Health Care Reform Update: When and How?

Headlines this week focus on health care reform as part of economic relief … and whether the new President should forge ahead while he has political capital to do so.

Universal Health Insurance Coverage or Economic Relief — A False Choice
Jonathan Gruber, Ph.D.
New England Journal of Medicine
January 29, 2009

Now is exactly the right time for universal coverage, because it can play such an important role in growing our economy, while also enabling us to shift the focus of health policy discussions to approaches for addressing our largest long-term fiscal challenge: escalating health care costs.

Pelosi expects ‘major step’ on health reform in 2009
Jeffrey Young
The Hill
January 26, 2009

Health reform activists, from the political left to the business community, are urging President Obama and Congress to take advantage of the new president’s popularity and political capital to think big on health reform immediately.

Integrated Ethics: More than following the rules

Rosemary Flanigan
January 28, 2009

I was happy to read in Health Progress (Jan-Feb, 2009) that Ron Hamel of Catholic Health Association praised the U.S. Department of Veterans Affairs’ model for integrating ethics throughout its many institutions.

The model addresses three levels: decisions and actions, systems and processes, and environment and culture. I especially like the emphasis on leadership in creating the environment and culture.

What behaviors of leaders foster such a culture? They talk about ethics, encourage ethical discussions; they communicate clear expectations for ethical practice by recognizing when expectations need to be clarified, being explicit, giving examples, and explaining underlying values; they practice ethical decision-making by identifying decisions that raise ethical concerns, addressing ethical decisions systematically, and explaining the reasoning behind decisions; and finally they support the local ethics program by knowing what it is (!!!)and what it does.

I know two of our discussion group are connected with VA hospitals—Nina out in Salina, KS and Terry here in KC. I’d love to hear the two of you tell us if the program is working!!!

The Center has long pushed for integrated ethics programs. Dear Robert Potter wrote and spoke extensively on the issue.

THANKS. Any comments from the rest of you?

Link: Fostering an Ethical Culture: Rules Are Not Enough, Ron Hamel, PhD, Health Progress, January/February 2009

Truth vs. Hope: Preparing Surrogates for Death

Rosemary Flanigan
January 26, 2009

I am considering using the article by Apatira, et al. “Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers,” Annals of Internal Medicine 2008; 149:861-868 for the self-education part of our February Ethics and Human Values Committee.

It is pointing to telling surrogates more truth about preparing for death—and less upholding the prospect for “hope.”

Has anyone read it? Do you think it would be a good choice?

THANKS.

Health Care Reform Update: Debate warming up

More analysis and speculation this week.

Wall Street Journal suggests healthcare debate will launch in March with a “major event.”

Analysis from conservative circles suggests that, when it comes to health care reform, cutting costs and creating jobs may be mutually exclusive.

Click here to view and share comments.

LL
January 23, 2009

Getting There from Here
Atul Gawande
The New Yorker
January 26, 2009

Many would-be reformers believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest.

Link: New York Times blog, “How Should Obama Reform Health Care?,” January 19

Great Expectations — The Obama Administration and Health Care Reform
Jonathan Oberlander, Ph.D.
New England Journal of Medicine
January 22, 2009

The political barriers to reform remain immense. The Obama administration has an agenda crowded with other priorities — the economy, taxes, Iraq, Afghanistan, energy policy — and a failure on health care reform could sap its political capital.

WSJ: Health Care Reform Is On Deck
Healthcare Blog
The New Republic
January 21, 2009

The incoming administration plans to move fast on his proposal to overhaul the health-care system, with a major event at the White House, likely in March, two Obama officials said. There, members of Congress and interest groups will hold a working session of sorts to launch the debate

The Fallacy of Health Care Reform as Economic Stimulus
Robert Book
Heritage Foundation
January 16, 2009

Health care reform might reduce health care costs, or it might create new health care jobs, but it cannot do both simultaneously.

Presumed Consent for Organ Donation? An Unlikely Fix

Tarris Rosell, PhD, DMin
January 23, 2009

Would changing the way we ask for organ donations—i.e., by not asking—make a dent in the transplant waiting list? “Presumed consent” is policy in a few nations less individualistic than our own. Has it helped? Our British cousins want to know.

The United Kingdom may be considering a change from their current opt-in system of organ donation after death, to one that would presume donor consent unless the donor or next of kin specifically were to opt-out prior to surgical recovery of usable body parts.

Science Daily reports optimistically on a systematic review of 26 studies and opinion surveys currently posted on the website of the British Medical Journal.

The review, compiled by the Centre for Reviews and Dissemination at the University of York in the U.K., suggests a correlation between presumed consent policies and higher donation rates. However, the report carries significant caveats to these findings, as well.

We keep looking for ways to balance supply with demand in the currently lopsided system of donate and wait. Some donate while many nonetheless continue to wait.

“First person consent” laws passed in most states of the United States have done little to change the negative ratio. “Presumed request” protocols—a way of asking potential donors that presumes a favorable response—reportedly have yielded some success, but not without a turn-off factor due to an unfortunate association with high pressure marketing techniques.

Living donation of kidneys and other paired organs increased significantly over the past two decades, but tapered off more recently. Living donation too is not without ethical complications and statistical limitations relative to the shortage of donor organs.

LifeSharers (www.LifeSharers.org) innovatively and controversially aims to incentivize cadaveric donation by means of what their local business journal called an “organ club.” “Organs for organ donors,” is the LifeSharers tagline.

But after seven years and much national publicity, there are only about 12,000 members and a net gain of zero donors and recipients (http://www.lifesharers.org/faq.asp).

I think presumed consent laws also are no panacea to a growing and complex problem.

In any case, the U.K. is not the U.S.A. Even if the British buy into an opt-out system for organ donation, it seems unlikely that Americans will follow suit any time soon.

We retain a strong individualism that places less value on solidarity than on autonomy. It is not so everywhere, of course, and might not be descriptive of this society when a seemingly more communitarian Boomer Babies generation takes the reigns of power within the next 20 years or so.

By then, we hopefully will have discovered radically new clinical responses to end-stage organ disease, something less morally messy perhaps than organ donation and transplantation.

If not, will either the U.S. or the U.K. have presumed consent laws in place? Were this to happen, it is possible that donation rates could rise a bit, and that a few more lives could be improved and extended by transplant medicine. And if one of the few is your life or mine or that of our loved one, it surely will seem worth it.

Yet, it is not possible to meet the rising demand for transplantable organs by means of presumed consent, whether here or across the pond. The need is simply too great, and growing exponentially just for renal organs alone. The cadaveric donor pool is too small, no matter what laws are passed in the near or distant future.

Might there be a more fitting response to this shared dilemma?

What do you think? To view and share comments click here.

Link: Redefining death: A new ethical dilemma, American Medical News, January 19

Observing Martin Luther King Day

Rosemary Flanigan
January 19, 2009

Happy Martin Luther King, Jr Day to all. We just had a program at the Center—and didn’t 86 people show up!! I think people want to celebrate together.

First, I thank Francie for her MOST THOUGHTFUL organizational ethics issue from the perspective of an emergency department doctor. Questions like these MUST be addressed!!

How do the rest of you handle continued care for the un/underinsured?? I know that the Center, under Terry Rosell's leadership, has developed a service in the Kansas City area in which specialists sign up to see a certain number of such patients on a pro bono basis—but that is charity trumping justice. It need not be that way.

AND, just to use one e-mail, a friend at the Consortium gave me “Hope, Truth, and Preparing for Death: Perspectives of Surrogate Decision Makers” from the 2008:149:861-868 issue of Annals of Internal Medicine. This is a great article for ethics committee education—excellent real arguments when the physician says, “I can’t tell she’s dying; it will destroy her hope.”
MARVELOUS!

Happy day!

Health care reform: Sharing Best Thinking

January 16, 2009

Barack Obama becomes President of the United States next week. This week numerous individuals and organizations shared their best thinking on reforming America’s health system.

As Susan Dentzer of Health Affairs says, “Let the festivities begin.”

Here are links to various reports and commentary. Please share or view your comments by clicking here.

Perspectives: Reform, Health Affairs, January 16

Visions for Change in U.S. Health Care — The Players and the Possibilities, John K. Iglehart, New England Journal of Medicine, January 15

Health Care Reform — Why So Much Talk and So Little Action?, Victor R. Fuchs, Ph.D., New England Journal of Medicine, January 15

A prescription for health care, Minnesota Public Radio, January 14

Respecting Patient Plight and Hospital Mission

Rosemary Flanigan
January 13, 2009

Myra Christopher and I are teaching a class this week at the Kansas City University for Medicine and Biosciences. This is one of the three medical schools we have in KC and it has recently added a graduate degree in Bioethics. Terry Rosell is an adjunct faculty member there and we at the Center help him out from time to time.

Myra and I are to talk about ethics committees—an easy task—and I thought that the last hour’s case analysis should be in organizational ethics instead of clinical ethics—maybe because clinical ethics receives the major focus throughout the course.

So I looked in Kuczewski and Pinkus’ Casebook, and found one that the authors did NOT use as an ethics committee consult; instead, it is correspondence between the CEO and the CFO. I thought, “Why not have the CEO send the correspondence to the ethics committee?” and that’s what I did when I adapted the case. The ISSUE is non-payment of emergency room bills, especially prescription drugs.

I think it is a dandy ethical analysis to try to create measures that both respect the patient’s plight AND respects the mission of the hospital to act as good stewards of its resources.

HELP!!! What do you think?? (I’ll tell you some of the “CFO’s” suggestions later, but I see no reason why those suggestions couldn’t have been equally made by a good ethics committee.)

Please share and view comments by clicking here.

Can "Living Wills" Work?

Bill Colby, JD
Senior Fellow, Law and Patient Rights
bcolby@PracticalBioethics.org

Next Monday’s American Medical News includes an article that examines living wills. [Link below.] The gist of the article is that living wills don’t work. One of my resolutions for our Bioethics Center is that in 2009 we will work to fix this problem.

In 1975 American society began in earnest the discussion about something the media named the “right to die.” A lawsuit over the ethics of turning off the respirator for a woman named Karen Ann Quinlan hit the national news. The following year, California passed the first living will law. In the years that followed, other states passed living will and all kinds of end-of-life laws – durable power of attorney for healthcare, surrogacy, DNR, brain death definitions, and more.

I interviewed Missouri legislators in the 1980s as potential trial witnesses for the Nancy Cruzan case. Those legislators thought that when they passed the 1985 Missouri living will law, they were “solving” cases like Nancy’s. Lawmakers who passed the 1990 federal Patient Self-Determination Act thought the same thing.

But laws by their very nature have limits. I think the focus of the AMN article is right. We need to simplify the “legal part” at the end-of-life. And we need to urge people to do a much better job of talking to one another.

We will be digging for some creative solutions at this Center to do just that in the months ahead. Stay tuned.

What do you think? Please share and view comments by clicking here.

Link:

Defective directives? Struggling with end-of-life care
Kevin B. O'Reilly
American Medical News
January 12, 2009

"There's always a question of what exactly the person meant and whether their current clinical circumstances warrant a change in plans," said Dr. John Lantos, John B. Francis Chair in Bioethics at the Center for Practical Bioethics.

Health care reform: will it be deja vu all over again?

Lorell LaBoube
January 9, 2009

Seems like just yesterday that this writer was in the middle of the health care reform debate – circa 1992 and 1993, that is. Those were the days of Harry and Louise nationally (remember those TV ads?) and an effort by Governor Mel Carnahan to reform healthcare in Missouri.

At the time I was director of public affairs for the Metropolitan Medical Society of Greater Kansas City. There were many trips with physicians to Washington DC and to Jefferson City. There were public forums and many interviews with the news media. Doctors, patients, insurance companies and others were determined to make their voices heard.

We can expect the same this time around with a new president and new Democratic Party majority in Congress. (Sound familiar?)

That said, with this blog we begin the Center’s effort to serve as a place for ethical discussion during the health care reform debate. You will see and hear commentary from people like John Lantos, MD, the Center’s John B. Francis Chair in Bioethics. He was a member of Hillary Clinton’s task force on healthcare reform.

We will provide links to headlines on the latest developments. And opportunities for you to comment on these developments as they unfold.

Will it be déjà vu all over again? Let us know what you think.

Click here to view and share your comments.

Links:

Video: Why healthcare reform comes so hard, interview with Steven Schroeder, MD, speaker at the Center’s 2008 Flanigan Lecture. (8 minutes 52 seconds)

Daschle Lays Out a Plan to Overhaul Health Care, New York Times, January 9

Health care journalism in survival mode

Lorell LaBoube
January 1, 2009

Today’s New England Journal of Medicine presents the “pitfalls of health care journalism” with a piece by Susan Denzter of Health Affairs and the NewsHour with Jim Lehrer on PBS.

Much of what she says is spot on.

“The news media need to become more knowledgeable and to embrace more fully our role in delivering to the public accurate, complete, and balanced messages about health,” Denzter says. “With some additional skills, care, and introspection — and a change in priorities — we can produce coverage more in line with our responsibilities.”

The first part of that quote is absolutely correct. The last part of the quote referencing “introspection” and “a change in priorities” will be difficult goals to achieve in today’s media environment.

Just today the Kansas City Kansan announced – online – that it was no longer publishing a printed newspaper after January 10. The Christian Science Monitor and The Capital Times in Madison, Wis., are among many that have taken this step.

The Kansas City Star announced massive layoffs in 2008. They weren’t alone in the newspaper industry. TV and radio broadcasting have not been immune to these pressures.

What does this mean?

The media is in a survival mode. This is not an environment for introspection and their priorities are to survive while remaining relevant.

Still, even in this environment health care reporters take their job seriously. An October 10 post of this blog carried a Q & A with Alan Bavley, longtime medical writer for the Kansas City Star. “Journalism is still a rough and tumble environment,” Bavley said. “There are deadlines to meet. Limited space in a newspaper. Limited time for a broadcast. We try to do our best.”

So what should we do as nonprofit healthcare organizations in this environment?

Face reality. Traditional news holes are shrinking. Reporters will come and go.

It’s up to us, when we have stories to tell, to engage and educate reporters at every opportunity. We have to accept our responsibility to improve health care coverage along with journalists.

As Ms. Dentzer says, “it will take many expert hands to ensure that the health news the public reads really is fit to print.”

What do you think? View and share your comments by clicking here.