quality.”

They go on to observe that this is not necessarily a completely fair comparison because, for example, the economy was different in the two 3-year periods (always a problem for research in the real world; it changes!). But they remain guardedly optimistic about, or at least resigned to, VBP; their final line, scarcely a rousing call to action, is “It will be critical to ensure that VBP is as good as it can be.” They call for the Patient-Centered Outcomes Research Institute (PCORI, see Patient-centered research: answering the questions that matter to people, April 22, 2012) to study it.

The other thing that will be important is how well the quality measures actually measure quality. Of the initial two, “clinical process”, which accounts for 70% of the withhold, are the same ones that have been in place for several years (such things as getting a beta-blocker after a heart attack and getting antibiotics within a certain period of time if you are diagnosed with pneumonia). “Patient satisfaction” is also a good thing; clearly we all want hospitals to be clean and quiet and to have doctors, nurses and others communicate with us clearly and completely. Keeping people out of pain in the hospital is also the right thing to do, but sometimes (although more often in outpatient settings) it comes into conflict with efforts to monitor how often doctors prescribe narcotics. In an interesting piece in the “Science Times” section of the NY Times on May 1, 2012, E.R. Doctors Face Quandary on Painkillers by Catherine Saint Louis, an emergency room doctor notes this conflict and observes “If you’re going to criticize me for not giving out narcotics, and you never praise me for correctly identifying a drug-seeker, then I’m going to give out narcotics.” Indeed. While this stimulus-response (known as the Hawthorne effect – behavior changes depending on what is being measured) is the basic idea behind VBP (along with monetary incentives), it illustrates that sometimes incenting a desired behavior can have an unintended negative impact.

In general, hospitals, especially the more financially successful ones, are very good at modifying their behavior in response to economic incentives. While we can hope that this results in higher-quality care for patients, all too often it appears that they are just “gaming the system”, seeking to do only those things that make them money and avoiding patients who may put them at risk. The problem is that not all hospitals are starting off with equal resources, and those with the biggest challenges (in terms of unreimbursed patients) will probably do worse under such a system. While Ryan and Blustein note that “CMS has pledged to monitor whether VBP leads to ‘changes in access to [care] and the quality of care furnished to beneficiaries, especially among vulnerable populations’”, the also observe that impact on hospital bottom lines is likely to precede any significant quality changes and that the impact may be particularly great on “…safety net hospitals, which operate of very small margins.”

This is, to me, very important, because these are the hospitals that provide disproportionate care to poor, uninsured, and generally medically underserved people. Because such hospitals are often located in poor neighborhoods or rural areas, or because they depend on (almost constantly decreasing) public funding, they are not among those that already have a robust bottom line and will be able to invest in the equipment and process changes needed to be the “winners” in VBP. They are also likely to have a lower percent of Medicare patients, in part because once people, even poor people, receive Medicare they are no longer uninsured, they can and sometimes do go to hospitals perceived as “better”, and because the proportion of people who are sick enough to be in the hospital despite being younger (under 65) rises as socioeconomic status decreases (see “social determinants of health”, discussed in several previous blogs, including Michael Marmot, the British Medical Association, and the Social Determinants of Health, November 1, 2011 and Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010).

When I first heard of value-based purchasing my initial reaction was both pleased and confused. Wow, I thought, they are actually going to pay for medical care based upon values? I almost immediately realized my mistake – that their main “value” was paying less money. It is possible that the “other kind” of values do play a part; if Medicare is going to pay more for higher quality, or less for lower quality, that is something. But there is another value that is still missing, and that is the value of ensuring that access is high-quality is available to and provided for everyone. Hospitals (the “high end” ones) are already trying to figure out how they can divest themselves of Medicare patients, on whom they already make less money, and replace them with patients with better insurance. To the extent that they are successful, it will just add Medicare recipients to the growing list of “less desirable” patients.

Maybe we need to move to a program in which no people are “less desirable”. Where everyone is covered. Where hospitals that care for the most needy do not suffer as a result; where hospitals that cater to the least needy do not profit from this decision.

Then, perhaps, Medicare – for all – could really base its payments on value, and on values.

Patient-centered research: answering the questions that matter to people

“Large investments are too often made in studies that provide poor-quality evidence,^1​ are overtly biased,² are not applicable to most patients,^3​ or yield results that do not address the real concerns of individuals facing clinical decisions.^4,5”  [1] (Patient Centered Outcomes Research Center, JAMA, April 18, 2012)

Indeed. This is not only “too often”, it is in fact characteristic of most research, whether sponsored by the National Institutes of Health (NIH), foundations, or private companies. The reasons for this are that it is easier to do and it relatively well funded (thus the “large investments”).

Many years ago, researchers, particularly those providing primary care, distinguished between “disease-oriented evidence” (DOEs) and “patient-oriented evidence” (POEs, or later, adding “that matters”, POEMs). The first is about showing that a treatment improves a disease. The second is looking at what treatments improve the life of a person. There is a big difference. A simple example might be in looking a regimen for diabetes that minimizes the complications from high blood sugar by keeping the average blood sugar much lower than had previously been the goal (called “tight control”). Disease-oriented evidence might show that using frequent insulin injections to keep the blood sugar in the low-normal range reduces the long-term negative effects of diabetes. A patient-oriented approach, however, looks at the overall impact on the person, not just the disease. Does the patient find it difficult to administer more frequent injections of insulin and check their blood sugar? Do they spend a significant amount of time with blood sugar that is in fact too low (after all, reducing the average increases the probability that sometimes it will be too low), and feel fuzzy-headed and unable to live the lives they wish to? Or feel dizzy? Or that a certain percent actually pass out from low blood sugar? Maybe break their hips and end up in the hospital or even dying from its complications? Even though their diabetes is in “good” control? “The disease was controlled but the patient died from a complication of treatment” is not a desirable patient-oriented outcome!

The motivation for private companies, most often pharmaceutical companies, to fund disease-oriented research is fairly obvious. Their sole agenda is to make profit, so they are interested in supporting research that shows that their drugs are effective for treating certain conditions. They have a number of advantages in this arena:

·         Showing “effectiveness” requires, by FDA criteria, only to show that a new drug or other treatment is more effective than placebo, not than the currently available treatments;

·         Since they are paying for it, they can suppress the publication of results that do not show their drugs in a good light;

·         They have to show only that it modifies the disease, not that it is the best choice for any individual patient (thus it is Disease-oriented, rather than Patient-oriented);

·         In lieu of patient-centered research, they have huge marketing budgets (far in excess of their research budgets) to advertise their products to both providers and directly to patients once they have been approved by the FDA.

Why NIH would mostly fund this sort of research is more complicated. Part of it is that an entire industry has been built around doing disease-oriented research, largely in biological science laboratories, but also in doing clinical trials in people. Thousands of academics and the institutions at which they work are dependent upon such funding to maintain and advance their careers and institutions. The review committees that make recommendations to approve or disapprove funding are “peer” committees, made up of people who do, largely, the same kind of work. This is good because they can understand and evaluate the science involved (a really bad thing would be for a group of politically-appointed ideologues to make the decisions, and this sometimes has occurred), but they are limited by their understanding of how research is done and what its goals should be. This relates to a second challenge – patient-oriented research is more complicated, more difficult to do, and leads to less “clear” outcomes. Of course, it is more relevant to patients and their providers making decisions about their care, but it is harder to fit into a rigid research model in which all but one variable is tightly controlled. This can lead to research that is done because it is possible to do it, rather than because it answers the questions that we have (see “Defining Streetlight Research”, February 26, 2009). Most traditional NIH researchers have no objection to patient-oriented research, but in an era of limited funding availability might be quite concerned if funding it decreased the amount available for the kind of work that they do.

Trying to address this, the Affordable Care Act of 2010 established the Patient-Centered Outcomes Research Institute (PCORI) to apply the rigorous standards of Clinical Effectiveness Research (CER) to treatment of patients, not diseases. One clear need here is that people, particularly older people, often have more than one disease. The “right” treatment for a patient’s cancer needs to take into account its effect on his/her diabetes – or heart disease, hypertension, arthritis, depression, alcoholism, glaucoma, poverty, and yes, maybe, another cancer – in any or all combination. Because we care for the person, who may have any or all of these conditions, primary care doctors are likely to be more sensitive to these interactions than are physicians caring for only one of them. It is for this reason that we have advocated for a National Center for Primary Care to look at the comprehensive care of patients differently than the existing disease-oriented Centers (e.g, the National Cancer Institute, the National Center for Heart, Lung and Blood Disorders, the National Institute of Mental Health) have.

The article in the April 18, 2012 issue of JAMA from which the opening quotation is drawn, “Methodological Standards and Patient-Centeredness in Comparative Effectiveness Research”, includes the following case as an example:

“A 78-Year-Old Man with Heart Failure, Diabetes, and Renal Failure. Mr B was admitted to his local hospital for the fourth time this year. Mr B experienced symptoms of shortness of breath and weight gain that led him to contact his physician, who recommended another hospitalization. He lives with his wife in a 2-story house located 30 miles from the hospital. He has recently been unable to climb the stairs to his bedroom. Mr B requires outpatient hemodialysis 3 times per week, but missed his last dialysis treatment because he felt too tired to go. This is his second hospital admission after missing a dialysis appointment. After each admission, Mr B received standard discharge instructions on how to care for himself at home. Mr B's highest priority is his independence, including the ability to drive and to remain in his own home.”

To make appropriate decisions about Mr B’s care requires not only considering the interplay of his several chronic diseases, but the circumstance of, and his own preferences and goals for his life. This cannot be done by employing solely the findings of disease-oriented research.

PCORI is not a National Institute for Primary Care, but it may help to achieve some of the same goals. In the same issue of JAMA, Joe Selby (the director of PCORI) and colleagues list the both the statutory criteria for PCOR-funded research:[2]

1. Effect on the health of individuals and populations
2. Probability of improvability through research
3. Inclusiveness of different populations
4. Current gaps in knowledge/variation in care
5. Effect on health care system performance
6. Potential to influence decision making
7. Patient-centeredness
8. Rigorous research methods
9. Efficient use of research resources

and their proposed priorities for national research:

1. Assessment of options for prevention, diagnosis, and treatment
2. Improving health care systems
3. Dissemination and communications research
4. Addressing disparities
5. Accelerating patient-centered outcomes research and methodology

None of these are disease specific, although unquestionably much of the research that is funded by PCORI will look at people with specific diseases. These criteria, however, recognize the need for treatment plans to take into account all aspects of a person, and by extension the family and community of which they are a part. This includes addressing the disparities that exist between groups, especially poor and minority groups; that is to say, addressing issues of social determinants of health and social injustice.

Maybe we will finally get funding for studies that provide us will more useful information for caring for actual people.

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[1] Methodology Committee of the Patient Center Outcomes Research Institute, “MethodologicalStandards and Patient-Centeredness in Comparative Effectiveness Research”, JAMA, 2012;307(15):1636-1640. doi: 10.1001/jama.2012.466.

[2] Selby JV, Beal AC, Frank L, “The Patient-Centered Outcomes Research Institute (PCORI) National Priorities for Research and Initial Research Agenda”, JAMA 2012;307(15):2583-4. Doi: 10.1001/jama.2012.500

"Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing

Years ago (OK, decades ago), when Woody Allen was a standup comic, he did a short, famous bit called “Eggs Benedict”. The narrator (let’s say “Woody”) is having pain in the chestal area (a great formulation which has long been popular in my house). He is pretty sure it is heartburn, but is worried and doesn’t want to pay the $25 to see a doctor (I told you it was a long time ago). Luckily his friend, Eggs Benedict, is having the same kind of pain. He figures if he can get Eggs to go to the doctor, he can find out what it is and save money. It works, and Eggs finds out it is heartburn. Two days later, he discovers Eggs is dead. He immediately checks into the hospital, has all kinds of tests, and discovered he has – heartburn. The bill is $110 (it was a really long time ago!) He goes to see Eggs’ mother and asks if his friend suffered much. “No,” she says, “the car hit him and that was it!”

I was thinking about this story when I was asked to call into a local radio talk show to comment on “Choosing Wisely”, an initiative of the American Board of Internal Medicine (ABIM), which calls on medical specialty societies to list 5 tests or treatments frequently performed in their specialty that they recommend not be done, or not be done on most patients. In the recently released report, 9 medical specialty societies are represented, for a total of 45 recommendations, which can be found here. The 5 for my own specialty, Family Medicine, listed by the American Academy of Family Physicians’ (AAFP), were:

1.  Don’t do imaging for low back pain within the first six weeks, unless red flags are present.

2. Don’t routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for seven or more days, or symptoms worsen after initial clinical improvement.

3.  Don’t use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors.

4.  Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients without symptoms.

5. Don’t perform Pap smears on women younger than 21 or who have had a hysterectomy for non-cancer disease.

Each is backed by the evidence, and is accompanied by a summary of the reasons. For example, for #2: “Most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 % of outpatient visits for acute sinusitis. Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs.” Big money for a treatment that doesn’t work, and can cause bad side effects (allergies to the antibiotics and increased resistance of bacteria to antibiotics, for two).

The talk radio hosts had questions, especially about treatment of cancer. One of the American Society of Clinical Oncologists’ (ASCO) recommendations is “Don’t use cancer-directed therapy for solid tumor patients with the following characteristics: low performance status (3 or 4), no benefit from prior evidence-based interventions, not eligible for a clinical trial, and no strong evidence supporting the clinical value of further anticancer treatment.”  That seems like a no-brainer to me, but they wanted to know “What if a patient wants treatment for cancer anyway?” I said I thought it was the responsibility of the doctor to point out that the treatment would not help, and would not only cost money but would have a lot of toxic side effects; I said that I thought most people, if they knew they were going to die from their cancer and the treatment would not help, would not wish to spend their last days and weeks nauseated, losing their hair, and being unable to interact comfortably with their loved ones.

The radio hosts also said “We are always told patients should be self-advocates. What if advocating for ourselves we say we want antibiotics for our sinusitis?” I said that self-advocacy was really important, because no one but the patient and their family could really identify what their health goals were. But this was different from deciding what treatment you wanted; going to the doctor is not going to the grocery store with your shopping list that may include both healthful and bad-for-you foods. It is critical that you identify where you want to go and work with the doctor, or other provider, to come up with a plan that is mostly likely to get you there safely and effectively.

Coincidentally, the same week I facilitated the discussion about futile treatment at the end of life for a group of third-year medical students in their medical ethics course. They had just received a lecture from a distinguished medical oncologist, who presented the four core principles of medical ethics: Autonomy, Beneficence (do good), Non-maleficence (do no harm), and Justice. They also read several articles documenting cases in which end of life decision-making did not go smoothly or well, and the article “How Doctors Die” by Ken Murray, that I have previously discussed (How people die, and how should we?, April 7, 2012). One of the cases involved a patient with terminal cancer who had already failed treatment, and for whom further treatment would be futile (although not without adverse effects). He had agreed to hospice, and to comfort care, until a relative (a physician!) came to town and demanded additional treatment for him, and convinced him to as well.

The medical students, who had  all been through clinical experiences and most of whom had been part of teams that confronted dealing effectively with dying patients, were in agreement with the physician in the article, and with each other, that the treatment was futile and would be a bad idea. However, several felt that, if the patient demanded it, the principle of Autonomy required that it be given. Others noted that this might violate the principle of Non-maleficence. I pointed out that that there were many areas in which we do not allow the patient to pick his/her treatment of choice. For example, we do not allow people to walk into a pharmacy and buy narcotic pain relievers without a prescription, no matter how much they might want them. Certainly the effects of chemotherapy poisons were at least as great.

These are not always easy decisions, but it is one of the reasons being a doctor is hard, respected, and well-paid. If everything were a simple algorithm and one could just memorize the right answer as these medical students were expected to do so often on their multiple-choice tests, it could be done by someone with much less training. Sure, it is possible that someone getting antibiotics for viral sinusitis to get better – indeed they usually do, with our without the antibiotics. Temporal association is not cause. Thus, even when you do the right thing, based on the evidence, and do not get a test or treatment, it is still possible that you will end up worse.

As Eggs and Woody discovered.

How people die, and how should we?

On January 4, 2012, "How Doctors Die"; post on Zocalo Public Square by Ken Murray, I called attention to “How doctors die: it’s not like the rest of us, but it should be” a very articulate discussion by Dr. Murray about how the physicians he knows generally eschew “heroic” interventions at the end of life. This is because they know how futile, and often painful, such interventions can be and how disruptive they can be of the little time that they have left. Physicians know more than most other people about what is likely to work and what is not; they also know more about what is likely to just cause discomfort. I hope that Dr. Murray’s article will be widely read by both the physicians who make recommendations for patients at the end of life and the non-physician public who make decisions about what they want for themselves and their loved ones.

A version of Dr. Murray’s piece later appeared in the Wall St. Journal on February 25, 2012 with the headline “Why Doctors Die Differently”. It is discussed by Dr. Kenny Lin in his blog, Common Sense Family Doctor, “Addressing gaps in end-of-life planning”, March 15, 2012. Dr. Lin focuses on the important issue of “advance directives”, which includes Living Wills and Durable Powers of Attorney for Health Care (DPOAs), mechanisms through which people can help to ensure that their wishes for how they want to be treated – or not treated – at the end of their lives are honored, even when they themselves are not able to make specific decisions. A DPOA designates one person – one with whom, hopefully, you have had serious discussions about what you really want – to be your decision maker. This is very important; while under the law spouses have the right to make decisions, when there is no spouse and are multiple adult children there is no provision for who decides other than DPOA. There is no provision for a majority vote. While it is always best if everyone in the family agrees on a course of action, it doesn’t always happen. There may be several children in agreement, and one who wants something different. Sometimes this ends up in court, with a judge deciding. This is not the best scenario, which is why there should always be a DPOA. It does not solve every problem, but it definitely helps to have a specified decision maker. This issue is also addressed, from a patient and family perspective, in a recent NY Times Op-Ed by Sylvia Jacoby, Taking responsibility for death (March 31, 2012).

Such planning, however, requires thinking about hard issues. You have to decide if you want to have cardiac resuscitation if your heart stops, or be placed on a ventilator (breathing machine) when you can’t breathe on your own, or be “fed” through your vein when you can’t eat. These are all legitimate medical interventions that can have real value when there is an acute problem that is likely to be reversed (someone is temporarily unable to eat or swallow, or breathe on their own, but are likely to be able to in time). Cardiac resuscitation, which involves electric shocks and chest compressions, contrary to what you see on TV shows, hardly ever “works” when applied to people at the end of life whose body is in the process of dying, if by “work” one means a reasonable period of survival. It sometimes gets the heart re-started, but most of the time it happens again. A small percent of people who receive this treatment leave the hospital, and very few are back to “normal”. It is great to do for healthy younger people who have an episode of trauma (like on TV) but is unlikely to have benefit for folks at the end of life.

So why do we do it? Not only cardiac resuscitation, but so many other interventions that are of little or no benefit, especially when the body is suffering from the failure of multiple organ systems. And when, as indicated by Murray and Lin and many others, it is not what doctors want for themselves? As usual there are many reasons. Part of it is that doctors are, by and large, trained to do “whatever can be done” if there is “a chance”. However, a chance of what? This is a big question. To stay “alive” but unaware of one’s surroundings (from dementia, coma, or both), on a ventilator, and often in pain, for a few days, hours or minutes?  Even when doctors think about this issue, they often worry that if they don’t do something, they may be criticized, or even sued, by the patient’s family; they tend to go with the idea that doing something is always safer (from this point of view) than doing nothing.

The whole field of palliative care exists to help people and their families get through the inevitable process of dying with dignity, but there are far too few palliative physicians relative to the number of doctors trained to “do something”. Years ago, a co-worker’s elderly mother was dying in the intensive care unit (ICU). I went to visit. The woman was very far gone and unable to understand anything; the family, several adult children, was being asked to give permission for a fairly invasive procedure. They had been told it might “help”, and asked me what I thought. I was pretty sure it wouldn’t, but first checked with the doctor to see how he thought it would. I then spoke with the family and asked what “it might help” meant to them. They said that they hoped that it would make her “better”. I asked if this meant that she might become conscious, alert, maybe be able to talk with them, maybe be able to say goodbye one last time before she died? Yes, that is what they meant. I gently explained that this procedure might help correct some laboratory values, but that there was no way it was going to make her “better” in the way they hoped, although there was a good chance that she would still experience the pain associated with doing it. They opted not to have it.

Why didn’t the doctor make this clear to them? Perhaps it was because he was young, and wanted experience doing the procedure, and really thought that making lab tests better was “helping”. (There is an old joke that at Harvard students and residents were always pressured to make sure their patients had normal laboratory tests; the patient might die, but it was critical that they did so with their electrolytes in “perfect Harvard balance”.) Perhaps he had been trained to always “do something”. Perhaps he saw this large, hovering family and was concerned that they would be upset, might sue, if he didn’t.

Or perhaps he didn’t know how to talk to them. Is there a social justice issue here? After all, death comes to everyone, and as Dr. Lin points out, advance directives are important for all people to have, not just members of communities that have suffered health disparities. But often the social class or ethnic difference between doctors and patients makes communication more problematic, makes it harder for doctors to know how to best address what are already difficult issues, makes patients’ families suspicious of whether a treatment being offered is “research” being done on someone because they are poor or minority, or, alternatively, whether a treatment is not being offered for the same reasons.

I have cared for many people who were dying but whose families wanted more done. People who already had advanced dementia and whose physical bodies were falling apart. People whose heart and kidneys and lungs were failing, who couldn’t swallow and might choke on even a small amount of food, but whose families believed that if we didn’t do a surgical procedure to poke a hole directly into their stomach we would be starving them; who thought that if we didn’t plan to do cardiac resuscitation or given antibiotics for a possible pneumonia, that we would be killing them. Sometimes I am able to point out that death happens to everyone, and that having your heart just stop, or having pneumonia, or not being fed, are relatively easy painless and natural ways to die. Sometimes I am believed and sometimes not.

While there are, of course, times when a family member is truly “crazy”, paranoid or delusional, a more common issue is that they are just acting out their guilt. The stereotype (because it often happens) is the “son from California”, who flies in at the end of life, has usually not been involved in the care of his parent for years while a sibling (usually a sister) was doing all the work, and who now wants “everything done”. (A really good reason for one person to be designated DPOA.) But sometimes there is simply a trust issue, not being sure that the doctor, especially one from a different class, race or ethnic background, is really treating their parent with the respect that they deserve, with the respect they would give to one of their own family members.

Perhaps if more people understood what Dr. Murray is saying about what it is doctors really want for themselves and their families, or if their doctors took the time and energy and effort to explain it to them, folks would be more able to believe and accept it when the best course is not to do any more.

Reproductive Rights -- and wrongs

The “debate” on reproductive rights has taken a turn to the far right with recent laws passed in several states that create greater obstacles for women who wish to obtain abortions. Probably the most famous commentary is a series of Doonesbury strips that ran (or didn’t run, or ran on the editorial page, depending upon your hometown paper) from March 12-16. Its focus is the Texas law requiring, among other things, that women have a transvaginal ultrasound examination before obtaining an abortion. It also requires that they receive “counseling” scripted not by their physician but by the state legislature and governor (see the final strip in the series, March 16).

Unquestionably, the “Doonesbury” strips are effective but face an uphill struggle in the effort to counterbalance the extremely well-funded efforts of right wing organizations. Their “think tanks” have been writing bills that are introduced in many states with virtually identical language. For an excellent discussion, see Paul Krugman’s “Lobbyists, Guns, and Money” (itself a parody of the title of a Warren Zevon song), about the American Legislative Exchange Council, ALEC, in the NY Times, March 26, 2012. Kansas, my home state, is in the process of passing a bill that will require doctors to inform women of the increased risk of breast cancer from having an abortion. This might seem reasonable, except that it is simply not true.  How can they get away with this? Well, we can examine the syllogism, which goes something like this: there is a somewhat higher rate of breast cancer in women who have never had a term pregnancy, so if you have an abortion instead of carrying to term you might be in this higher risk group. Of course, this misses a whole lot of bases. Women who have abortions frequently have had previous term pregnancies (which sometimes contributes to why they want the abortion), and or they may have term pregnancies later. Even if they never have a term pregnancy, no one has ever studied whether having a pregnancy at all (even one ending in abortion) puts one in the higher or lower risk group, or in the middle. Most important, for this discussion, most of women who never get pregnant do not get breast cancer, and many (probably most) women who do get breast cancer have had babies. Having a term pregnancy, or multiple pregnancies, is not protective.

Of course, this is not really the issue. The issue is that anti-abortion forces wish to prevent abortions by making it more difficult for women to obtain them. Thus, the veracity of the information that the laws written by ALEC promote is not important to its supporters. There has been some discussion about the fact that these laws that affect women but are written and passed primarily by male lawmakers. The suggestion is that it indicates a profound misogyny. I agree. These guys are often flagrant hypocrites who indulge in sexual (as well, of course, of financial) shenanigans, but feel no compunction about limiting the rights of women. This view is prominent in both the Doonesbury cartoons and in this creative effort by Salt Lake City Dispatch political cartoonist Pat Bagley in which he attaches the “I thee rape” Doonesbury, not run by that paper, to his own critique of this hypocrisy. It is the same misogyny which not only leads to abortion restrictions, but to restrictions on the availability of contraceptives, one of the two things that actually reduces the abortion rate (the other being accurate and widespread sex education, another “no-no” for the right), through insurance plans.  While, of course, ensuring that that these same plans cover Viagra and other drugs that help old guys get erections. It is part of worldview that sees men and women as not only different, but hierarchically related with men firmly in control. Women are subsidiary, not supposed to make noise, do what they are told, and certainly not make any decisions about their own lives, health or reproduction.  

Those who oppose abortion, but also support contraception and sex education, have a coherent position. The imaginary story line is that once a woman is forced to have a baby, she will want to keep it and care for it and be able to do so, or, at least put it up for adoption where someone else will do so. But while sometimes one of these two things happens, it is obviously a fantasy to think that it is the norm. We all hope that all children can be brought up in a loving, supportive, and financially secure family, whether birth family or adoptive, with all options open to them. But this is simply not the case for too many children, and those opposed to abortion are not doing anything to make it more likely by cutting support for health care, childcare, and education. Which is, of course, one reason it is hard to call them pro-life (along with their support for war and capital punishment).

Another part of the Kansas law forbids state employees from doing abortions. This might seem unnecessary, since it is already state law that abortions cannot be performed (with some rigid exceptions to save the life of the mother) at the University of Kansas Hospital, the only state owned facility. It also might not prevent medical school faculty from doing abortions at other facilities for which they are paid with funds that come from the physician practice plan rather than the state. It does, however, directly affect residents, physicians in training, especially in obstetrics and gynecology (OBGYN). The accrediting body for OBYN requires that residents receive training in abortion (which they may opt out for religious or moral reasons) and in evacuating the uterus when there are stillbirths (which involves the same procedure), which they may not opt out of. Currently, OBGYN residents at KU who do not opt out of abortion training receive this in an out-of-state program, but if this bill passes intact it would forbid them from doing that, as the residents are state employees. This would put the entire OBGYN training program in jeopardy, and it would likely be placed on probation, potentially closed, a problem noted by even some usually anti-abortion legislators. But to the anti-abortion movement, this is not a problem. They see this collision course as desirable and hope that a series of such state laws would force the OBGYN accrediting body to eliminate this requirement. Then, ultimately, there would be no one being trained to do abortions, there would be no one doing abortions, and voilà! -- there would be no abortions! Without the admittedly effective, but messy, need to encourage crazy people to assassinate them, as was done with Kansas physician George Tiller.

According to the Kansas City Kansan article, “Brownback mum on KU Med Center, abortion issue”,

“Gov. Sam Brownback refused to say where he stood over legislative efforts aimed at stopping Kansas University Medical Center medical residents in obstetrics-gynecology from training in abortion-related procedures. “I’m studying the issue,” Brownback said at a news conference. Abortion rights advocates, and even some legislators who have opposed abortion, say the medical residents need the training to maintain KU’s accreditation and to be able to handle emergency pregnancies. But anti-abortion advocates disagree. Brownback has signed into law several anti-abortion measures and has welcomed the Legislature’s work in this area.” Yes, he has. Funny he hasn’t yet read the one-page bill.

Of course, the biggest flaw in this logic, beyond its complete arrogance and lack of respect for women, is the assumption that eliminating officially sanctioned training of physicians in abortion would end, or even significantly decrease, the number being done. What it would do is to decrease the safety of abortions, to increase the number of women who seek and obtain “back alley” abortions. It would, quite simply, kill many women.

But the proponents of such policies and legislation seem to have no problem with that. They are, after all, not fetuses.

Beyond Flexner Conference on the Social Mission in Medical Education

"Beyond Flexner: Social Mission in Medical Education", to be held in Tulsa May 15-17, promises to be a major conference in addressing and enhancing the social missions of medical and other health professions education.

Chaired by Fitzhugh Mullan, MD, of George Washington University and the Medical Education Futures Study, and Gerald Clancy, MD, President of the University of Oklahoma - Tulsa and Dean of the School of Community Medicine there, feature speakers will include David Satcher, MD and H. Jack Geiger, MD.

I have no idea whether others will bring this up, but I am again motivated by having recently reviewed the literature on why under-represented minority college students who want to become doctors don't end up applying. Barr, et al, found a negative experience in a chemistry course was the single largest cause[1]. How much is the ability to use complex chemistry important in a physician compared to commitment to meeting social missions? Indeed, other than passing the first two years of classes and USMLE I, is it useful at all?


I hope that these are the kind of issues we address.

I will be there and look forward to joining a lot of enthusiastic and creative colleagues!


[1] Barr DA, Gonzalez ME, Warant S. The Leaky Pipeline: Factors Associated With  Early Decline in Interest in Premedical Studies Among Underrepresented Minority Undergraduate Students, Acad Med, 2008; 83:503–511.

The 2012 Matthew Freeman Social Justice Awards

In my blog, “Alabama, “illegals”, and hate: We must take back the narrative” on March 11, 2012, I discussed some of the points made by Oscar Chacon, Executive Director of the National Alliance of Latin American and Caribbean Communities (NALACC), in his talk “Latinos and the Justice System: Challenges and Opportunities”, the 2012 Matthew Freeman Memorial Lecture on Social Justice at Roosevelt University on March 8. Chacon describes the purposeful development of a social narrative over the last 30 years that has served to demonize immigrants, and particularly those from Latin America.

In that piece, I note that this is part of a larger narrative that has been created affecting health, reproductive and women’s rights, and the substitution of belief for evidence. I also note that there is opposition. I mentioned the Occupy Movement, and I want to cite the work done by the two Roosevelt students who won the Matthew Freeman Social Justice Awards. On a smaller scale than “Occupy”, these two students, as those who have won in prior years, have done incredible work to help create a more just and tolerable world, the kind of world that we want to live in.

Daniel Smrokowski, an undergraduate journalism major, is the founder and executive director of the blog SpecialChronicles.com, for which he is the host and producer of the Special Chronicles podcast. He is a Special Olympics athlete and a global messenger (speaker) for Special Olympics Illinois. At WRBC:The Blaze, the student-run radio station at Roosevelt, he is the station director and an on-air personality. Daniel enjoys spreading the message to respect those, like himself, with intellectual disabilities.

Sarah Heeger, a graduate student in school counseling, has renovated and developed a program at Jones College Prep to guide undocumented students through the college planning process. By establishing relationships with college representatives and faculty, she has been instrumental in ensuring students receive the help they need to pursue their education. As a result of her advocacy efforts, and the creation of a nonthreatening environment, undocumented students are able to express their future goals and concerns and receive counseling, guidance, and support to pursue their dreams.

These are two amazing young people. I almost said extraordinary, and they are, but they are also, in the best sense, “ordinary”, regular human beings who are not “well-funded” by billionaires but who are motivated by caring and concern and love and respect for themselves and others. Missouri may be considering placing a bust of Rush Limbaugh (clearly someone who is bought and paid for) in their state Hall of Fame, but all for the rest of us there are Daniel and Sarah.

Congratulations, and may you continue your great work and be roles models for others across the US and the world. 

Alabama, “illegals”, and hate: We must take back the narrative

The state of Alabama has outdone Arizona with an anti-immigrant law that is even more anti-human in its degrading approach to and impact on people who are immigrants, visitors, and native Americans with Spanish surnames or who “look” Hispanic. H.B. 56, documents Allen Perkins, MD, Chair of Family Medicine at the University of South Alabama in Mobile in his blog, Training Family Doctors, “…requires schools to check and report the immigration status of their students. It instructs police to demand proof of immigration status from anyone they suspect of being in the country illegally (if stopped for another reason), even on a routine traffic stop or roadblock. It also invalidates any contract knowingly entered into with an illegal alien, including routine agreements such as a rent contract, and makes it a felony for an unauthorized immigrant to enter into a contract with a government entity.”

 He also notes that “…there were some really hateful provisions written in but enjoined as non-enforceable at this time (but liable to be enforced in the future): ‘It is a crime to harbor or transport unauthorized immigrants; unauthorized immigrants cannot enroll in or attend public universities; it is  a crime for unauthorized immigrants to apply for, solicit, or perform work; it requires that schools check and report on the legal status of their students and their students’ parents; and lastly, it is a crime to be without status in the United States.’” In a later blog entry, he describes specific incidents of harassment by regular people (e.g., store clerks) of – regular people, even American-born, because of their ethnicity. In other words, H.B. 56 has given folks in Alabama a license to be racist, which many in the state feel is particularly shameful given its history of slavery, Jim Crow, and opposition to civil rights.

Dr. Perkins worked to get the 2013 national conference of the Family Medicine Chairs’ organization, the Association of Departments of Family Medicine (ADFM) to Mobile, which he considers a diverse and vibrant city that was also in need of some economic boost, particularly given the recent hurricanes and more recent oil spills that have ravaged its shores. The agreement for the conference was all signed when H.B. 56 became law, and many members of the organization protested. This included Latino chairs, who felt that, in addition to opposition to the law, they might well be in personal danger. The conference will be moved, at considerable expense to the organization – and to the city of Mobile. Dr. Perkins includes in his blog a political cartoon (reproduced here) from the Mobile Press-Register, which also had a strong editorial about it.

The Alabama law does not stand in isolation, nor do Alabama and Arizona together. Both laws were, as it turns out, largely written by an ambitious attorney and law professor from the University of Missouri-Kansas City who now is serving as Secretary of State for Kansas, Kris Kobach. Kobach’s work is only one of the most recent chapters in a 30-40 year effort funded by incredibly wealthy right-wingers such as the Koch brothers of Wichita, Richard Scaife, and others, to rewrite American values. They have used the vehicles of conservative “think tanks”, talk radio and TV outlets such as Fox, funding individual organizations, and paying for lots of messaging (including the Super-PACs now thriving in this election season thanks to the Supreme Court’s Citizens United decision allowing unlimited corporate funding of political advertisements, one of the greatest “victories” of this effort) to create a narrative that, while essentially false, is widely believed by many Americans.

The development, implementation, and impact of this narrative as regards immigrants was the topic of discussion by Oscar Chacon, Executive Director of the National Alliance of Latin American and Caribbean Communities (NALACC), who gave the Matthew Freeman Memorial Lecture on Social Justice at Roosevelt University in Chicago on March 8, 2012. Our history in the US includes immigrants of all national backgrounds being vilified, persecuted, and demeaned (see, as just one instance, my discussion of some of the events surrounding the Boston police strike of 1919 described in Dennis Lehane’s novel “The Given Day”, Immigration and the US: Happy New Year, December 30, 2010). African-Americans, brought here as captives, along with our only non-immigrants, American Indians, have occupied a special places of discrimination and oppression. Nonetheless, during and after World War II we began to see ourselves as a “nation of immigrants”, symbolized by the beckoning torch of the Statue of Liberty, and its inscribed sonnet "New Colossus" by Emma Lazarus. We realized that the US had grown strong by this continuing infusion of the boldest (they emigrated, right?) from other nations prospering in this land of opportunity (the continuing oppression of African Americans and American Indians notwithstanding).

Mr. Chacon noted that, in 1970, immigrants of Latin American origin (which term he prefers to “Latino” or “Hispanic”, words not used outside of the US) were a minority of immigrants, and Mexicans a minority of those. The perception of Latinos in popular culture was generally positive, represented by handsome, suave, and debonair actors such as Cesar Romero and Ricardo Montalban and the character of Ricky Ricardo portrayed by Desi Arnaz. (Of course, many of those without accents, such as Anthony Quinn, Raquel Welch, and Martin Sheen felt the need to change their names, a practice also common among many minority performers such as Jews and Italians.) Since that time, immigrants from Latin American have become the majority (over 50%, but still less than 60%) of immigrants to the US, with Mexicans becoming the majority of those (over 30% of the total). The narrative that has been purposely developed over this period has served to redefine them as less than human, swarms coming to our shores who would all be here if they could, who are all Mexicans (Chacon, who is from El Salvador, is often asked what part of Mexico that is in!)

The narrative has created the term “illegals” to refer to people, when in fact only things or acts, not people can be illegal. People can do illegal things, including entering the US without official permission, or stealing, or committing assault, or driving over the speed limit and running red lights, but they do not become illegal people. This type of narrative serves to dehumanize them and thus makes it easier to oppress them. It has long been a common strategy adopted by the powerful to convince a portion of the powerless (say, Euro-Americans) to side with the rulers against other powerless people. It was very successfully done with Africans to make it acceptable for them to be slaves, and it has been a very conscious strategy to change the perception of immigrants of Latin American origin.

This narrative, pushed by right-wing ideologues, led to the passage of “IRA-IRA”, the “Illegal immigration and immigrant responsibility act” of 1996 – before 9/11 and under Democratic President Bill Clinton. In addition, major funders of the demonization have been the for-profit prison companies such as Corrections Corporation of America, that make huge amounts of money, paid for by US taxpayers at rates several hundred percent higher than their costs, to “house” arrested “illegals”. Latinos are arrested for “being illegal” but they also commit crimes and are imprisoned; their time served is, on average, less than that for African-Americans or even whites not because their sentences are shorter, but because they are regularly deported.

Has this narrative been successful? Read the news. Read this quotation from an article in the NY Times Magazine about an undocumented student (a young man who journeyed “…from cleaning windshields at stoplights and sleeping under a bridge in the Honduran city of San Pedro Sula to attending the sixth-largest university in the United States,”) who ran (and lost) for student body president at Texas A&M University: “…[a] professor, discussing the growth of Hispanics in Texas, said the state could have a Hispanic governor in the future. A number of students in the class hissed.” Note that the professor was not talking about an undocumented immigrant, or even an immigrant, just someone of Hispanic ethnicity.

This well-funded narrative is not limited to immigration of course. It has been largely successful in changing the words and terms of discussion in reproductive rights, women’s rights, and the entire vocabulary of liberal-conservative. And of course they have major impact on people’s health; after all, should we provide health care services to “illegals”? There is of course opposition to all these mythologies, and that opposition is growing. It is not as well-funded by the incredibly wealthy -- who are the real beneficiaries of suspicion and animosity among the 99+% -- but the Occupy Movement was and is real.

Alabama doesn’t need politicians passing laws that validate a new form of racism as it still struggles to move forward from its Jim Crow past. Nor does Arizona. Nor does Kansas, or Oklahoma, or any other part of the US, or the US as a whole. We must take back the dialogue, take back the words, and make the values of diversity and inclusion the ones that America and the American people represent.

ACA benefit programs: will state to state variation be good or bad?

With the passage of the Affordable Care Act (ACA) a larger portion of Americans will be getting health care coverage. For some, such as young adults who can now be kept on their parents’ insurance until 26 (provided their parents have insurance that covers family members!), there has already been benefit. As the 2014 roll-out of the most significant benefits gets closer, there is a lot of focus on the details, including the flexibility given to states to determine the benefits package that companies will have to offer, and whether it will be good or bad.

Writing in the New England Journal of Medicine, Alan Weil, MPP JD (“The value of federalism in providing essential health benefits”)^[1], provides a positive slant on the “federalist” approach to ACA roll-out, in which individual states will have flexibility in choosing which of 10 plans for providing “essential health benefit” (EHBs) they will use. While there are 10 EHBs that must be included, and the state insurance exchanges’ benefits must be based on a “typical insurance plan”, states will have considerable latitude in determining both what is “typical” and what scope to offer for these services; in addition, states will decide whether these plans need to cover benefits beyond those 10, and which they will be. Weil sees this as a good thing, citing the “states as a laboratory for good policy” in the sense that there will be different approaches. He cites 3 benefits: 1) different states, trying different approaches, will see which work “best” in the real world. For example, a single decision made by the federal government on what benefit package to offer (seen as the alternative) would, perhaps, cover treatments that turn out to not be of real benefit to people (he cites autologous bone marrow transplantation as an example of a treatment that was widely covered before it was found to be ineffective); 2) the “typical insurance plan” mandate would make people “have a plan similar to what their neighbors already have”; and 3) it would be consistent with local values. This last is somewhat problematic, since states are hardly very “local”, and have proven themselves to be very willing to enact policies that punish minority points of view (or even majorities, since much power resides, as at the federal level, with those constituencies with the most resources).

In the same issue of NEJM, Jennifer Prah Ruger PhD, writes “Fair enough? Inviting inequities in state health benefits”[2]. She makes many points about potential lack of equity in treatment that are not only possible, but are likely to result from allowing such state-to-state variation. The fact that Weil feels he has already dispensed with the “equity” argument: “The most common, but least convincing, argument against the secretary's federalist approach has to do with equity. It is a truism that state flexibility will yield differences within the country and that those differences cannot be defended on the basis of differing basic human needs for health care services. But those inequities must be viewed in context…” does not make such criticism illegitimate. In fact, Weil is making Prah Ruger’s point, that individuals will suffer negative health consequences because they live in one state rather than another. He sees this as acceptable; she does not. The strongest point that Weil makes is that a single national decision on a benefits package may yield a bad one; Prah Ruger argues that at least it would be consistent. I tend to agree more with her. While some states may have more generous benefits (and even better, since “more generous” is not always better if it provides access to ineffective or harmful services), many – and probably more -- will offer less than a federal program would. The current Medicaid program is a good example of how widely disparate benefits packages can be between states and how much people can suffer from a lack of benefit.

The most important point that Prah Ruger makes derives, interestingly, from Aristotle, the principles of horizontal and vertical equity. Vertical equity means that people with different sets of needs receive different quantity and quality of services (she uses the example of the difference between the treatment needed by people with conjunctivitis and glaucoma to restore “normal ocular function”; perhaps a better one would be between those with myopia and glaucoma). Horizontal equity would require that different people with the same needs have the same treatment options available. She makes clear that such principles do not require that everyone get the same benefits or the same outcomes, but that the principle of proportionality should apply, “…that similar cases should be treated similarly and different cases differently, in proportion to their differences.”

Vertical equity, in which everyone gets the same services whether they need them or not, obviously does not make sense. While the same services should be available to everyone when they need them, whether employed by ACA, a national health insurance system, or private insurance companies, it does not make sense to offer the wrong services to people when they are more expensive, nor is it reasonable to offer inadequate services because they are less effective. Understanding the relative cost and benefit of services to different people in different sets of circumstances is critical to both containing cost and increasing quality. A very interesting “Viewpoint” on this issue is offered by Robert H. Brook, MD ScD in JAMA (“Do physicians need a ‘shopping cart’ for health care services?”^[3]). He describes the on-line shopping most of us are familiar with, which gives us the cost of the items that we are interesting in purchasing, offers us both alternatives and other options that “people who bought this item might be interested in”, and tabulates what we have ordered in our shopping cart. And gives us at least two opportunities to not order, by asking us to confirm our intention. He does not argue that physicians should always order cheaper tests or therapies, but by knowing what the “basket of services” they are ordering for patients would cost, both for the patient and the insurer (“For example, if the insurance company paid the pharmacy $80 and the patient paid $8, the cost of this service is $88,”), they would have a better sense of what was of most value.

Horizontal equity, however, is really the most important issue. The absence of this characteristic is the fatal flaw in our current “system” and is likely to continue even with ACA. It means that everyone doesn’t get the most appropriate therapy for their condition, but rather that some people do not get enough, while others may get too much and even suffer ill effects as a result. Despite scare stories about rationing, the fact is that we have always had rationing, but it has been on the basis of the resources (mainly financial) a person has rather than on the basis of need. The problem with having different options in different states is that it will be the most disenfranchised who lose out in the states with meaner benefit packages, while those with resources will be able to access care.

Making the right care available to all the people who need it is the only reasonable goal for a health system. The rest is distraction.

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[1] Weil A, The value of federalism in defining essential health benefits.,N Engl J Med. 2012 Feb 23;366(8):679-81

[2] Ruger JP, Fair enough? Inviting inequities in state health benefits.,N Engl J Med. 2012 Feb 23;366(8):681-3

[3] Brook RH, Do physicians need a "shopping cart" for health care services? JAMA. 2012 Feb 22;307(8):791-2.