What doctors are talking about with healthcare reform

If medicine becomes, as Nazi medicine did, the handmaiden of economics, politics or any force other than one that promotes the good of the patient, it loses its soul and becomes an instrument that justifies oppression and the violation of human rights. — Dr. Edmund D. Pelligrino, M.D., “The Nazi doctors and Nuremberg: Some moral lessons revisited,” 1997.

When it comes to the future of our healthcare, having both eyes open is especially critical. It’s easy to believe that the solutions to our anxieties about medical care are simple. It’s even easier to miss the profound unintended consequences for us when we look to solutions in the wrong places.

To understand the plans being made for reforming our healthcare system necessitates going to sources behind the scenes, such as medical sites, unfrequented by much of the public. We won’t get the full story by only turning to sources of information that feel comfortable and confirm what we want to believe is true. We especially won’t gain understanding from those telling us whatever we want to hear.

The good-sounding words, used by those trying to convince us that their plans and healthcare recommendations are best, often have very different meanings to them than we think they mean. Learning the lingo is critical or we can be left with some very unpleasant surprises. “Quality” of care is one word that’s undergone the most perverse change in definition.

A new article in the Journal of the American Medical Association, “Improving the Quality of Health Care,” chronicled the evolution of this term and how healthcare reform has come to mean control over lifestyles and medical care choices. It was also a revealing look at some of the reasons behind the growing sentiment of blaming people with chronic diseases as having failed to take personal responsibility for their health, using more than their fair share of resources, and their healthcare costs burdening others. In answering for policy makers the question “Who is responsible for what?”, this article also revealed why we’re hearing more calls to make access to affordable medical care conditional on people complying with diets, “healthy” lifestyles and preventive interventions decided by someone other than us or our doctors.

Most of all, this article illustrated the fundamental shift in the moral purpose of medicine, that we’ve observed before, from caring for patients to prioritizing the economic interests of the collective good. It was reminiscent of the sobering assessment of medical ethics by the country’s foremost medical ethicists, Dr.Edmund D. Pelligrino, M.D., Professor Emeritus of Medicine and Medical Ethics and Adjunct Professor of Philosophy and served as Director of the Center for Bioethics at Georgetown University.

Lead author of this article was James Frank Wharam, MPH, at the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care in Boston. Wharam and colleagues began by looking at the definition of health care “quality.” A common definition of “quality,” they said, is measures that increase the likelihood of desired health outcomes. But, they asked, whose “desired health outcomes” should be promoted? “Health outcomes desired by administrators, insurers, and pay-for-performance architects may differ substantially from those of patients,” they wrote.

They pointed out that “quality” of health care is popularly viewed, especially among the public, as responding to the needs of individual patients and about patient-level care. That was true once, but isn’t anymore. This view “contrasts sharply” to current approaches of quality of care, they wrote, that are focused on populations — public health care is about what is best for the population or healthcare system, and achieving equal distribution of resources, not what is best for individuals.

First, health systems ought to maximize efficiency before engaging in explicit rationing. Second, savings should be distributed broadly across the population to facilitate the achievement of patient health goals, perhaps reserving a portion as an incentive for those individuals achieving these efficiencies and distributions. Third, systems ought to promote equitable resource allocation.

[A] seldom-discussed implication is that patients also have obligations to promote quality population care. This is why, for example, patients are not ethically justified in demanding that health systems “do everything” to facilitate their individual health care preferences.

In other words, under today's meaning, people have a duty to be healthy for the good of a healthy population and no individual should utilize more than their share of resources. Rationing is intrinsic in any health system allocating limited resources and must prioritize those adding to the efficiency of the system.

[H]ealth care quality can be defined as “the degree to which physicians and health care institutions fulfill their care obligations to individual patients, and the degree to which patients, physicians, and health care institutions enable these obligations to be fulfilled justly across the population.”

When people hear the term “quality improvement,” it is not a patient-centered definition. Pay-for-performance (P4P) measures actually equate “quality” with achievement of predetermined population health targets, they wrote. These often infringe on the choices that individual patients or doctors might make because they are written by third parties, often with vested interests in the outcomes. “Population-centered goals are chosen in a top-down manner.”

In reality, policy makers, health care executives, disease advocates, and scientists with clinical or epidemiological expertise effectively choose population-level goals and thus impose obligations in a manner that might infringe on patient and physician autonomy. Without fair deliberation, such goals, however wise, cannot claim legitimacy.

This external and even “forced” population-level approach implies, at best, improved health and reduced costs for patients whose goals match those of policy makers. At worst, physicians could overlook urgent patient goals, provide inappropriate care [as defined by policy makers], and increase costs via excess testing. Unmeasured domains of quality, such as communication, compassion, and trust could deteriorate as clinicians divert attention to limited sets of performance targets.

As we’ve seen, the P4P measures are not proven measures of improved clinical outcomes for patients, but about meeting performance measures based on interventions and meeting targeted health indices (BMI, blood pressure, blood glucose and lipids), that all too often mean profit for their third-party creators and aren't always best for individual patients.

A major objection with the current P4P measures, the Harvard writers asserted, is that doctors are held accountable for the small set of the population who have chronic diseases or undesirable health indices, “based on things that are outside their control.” In essence, doctors are penalized for sicker patients or if their patients don’t follow the screening tests, obligatory medications, and diet and lifestyle interventions determined by those behind the P4P measures. The underlying fallacies that makes these unsound, is that the targeted health indices are, in fact, not amenable through diet and lifestyles and are discriminatory, notably against those who are aging, minority, deprived social class, and with specific genetic predispositions.

In reinforcing these fallacies, though, P4P measures can be a technique to move some doctors to get behind blaming patients for their health problems and into policing lifestyles. As with these authors. In the name of fairness, the Harvard authors wrote, performance measures should include patients and their “shared care responsibilities.” Third party groups should develop “specific lists of care obligations” tailored to diseases and carefully design incentives into health care systems, they advised — incentives that deny individuals’ rights to make decisions over their body and lifestyles, especially the oppressed. While holding patients responsible for their health problems might seem reasonable on the surface, it doesn't hold up to careful scrutiny or how it's often being applied.

If you’re fat, old or sick, you will do what they say or pay

Beliefs have been building among the public and public policy makers that people with chronic conditions have brought their conditions on themselves due to bad diets and lifestyles, and the most costly chronic conditions can be prevented by “healthy” diets and lifestyles, despite evidence to the contrary.

When people were free to buy their health insurance and healthcare from anyone they choose, and had options of plans that best met their needs, lifestyle choices that other people made didn’t concern them. But as taxpayers are increasingly forced to fund healthcare for others, blame against those seen as costing them money because of “poor lifestyle choices” grows, as does sentiment that “we shouldn’t have to pay for their bad choices.”

For those who only read familiar sources of information from like-minded people, the degree to which this sentiment has grown among those working to reform the healthcare system will be a disturbing realization. The designated Health and Human Services Secretary, Tom Daschle, for example, advocates the creation of a federal health board that will decide and regulate what treatments people can/will receive to ensure “quality” and impose price controls to reign in costs. According to his book, Critical: What We Can Do About the Health-Care Crisis, Daschle proposed federal oversight modeled after the UK’s National Institute for Health and Clinical Excellence (NICE). It will override doctors or consumers’ choices and decide what care is “quality” or too expensive, effective or obligatory. It is like the model tested in Massachusetts.

One internal medicine doctor, who said he consults for Medicaid managed care in reviewing performance measures, wrote this week that if taxpayers are forced to fund healthcare, then those getting the care have a responsibility to taxpayers to reduce their future health problems and associated costs. “If I’m going to disproportionately fund your health care,” he wrote, “then shouldn’t I have the right to add a few conditions?” His disturbing proposals were not unlike what others are discussing.

What we are considering here are preconditions before the public is allowed to receive government support for the costs of their health care, he wrote. “The state has a practical interest in keeping the workforce healthy and reducing the economic burdens from people who become sick and disabled as a result of unhealthy or risky lifestyles.” If people want health care provided by the government at discount, then they have to adhere to lifestyle changes and accept a doctor telling them to lose weight, he wrote.

For those who might try to short-circuit the system by convincing their doctors to give them a clean bill of health so they can get their reduced-cost healthcare, that’s already been considered, too. This is where electronic medical records come in, he explained. Compliance could be easily recorded and monitored by the government and third-party payers through electronic medical records without relying on doctors.

“In a future socialized health care system, physicians will likely be put under the government microscope to ensure adherence to several measures of health care quality as a requirement for participating in such a system,” he wrote. “It would be short-sighted not to hold patients accountable as well.”

“There are several measures we can use that would give us a good picture of compliance and that could be easily recorded into an EMR,” he wrote. These include:

keeping appointments for follow ups, referrals, and treatments and required testing… Compliance with regular preventative health testing such as endoscopy, cholesterol testing, diabetes screening, testing for osteoporosis, mammography, pelvic exams and PAP smears. Regular screening (by history) for substance abuse (illicit drug use, tobacco use, alcohol abuse) and in office counseling on the health risks and ways to quit if needed… Weight, waist circumference, height and calculated BMP together with gender, age, and race can give a pretty good idea of the multitude of health risks associated with obesity that can increase future morbidity and mortality and health care costs…

“Such a system might have to work something like social security disability,” he said, where eligibility is not determined by the physician. “Instead, government auditors can easily look at the [sic] just those variables as stated above that are entered into an EMR (another reason to tout the universal adoption of EMRs).”

Designing incentives to make compliance obligatory has proven simple. People who do not comply with healthy lifestyle mandates can go without government-subsidized healthcare or government benefits, like the wellness programs already piloted in several states. Medicaid recipients can “choose” to comply if they want care for their special needs babies, like the approach in West Virginia.

Other viewpoints

Not all healthcare professionals who’ve been following these developments are as ready to relinquish medicine focused on caring for individual patients. But, in light of what is being planned for healthcare reform and the influence of powerful stakeholders with millions of dollars in place and secured, what can people do? Various ideas have been floated, but one doctor offered some suggestions to consumers.

Dr. Steven Knope, M.D., concerned about plans to model our healthcare reform after the UK, said rationing controls government costs and “NICE’s denial of care is legendary — from the arthritis drug Abatacept to the lung cancer drug Tarceva. These drugs are effective. It's just that the bureaucrats don't consider them cost effective.”

While some might believe that a government managed system won’t lead to rationing, he said it is inescapable:

There is simply no other way to run such a system. If patients on a national plan had a blank checkbook for their medical care, the system would go bankrupt long before the projected insolvency of Medicare. There is only so much money that Congress can appropriate for healthcare. Somebody has to ration that taxpayer money. If the money is controlled by the government, who else but government bureaucrats will decide what care gets rationed? You, the patient? Your doctor? Hardly. There will be some group of people, equivalent to "medical directors" at an HMO, who decide if, when and at what age you can get your knee replacement.

His advice was to maintain private medical care if at all possible and, if you’re relatively healthy, look for a high-deductible insurance plan with the least amount of managed care. That won’t be possible for people in Massachusetts, which controls the type of insurance plans people must purchase, or when a national managed care program gets in place, though. He fears that “all indications are that there will be attempts to ram a national healthcare program through Congress early in the Obama administration,” explaining:

They will create a false sense of urgency, just as they did with the "financial bailout" of our economy. No time to study the issue; this must be done or the society will collapse!.. [Daschle] was just quoted in the Wall Street Journal as saying that the new Congress needs to act quickly. "We need to be on the offense. This time around, lawmakers cannot try to address every detail when it comes to legislation. Details kill." Daschle said.

"Details kill?" "Lawmakers cannot try to address every detail?" We are just going to guarantee medical coverage for every American on the backs of the American taxpayer and we don't have time to discuss the details of how it will work or how it will be paid for? Every good lawyer I've ever retained has reminded me that the devil is in the details! It looks like we are in for a devil-of-a-new program.

For the public that’s only heard the marketing from mainstream and social media, the realization of healthcare reform will sadly come when it affects them.