Friday, June 26, 2009

"Because that's what we do here..."

Rosemary Flanigan
June 26, 2009

The June 23 Time magazine has an article on healthcare reform (Michael Grunwald’s “How to Cut Health-Care Costs: Less Care, More Data”)which begins with a story about Ezekiel Emanuel, who spoke here in KC two years ago on pandemic policies, and is now near brother Rahm in the Obama White House.

The article says, “Ezekiel Emanuel got a memorable introduction to our haphazard health-care system on his first visit to a cancer ward as a medical student. The white coats were ordering a transfusion for a teenage girl, and since shyness does not run in his family. . . .he interrupted to ask why.

Because she had Hodgkin’s disease and her platelets were below 20,000, the team explained.

Emanuel still had questions: Was there evidence for that protocol? Don’t some hospitals wait until 10,000? Why 20,000? Because that’s what we do here, one doc replied.”

“Because that’s what we do here. . . .”

I am reminded of those years I taught undergraduates that to cling stubbornly to the status quo was immoral.

I won’t hastily judge the “immoral” part—but I will question if our healthcare professionals, like banking, insurance, investing professionals, realize that “the unexamined habits of one’s profession are not worth continuing.” (With apologies to Socrates.)

Will the rich resources of reflective ethics committee members be tapped when professionals need to reconsider “that’s what we do here” in the age of reform?

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Blogger Practical Bioethics said...

From John Yeast, MD:

There is an logical, but evolving body of consensus for practicing ‘evidence-based medicine’, and providers are being challenged by payors, hospitals, and their professional societies to do so.

While we have an aggressive group of clinicians developing pathways and order sets grounded on solid evidence, the role of the ethics committee in supporting these endeavors is very interesting, and potentially very powerful

Friday, June 26, 2009  
Blogger Practical Bioethics said...

From John Carney:

I know it’s unlikely that you were looking for reply dealing with how policy may impact this issue, but here goes…

In many cases we do know what is best (evidenced based) care, but much variability still occurs across the country.


Dartmouth has been studying this issue for years and we know now that there are three reasons for variability in care:

1. Effective Care (evidence based) is not delivered where it should be because providers don’t follow best practices.

This is just as true where high technology is available as where it is not. Sometimes due to #2.

2. Supply sensitive care (too much availability). More is NOT better. Excess capacity. We do it because it is the local norm and it gets paid for, so in some cases we provide an aggressive response where outcome data do not reflect benefit.

3. Preference sensitive care - treatment decisions where it is not clear and patient attitudes vary. Unwarranted variations reflect the limitations of current evidence and the failure to ensure that patients are making fully informed choices.

What is most interesting is that there are folks out there and regions of the country who do it right a lot of the time.

Dartmouth is studying their characteristics and practices and we are confirming through research what many have suspicioned for awhile.

a. The incentives are misaligned. We need to sponsor health reform that encourages physicians and other providers to belong to Accountable Organizations.

b. Develop comprehensive performance measures that reassure patients that lower costs are compatible with higher quality and better outcomes.

c. Implement payment reform that rewards a. and b.

John Carney
Vice President for Aging and End of Life
Center for Practical Bioethics

Friday, June 26, 2009  

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