On Mary-Charlotte Domandi’s Santa Fe Radio Cafe – February 6, 2011

For those interested in listening to a one hour talk show interview on Prevention vs. Treatment see Mary Charlotte Domandi’s Santa Fe Radio Cafe from February 6, 2011:  http://itunes.apple.com/us/podcast/monday-february-6-2012/id251501948?i=110315265.

Birth Control, Religious Freedom, and Moral Dilemmas

In the Wall Street Journal today (January 25, 2012) Archbishop Timothy Dolan argues that the mandate to cover birth control for all Americans, without excluding conscience-driven religious organizations like the Catholic Church, is unfair. He argues that the US Constitution prohibits such mandates on religious institutions.

He admits that the religious exemption included in the Obama rules regarding coverage of birth control would include religious organizations that primarily engage in serving people of their own religion. But Dolan wants a broader exclusion of any employment by any Catholic organization.

My guess is that Dolan will be happy to continue to accept Federal funding for Catholic Family Services and other religiously-based organizations that provide services to non-Catholic families. Such Federal funding generally helps to defray overhead costs for the core mission of such services (Jewish Family Services also benefits from these kind of arrangements in various cities) while providing fee-for-service or contract services to help the needy and indigent.

Apparently the separation of church and state isn’t as broad as Dolan makes it sound.  (He also accepts tax-free accommodations for his various real estate and sales activities, tax-free public services like fire and police, etc.) In essence he is saying, “I’m a citizen when I want to be.” While I agree with the right of freedom of religion without interference by the state regarding beliefs and ability to worship, I don’t agree on religion’s being able to pick and choose when it engages and when it doesn’t with the state on its own terms.  After all, freedom of religion is a state-given (constitutional) benefit.

But I’m no constitutional scholar, nor an academic on how the church (generically) benefits from its constitutionally-defined separation from federal/state/local citizenship. I would note, however, that the church does follow some other government employment laws and rules and regulations without current constitution-related separation arguments. So they clearly comply when they want to.  The question is, what is the right balance of engagement and compliance vs. belief-driven dissonance?

Let’s look at Dolan’s concluding three paragraphs, which is where his logic is incomplete.

In the third-from last paragraph, Dolan states, “Coercing religious ministries and citizens to pay directly for actions that violate their teaching is an unprecedented incursion into freedom of conscience. Organizations fear that this unjust rule will force them to … Stop serving people of all faiths…or stop providing health-care coverage to their own employees.”

This is what ethicists call a moral dilemma: when two (or more)_ options are available, all presumably equally important yet also independent and exclusive (I can’t do two or more actions, only one right now), all of which  would be morally right, and a decision must be made. So the church in this case would have to decide: do I act on my principles related to birth control, or on other principles:  helping the indigent no matter their religious affiliation; providing fair and just benefits to our employees. OK, a difficult decision if all of these items are equal.  This is a true moral dilemma.  There are lots of Catholic teachings about the vision of what a Catholic conception of a good society with social justice entails.  As Nuala Kenny states in chapter 13 of Prevention vs. Treatment:  What’s the Right Balance? :

• Dignity of the human person
• Social interdependence and social solidarity
• Commitment to the common good
• Special obligation to the poor and vulnerable
• Stewardship of resources
• Subsidiarity decisions should be made at level of those most affected.

The church then needs to decide if this concept of social justice for the poor and vulnerable, something they tend to generously through various services they provide to non-Catholics as well as Catholics, is less important for the common good than not providing birth control as a benefit.  They could provide the benefit while preaching to their employees that it shouldn’t be used, in order to be in compliance with the federal rules.

In terms of the fair and just dealing with employees, the Church has been out in front of this issue for many years both in the US and abroad.  If the church values this then it is hard to see how they would terminate health insurance benefits for their employees.   It would have determined that the health and well-being of its employees is less important than its concern about the provision of birth control benefits.  It could compensate employees for the foregone costs of health insurance and discontinue the benefit.  Employees would then be obligated to purchase health insurance from exchanges or elsewhere, which also would be providing the benefit.  This is a reasonable choice for the church, though inconveniencing its employees.

In the second paragraph from the end, the Archbishop states, “…the Obama administration has failed to show the same respect for the consciences of Catholics and others who object to treating pregnancy as a disease.” Indeed in this case the archbishop simply has it wrong – the Obama administration is treating birth control as it should be treated – a preventive measure. This is evident in their stating that there would be no copays or deductibles – operative as a benefit only under the prevention provision of the ACA. For many years women have argued that pregnancy is not a disease.  And I think they are right.  But preventive measures are not taken only to avoid disease. Such measures are also taken to enhance well-being.

If society is to take social determinants of health and well-being seriously, then they cannot ignore the effects of unplanned pregnancies on such social determinants. And the church cannot simply pick and choose when they wish to do so.  So Timothy Dolan and other Archbishops around the country do have what is seemingly a moral dilemma:  stick with their opposition to birth control, or stick with their support of the needy and vulnerable, or stick with their support of just and fair employment practices.  Which will it be?  Are these mutually exclusive?  Or will a better, non-exclusive balance be struck?

 

Addendum 1/27/12:

David Skeel has a short op-ed in the Wall Street Journal discussing this issue regarding how the courts decide many of the issues at stake.  In particular he mentions the narrow religious exception permitted under the Obama rule consistent with earlier Supreme Court rulings (Hosanna-Tabor).

Whose Bait and Switch? We all need fair play in health care.

When I was a resident my “mentors” did what most physicians do:  they taught me how to write-up preventive screening procedures as diagnostic or therapeutic ones so that they (and the patients) could get reimbursed by insurers.  So, a screening mammogram to detect early breast cancer, which wasn’t covered in the 1970s and 1980s in most insurance contracts, was written as “mass, rule-out cancer” or a screening resting EKG (which we now know is of little value) was recorded as “chest pain, rule-out ischemic heart disease.”

Surveys of physicians done by reputable researchers in the late 1980s and repeated in the late 1990s/early 2000s showed many physicians knowingly coded screening procedures fraudulently (see for example JAMA 1989;261(20):2980-85; JAMA 2000;283(14):1858-1865).  In the 1989 survey the researchers found that,

The majority [of physicians] indicated a willingness to misrepresent a screening test as a diagnostic test to secure an insurance payment…Most physicians indicated a willingness to engage in deception in some circumstances, justifying their decisions in terms of the consequences and placing a higher value on patient welfare and keeping confidences than on truth telling.

In the 2000 article, Wynia, et. al. concluded that:

A sizable minority of physicians report manipulating reimbursement rules so patients can receive care that physicians perceive is necessary.

Now the tables have turned.  The health reform act (known as the Accountable Care Act, or ObamaCare) has a provision that requires prevention procedures to be covered at 100% without a co-pay or deductible.

Secondary prevention is the use of screening procedures like colonoscopy to detect existing disease before it has signs or symptoms (see Prevention vs. Treatment:  What’s the Right Balance? pages 12-13 for more details). This preventive screening procedure means that something is being done without a suspicion of existing irregularity –  cholesterol is being checked to see if it is abnormal (not because it’s been abnormal and the patient wants to see if treatment has brought it down), or a colonoscopy is being done when there are no symptoms or signs that would suspect colon cancer (not because of an already established positive blood stool test, or presence of previous polyps, or prior diagnosis of colon cancer).

So physicians can get rid of their deceptive practices of old and request the procedure for what it is.  Let’s hear it for the system now encouraging moral integrity for physicians!  At least given old practices.

Covering new benefits, of course, costs more money for insurance plans, which will have to raise premiums to cover these new benefits.  If the actuaries for insurers haven’t already raised the premiums (or requested raises, which the state insurance commissioners may have nixed or reduced), then no pity on them – they had fair warning.  But presumably they have factored these newly covered benefits into their premiums, so now, as reported by the AP (see here), they are simply gaming the system the way physicians have for years.

In my experience in the health insurance industry in the 1980s and early 1990s we found many physicians gaming the system in many ways – up-coding procedures, mis-coding procedures, splitting (unbundling) what should have been bundled procedures, mis-dating follow-ups so they didn’t look as if they were for bundled payments, etc.  At the same time, reputable insurers tried to administer health insurance contracts quickly and fairly.  At Aetna, where I was medical director of the claims department, we prided ourselves on clearing claims very rapidly.  Where there were questions, we attempted to review and adjudicate the claim as soon as information was received to clarify the questions.  98-99% of all claims were paid without question.  But on a claims base of millions a day, 1-2% would still kick out >1500/ day.  Not all of these were medical issues, sometimes they were contractual benefits or eligibility ones which were handled by other departments.

Certainly we heard of irreputable insurers in the business, looking for ways not to pay claims.  But that wasn’t our culture.  I’ve been out of the health insurance business for 21 years, so things may have changed.  (OK, please don’t write in about your individual claim problem.  We’ve all had disappointments with one or more claims if we’ve lived long enough and submitted enough claims to health insurers.)

I’m not trying to be an apologist for insurers – I know they can be frustrating and difficult to deal with sometimes.  And certainly what they are doing now – changing the definition of a screening procedure to a diagnostic one because of findings from a screening procedure – seems deceitful.

My advice to individuals who experience this is to be sure that (a) your physician writes clearly that the requested procedure is for screening, (b) the screening requested is clearly within the guidelines of the US Preventive Services Task Force A or B recommendations, (c) you be vocal and proactive in talking with the insurer and provider in advance, and (d) if you get a billing surprise, appeal the decision as many times and layers as necessary.

So while the patient is asking for fair play from the insurer, at the same time the insurer is asking for fair play from the doctor and patient – don’t misrepresent the purpose of the test as screening if indeed it is diagnostic because of pre-existing symptoms or signs.  In that case the bait and switch isn’t the insurer’s fault, but the patient’s and doctor’s.  We all need fair play – honesty, not manipulation – in health care.

Does Prevention Save Money?

There is a significant difference between something saving money (net reduction in total expenditure) and being cost-effective (requiring less cost per outcome than something else). Sarah Kliff from the Washington Post takes on this question by discussing Louise Russell’s chapter 3 in Menzel’s and my edited text, Prevention vs. Treatment: What’s the Right Balance? Doug Kamerow also addresses this question in more layman’s terms in his new text, Dissecting American Health Care, Commentaries on Health, Policy, and Politics (RTI Press, p. 29).

The argument Kliff looks most at is related to the table Russell shows (figure 3.1) by Joshua Cohen, et. al. that appeared in the New England Journal of Medicine in 2008. According to Google Scholar this article has been cited 195 times since its publication.

It seems to me there is one problem with Cohen, et. al.’s article: it lumps together apples and oranges in its comparison. To compare all well-defined studies of prevention with all well-defined studies of treatment ends up comparing such disparate items as genetic screening for inborn errors of metabolism and surgery for elderly men with prostate cancer. On a macro basis this may be the best we can do when asking the economic question of prevention vs. treatment. But such comparisons seem besides the point when mixed together. I’d rather see comparisons of like-minded prevention and treatment. For example, how does preventive statin use compare with coronary artery bypass surgery? Or more broadly, how does screening and reduction of risk factors for heart disease compare with treatment of preventable heart disease?

A discerning eye can see that prevention cannot impact all types of heart disease, e.g., already established unexplainable congenital heart defects, or right heart failure due to hereditary chronic lung disease. Many (perhaps most) diseases we find in medical textbooks do not have easily defined causes which can be short-circuited by prevention maneuvers. Just as we cannot prevent a disease in a non-at-risk population (i.e., a population that cannot get the disease in the first place – men don’t get ovarian cancer; women who’ve had total hysterectomies cannot get uterine cancer), we cannot prevent a disease for which we do not know predisposing risk factors or causative agents.

[Let me be clear that this doesn't mean we can't prevent disease without knowing its proximate cause. Scurvy was prevented in sailors without knowing about vitamin C per se; it was prevented by an observation of the relationship of the lack of citrus fruits and the profound spread of scurvy among sailors. In this case citrus fruits were a surrogate for the active vitamin C ingredient. There are many other such examples in the history of preventive medicine. See, for example. Burt Gerstman's Epidemiology Kept Simple, 2003, p 290]

One other problem with the cost-effectiveness analyses typically done: they discount the value of future lives. This almost automatically puts prevention at a disadvantage because by definition the effects of prevention are in the future, while the effects of treatment are usually gained in the short-term. So for every life saved in treatment this year, we would need two or more lives saved in the future through prevention if we discount lives. This has interesting ethical implications, the most obvious of which is: why is a life in the future worth less than a life right now? Menzel explores this issue in detail in chapter 11 of Prevention vs. Treatment and I won’t recount his discussion here other than to say that the economic rationale of discounting monetary value most likely doesn’t hold for the value of life, especially when an ethical analysis is done. Because we make health policy including not just dollars but also values, this may hold a very telling modification of the policy implications of Russell’s analysis.

Medical Management and Executive Leadership

In 1983 I became medical director of a staff model health maintenance organization in Lexington, KY. I practiced half-time in the clinic, while spending the other half-time re-organizing the health care system and hiring/replacing personnel. The HMO had been founded as a non-profit for poorer residents of the area.

One of my first challenges was to encourage staff that their key concern had to be the patients. Many of the employees were more interested in their own concerns. In other words, they were not customer focused. They had come to see our patients as a problem (non-adherent, poor health habits, less important than their own priorities), not their service client. Over the first year we changed that by instituting intensive training programs, customer satisfaction surveys, and performance evaluations. Employees who couldn’t make the switch were asked to leave. 50 of the 55 of them did.

Also we had to train the physicians to understand the concept of comprehensive, coordinated, integrated care. This was not just our primary care physicians who worked in the clinic, but also our specialists to whom we referred patients. We needed to train the specialists that we weren’t just referral sources; we were partners in the health care of our patients. We wanted to maximize convenience and quality care for patients, which often meant providing service to patients at one visit in the location they knew – the primary care clinics. And we wanted all non-emergency decisions to be made in partnership between the primary care physicians and the specialists.

Changing physician practice patterns is not easy. It takes daily review of practice habits by questioning medical leadership. It needs to be done collaboratively, and at the same time with a firm managerial hand. It requires training physicians to think differently fromt he way they are trained in residency. It requires a bit of humility on the part of physicians – they need to understand that they can continue to learn new competencies while they are practicing; they need to rely on their colleagues who may have complementary skills; and they need to broaden their creativity skills.

At the same time we needed to provide the physicians and staff with a feeling of personal control. While we implemented strong and strict performance standards for patient satisfaction (and quality control), we also provided the physician staff with greater control over their workday patterns – providing schedule flexibility and teamwork models to increase workflow efficiency.

All of this is in saying that the November 2 Atlantic Monthly article, “The Quiet Health Care Revolution” was a pleasure to read. Finally there are some places getting it right.

The danger is, of course, that once the larger insurer, Wellpoint, gets its hands on it it might be corporatized without the ability for continuing intrapreneurship.. I say this with some experience. For several years in the late 1980s and 90s I was medical director at Aetna, where I also headed a strategic investment unit. We looked at acquiring certain companies that might have let us do this same kind of work but without the medical ownership. My supervisor at the time was a wise man who had been with Aetna for a long time. He nixed more than one potential acquisition of an innovative and creative company of entrepreneurs because of his fear that “Aetna will destroy this” by requiring bureaucratic policies to be implemented that would stifle competitiveness and innovation in efficiency and effectiveness of care.

Alan Hoops is a smart fellow. I hope he’ll be able to avoid too much corporatization of CareMore, and will recognize that the essence of improvement in the health care system requires strong and close physician management and creativity.

PSA Screening and Prostate Cancer

Making health policy involves many different aspects of life:  scientific evidence of a highly predictive diagnostic test, reasonable price, competing resource demands, comfort and convenience of a test, seriousness of the disease being detected, impact of the disease on the individual and the population, etc.

Anyone who’s been involved in health policy debates will recognize that, except for predictive value of the test and actual cost of the test, both of which can be determined somewhat objectively, all of the rest of the items listed above are laden with values (and one can argue even arriving at the predictive value involved significant calls on various values in doing the studies).   Evidence-based medicine only provides information, it doesn’t provide a support of values and how they will be applied in society.

Rather than reproduce some of the less-than-obvious arguments about screening for prostate cancer here, those interested can find more information in Paul Menzel’s and my recent posting on the Oxford University Press blog website.

Can you remember…

…everything you did 15 years ago? I’ve gone to meals with younger colleagues with whom I haven’t had a prior acquaintanceship and two years later forgotten we had had lunch, and even who they were, mostly because we didn’t have a significant ongoing relationship at a time when so much was going on in my life.

Just yesterday I was in touch with a friend who is a family physician in Florida. I had coincidentally met a woman who was moving to my friend’s town and she was looking for a family physician. I recommended my friend and gave her his work phone number. When I was writing to my friend two weeks later I remembered the referral, but couldn’t remember the circumstances under which I had met the woman, nor could I remember her name. This wasn’t a matter of my bad memory, as much as the constant and intensive bombardment we have of data, much of which ends up being contextually forgotten because of its relatively trivial nature (trivial related to the daily meaning of our personal lives).

In this context, I can understand if Herman Cain doesn’t remember a woman with whom he had a meal and then allegedly made unwanted advances toward so many years ago. I’m not justifying or condoning his actions if he indeed did inappropriately touch her; that would be reprehensible. But if he forgot who she was, I could understand. I met with many entrepreneurs in the 1990s during my early venture capital days. Had meals or coffee with them. But I didn’t invest in their companies and don’t remember them now.

While I’m not justifying his actions, I also wouldn’t suggest that if he is “not remembering” because he is lying to avoid responsibility that would be inappropriate also, and further not justifiable.

The questions are, “How far back and how significant does one’s contact with someone have to be to be held accountable now for those distant actions? What is a reasonable balance – time, distance, maturity – to which we should be held blameworthy (or praiseworthy)?”

Lying vs. Reporting Child Abuse

Joe Palazzolo is a reporter for the Wall Street Journal. On November 8, 2011 he reported on the legal issues related to the Penn State scandal. In his article, “Child-Abuse Reporting Law is Challenge to Prosecutors” he states:

Some observers wonder why lying to a grand jury about knowledge of child-abuse allegations carries a stiffer punishment than failing to report them in the first place.

This is, to some extent, a parallel issue to why we prioritize treatment over prevention. If there is any doubt that we do, read chapter 1 of Paul Menzel’s and my recently published text, Prevention vs. Treatment: What’s the Right Balance? (Oxford University Press, 2011).

To answer Palazzolo’s quandary, in essence we consider breaching trust in testimony more harmful to society than preventing harm to children. The first preserves the integrity of our society. The second should preserve the integrity of individuals. Sometimes we prioritize one over the other, sometimes not.

Note that this is an explanation of how society has made legislation, not a justification. Most legislation is made linearly, not comparatively. Nobody sat down and said, “Is child abuse more or less important than lying?” The juxtaposition of the two occurs now because of the peculiar circumstances and conditions of the Penn State case. Is it the right balance? Will the Pennsylvania legislature see this juxtaposition and take action to either reduce penalties for perjury, or increase penalties for failing to report child abuse? Only those in Pennsylvania who vote and could put pressure on their legislatures will determine that question. It would be interesting to know, however, if the same relative penalties exist in most other states. Any lawyers out there who can research the questions?

Wealth and Conflicts of Interest

Carl Bialik’s column in the Wall Street Journal this past weekend (Nov. 12, 2011) discusses the “Income Ladder’s Sticky Steps.”  He tackles the difficult question of assessing mobility, showing how defining the strata may change the conclusions that can be reached, including issues such as (1) What age groups should be included? (2) How do you handle natural progress of careers; older employed folks usually make more than they did when they were younger because their careers progress? (3) Would we be better tracking longterm earnings, as there can be natural fluctuations from year-to-year?

These have important implications when trying to look at economic progress.  For example, the Occupy Wall Street folks claim they are the 99% who are below the chasm of the 1% highest earners.  Of course they are – the 99 out of 100 people will be in the 99% by definition.  Except for celebrity guests of the Occupiers (who likely are in the 1%), those with the time on their hands to protest will be in the 99%.

Bialik states, without making further comments, “And none of the income measures explicitly includes wealth, which is distributed more unequally than income.”  This is an important statement.  Bialik is not the only one who recognizes but does not deal with the issue of wealth.  In Conflicts of Interest in medicine and health care wealth is at least partially ignored.  How?

Most conflict of interest disclosure requirements for authors in journals or speakers in continuing medical education events include provisions to disclose relationships with companies or other interests.

The International Committee of Medical Journal Editors states:  ”Conflict of interest exists when an author (or the author’s institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties).”

The American Council on Continuing Medical Education (ACCME) states:

2.1 The provider must be able to show that everyone who is in a position to control the content of an education activity has disclosed all relevant financial relationships with any commercial interest to the provider. The ACCME defines “‟relevant‟ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

In the ACCME’s case financial relationships are defined as “…those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.”

How does this normally exhibit itself in CME speaking activities?  In my experience the moderator of a session will state “so-and-so discloses that (s)he owns stock in [Drug] Company” or “so-and-so discloses that she has been paid an honorarium by [Device] Company” and it is left at that.  As we know, disclosure doesn’t fix the conflict, it merely reveals it.   Loewenstein notes related to the physician-patient relationship,

Disclosure may give the adviser a “moral license” for strategic exaggeration in the adviser’s best interest. (“I told her I had a conflict—now, I can recommend the surgery.”) Having disclosed a conflict of interest, moreover, advisors may feel compelled to give advice in an extra-forceful fashion.

This may be similar for the speaker-audience relationship, “I [the speaker] have disclosed my conflict, now I needn’t worry about it, or I may feel free to discuss it even more than if it were hidden.”

However, the key question that needs disclosure is “What does this relationship mean to the speaker and how has it influenced his/her presentation of information?”  Simply knowing that someone has been paid an honorarium or owns stock in an enterprise doesn’t tell the audience if such ownership is meaningful.  More importantly, what does that represent in terms of one’s income or wealth?  If the speaker has net worth of $100 million, owning $10,000 of stock likely is relatively meaningless.  On the other hand, if the speaker’s net worth is only $200,000, that $10,000 of stock may be critical for how she wants to please either the commercial interest (to get more stock or honoraria) or the audience (to purchase more of the product offered by the commercial interest).

(As an aside, at a recent Harvard University Program in Ethics and Health conference conditional cash transfer payments to encourage health promoting activities in second world countries was discussed.  As I recall, levels of payments had to approach 20-30% of annual income to get behaviors to change substantially.  This, of course, differs from findings related to physician behavior, which is influenced by small pharmaceutical company gestures.)

So, while ignoring wealth as the denominator of disclosure is usually done, we should consider the issue as a much more important measure.  Further there likely is some interactive relationship between meaningful financial ownership (wealth) and income.  Income fluctuations may have little meaning if the amounts are small, or if one has equilibrium with a lifestyle that is fully supported by drawdowns on existing wealth (not requiring additional annual wealth through income or increases in, for example, stock value).

Because of the complexity of the interaction of wealth, income, and meaningful bias/influence the leading medically-related institutions are moving to requiring disclosure of any financial relationship between an author/speaker/influencer and a commercial interest.  This makes sense, in that research indicates that we often don’t let data get in the way of our biases, which can easily come from financial self-interest, and that even small conflicts can result in unconscious bias.   Until we have more reliable data on the relationship between wealth and income this is probably prudent, but also recognizably excessive.

How to find the right balance?  More easily done when more research is completed.

Hello and Welcome!

Welcome to Halley Faust Comments.

Many of our contemporary issues are conflicted by personal self-interest, commitment biases, incorrect information, and unbalanced consideration of alternatives.  For example, we often use the best of our traditions to compare the worst of others’ traditions – an unfair (and perhaps unjust) evaluation.

I’ll use this blog to discuss various events and ideas, particularly as they impact health care, prevention, and the Middle East.  I am a moderate in American politics – eschewing the extremes we seem to see more of lately.  My posts will pick up on contemporary issues and ideas and try to put out a balanced view, or at least point out where balance is missing.

I hope you’ll find my comments of value.  And I invite your comments on mine.

In the meantime, Happy Thanksgiving.