This news story appears to me to raise ethical questions.
http://www.cnn.com/2010/CRIME/12/30/mississippi.sisters.prison.release/index.html?hpt=Sbin
Apparently, two sisters in Mississippi received life sentences for an armed robbery that netted $11. Having each served 16 years in prison they are now each consider rehabilitated and no longer a threat to society. One sister's dialysis treatments three times per week is costing the state $190,000 a year. Governor Barbour's decision is apparently being well-received by all.
But ethically, an organ donation must be voluntary. Not even a court of law can require a person to become an organ donor even if a specific death will result for lack of a suitable organ. If this were a research proposal being considered by an Institutional Review Board (IRB) I think the IRB reviewers would be hard pressed to believe this is not a coerced consent. The state has apparently concluded that the sisters should not be in prison. Assuming the sister receiving dialysis will be eligible for Medicaid upon release, it is in the financial interest of the state for her to receive an organ transplant. From an ethical perspective, it seems to me that the better sequence of events would be to immediately release the two women and then ask the potential donor if she wants to make the organ donation. Is it possible that the prospective donor has refused to make the donation unless both sisters are first released from prison? If this is the case, does this amount to selling one's organ, which may be a violation of law?
Does this news story suggest that in the future a convicted criminal's "debt to society" might be paid by "voluntary" organ donations (to unknown others) in Mississippi? It seems to me that the state has a conflict of interest regarding the medical care of the sister needing dialysis and that making release contingent upon the organ donation may not be ethical or wise.
Friday, December 31, 2010
Monday, December 27, 2010
Challenges of managed care
The movie titled, Damaged Care is based on the experiences of Physician Linda Peeno. The movie, a Showtime docudrama staring Laura Dern in the role of Dr. Peeno, is a hard-hitting representation of the practices of "managed care" healthcare by some large providers prior to 2002, the date of the distribution of the movie. The movie can be no more shocking than the real testimony of the real Dr. Linda Peeno before a Congressional committee several years ago.
In reflecting upon this I remember the book title, "No Margin No Mission," by Stephen Pearson and others. I also think of the concept, Balanced Scorecard, which is a strategic management tool. The core idea behind Balanced Scorecard is that financial and other non-financial measures each be compared in a single report. In a personal communication several years ago a management consultant in Mexico told me had never been able to earn any money by selling the Balanced Scorecard concept to managers in a variety of industries. I conclude that business schools have reinforced the management concept of maximization rather than balance. It is certainly true that without financial margin an organization cannot continue to pursue its mission. The interests of owners (including stockholders) are usually defined in terms of the greatest possible profits. The pressures of competition that would force executives into more of a Balanced Scorecard perspective does not work as well in healthcare as in some other industries. How can the profit motive and the care motive coexist in large healthcare organizations? Can these motives somehow find balance both in individuals and in large organizations in which roles produce a splitting into factions with different primary interests?
In reflecting upon this I remember the book title, "No Margin No Mission," by Stephen Pearson and others. I also think of the concept, Balanced Scorecard, which is a strategic management tool. The core idea behind Balanced Scorecard is that financial and other non-financial measures each be compared in a single report. In a personal communication several years ago a management consultant in Mexico told me had never been able to earn any money by selling the Balanced Scorecard concept to managers in a variety of industries. I conclude that business schools have reinforced the management concept of maximization rather than balance. It is certainly true that without financial margin an organization cannot continue to pursue its mission. The interests of owners (including stockholders) are usually defined in terms of the greatest possible profits. The pressures of competition that would force executives into more of a Balanced Scorecard perspective does not work as well in healthcare as in some other industries. How can the profit motive and the care motive coexist in large healthcare organizations? Can these motives somehow find balance both in individuals and in large organizations in which roles produce a splitting into factions with different primary interests?
Sunday, December 26, 2010
Medicare end-of-life conversation regulation
The lead news item in today's edition of the New York Times is the Obama administration's decision to create a new Medicare regulation regarding paying physicians to discuss end-of-life issues with their patients.
http://www.nytimes.com/2010/12/26/us/politics/26death.html?pagewanted=1&_r=1&ref=todayspaper
Given the Administration's need to work with Republicans on a host of important issues I am sure that this decision is not a political strategy intended to enhance President Obama's prospects for reelection in 2012. It may actually have at effect, however. I think it increases the probability that Republican leaders will be unable to prevent Sarah Palin becoming the party's presidential nominee. In a race in which Palin is the Republican nominee for president, Obama is more likely to win.
We are certainly going to hear increasingly angry statements about "death squads" from the far right and characterizations of President Obama in the most negative ways, often couched in fundamentalist religious frames. For many, this is not about reason. For many, this is about government's intrusion on the sacred domain of the Almighty. Years ago, little could be done to prolong the lives of terminally ill people. Following death, doctors spoke the words, "we did all we could." And that was it. No one, and certainly not "bureaucrats" working for the national government were held responsible for "killing Grandma." Now that the burden of financing medical care falls increasingly on government, government itself is a risk of being blamed for the intensely personal consequences of the necessary rationing of medical care.
I have at least three concerns. One, I am concerned for our nation. It is not written in stone somewhere that the United States will always continue to exist in its present configuration. Issues that deeply divide the nation which some citizens see as nonnegotiable are a threat to the fabric of our nation. Two, creating policies/regulations regarding what conversations are reimbursed and what conversations between physician and patient are not reimbursed seems to me to be a bit troubling. I mean, do we really want to create a situation in which primary care physicians may say to a patient, "I am sorry but we have only fifteen minutes and I would prefer to talk with you about some topic for which my group practice will get reimbursed." Third, creating a system by which physicians are paid to talk to patients about end of life issues is one step away from specifying by regulation what the patient can (and cannot) be told by his or her physician.
The reality is that a large percentage of what is spent for medical care in the United States is spent to lengthen the lives of people who are near death in any case. This is a difficult call because in many situations the nearness of death is uncertain. It is likely that new technologies will increase the percentage of near-death spending in coming years. The potential need for medical care is almost infinite. Resources are finite. Rationing by some means is necessary. People do not want to make hard choices. We want it all. In the name of social equity, we want it all for everyone. It is "easy" for me to write this now working from what I perceive to be a rational perspective. It is more difficult to face these things in situations in which rationality may not be the primary criteria for decision.
http://www.nytimes.com/2010/12/26/us/politics/26death.html?pagewanted=1&_r=1&ref=todayspaper
Given the Administration's need to work with Republicans on a host of important issues I am sure that this decision is not a political strategy intended to enhance President Obama's prospects for reelection in 2012. It may actually have at effect, however. I think it increases the probability that Republican leaders will be unable to prevent Sarah Palin becoming the party's presidential nominee. In a race in which Palin is the Republican nominee for president, Obama is more likely to win.
We are certainly going to hear increasingly angry statements about "death squads" from the far right and characterizations of President Obama in the most negative ways, often couched in fundamentalist religious frames. For many, this is not about reason. For many, this is about government's intrusion on the sacred domain of the Almighty. Years ago, little could be done to prolong the lives of terminally ill people. Following death, doctors spoke the words, "we did all we could." And that was it. No one, and certainly not "bureaucrats" working for the national government were held responsible for "killing Grandma." Now that the burden of financing medical care falls increasingly on government, government itself is a risk of being blamed for the intensely personal consequences of the necessary rationing of medical care.
I have at least three concerns. One, I am concerned for our nation. It is not written in stone somewhere that the United States will always continue to exist in its present configuration. Issues that deeply divide the nation which some citizens see as nonnegotiable are a threat to the fabric of our nation. Two, creating policies/regulations regarding what conversations are reimbursed and what conversations between physician and patient are not reimbursed seems to me to be a bit troubling. I mean, do we really want to create a situation in which primary care physicians may say to a patient, "I am sorry but we have only fifteen minutes and I would prefer to talk with you about some topic for which my group practice will get reimbursed." Third, creating a system by which physicians are paid to talk to patients about end of life issues is one step away from specifying by regulation what the patient can (and cannot) be told by his or her physician.
The reality is that a large percentage of what is spent for medical care in the United States is spent to lengthen the lives of people who are near death in any case. This is a difficult call because in many situations the nearness of death is uncertain. It is likely that new technologies will increase the percentage of near-death spending in coming years. The potential need for medical care is almost infinite. Resources are finite. Rationing by some means is necessary. People do not want to make hard choices. We want it all. In the name of social equity, we want it all for everyone. It is "easy" for me to write this now working from what I perceive to be a rational perspective. It is more difficult to face these things in situations in which rationality may not be the primary criteria for decision.
From systems understanding to systems design
I have always been interested in analysis. As a child this was evident in multiple adventures in taking things apart in order to try to understand how they worked or why they were not working. As an adult my interest in analysis has been manifest in terms of studying object-oriented software, relational databases and service-oriented architectures. Understanding how hospitals function and why public policy often produces unintended results fits the pattern of my interests.
It is all about systems and about dynamic complexity. The basic challenge in hospitals is the existence of two competing basic needs -- the motive to serve and the motive to survive. These two needs play out in patterns of scenarios involving many stakeholders who themselves embody these two needs. The pattern is fractal. In public policy, the core problem is that stakeholders tend to feel threatened by new legislation and can usually find ways to modify their behaviors in ways not intended by those who created the legislation. Plus, our political system itself is in a dysfunctional state such that rational policy making is often not possible. Insight into why things are as they are is one thing. Learning to become a player in the existing system is another. Hoping to improve dysfunctional systems is quite another. As a child I was often frustrated by my having a greater ability to take things apart than to put them back together again. Now as an adult I hope to gain additional abilities not only to understand but to play and to possibly to help design complex systems. My hope is that the field of Public Administration becomes more of a design science, as I think Herbert Simon suggested.
It is all about systems and about dynamic complexity. The basic challenge in hospitals is the existence of two competing basic needs -- the motive to serve and the motive to survive. These two needs play out in patterns of scenarios involving many stakeholders who themselves embody these two needs. The pattern is fractal. In public policy, the core problem is that stakeholders tend to feel threatened by new legislation and can usually find ways to modify their behaviors in ways not intended by those who created the legislation. Plus, our political system itself is in a dysfunctional state such that rational policy making is often not possible. Insight into why things are as they are is one thing. Learning to become a player in the existing system is another. Hoping to improve dysfunctional systems is quite another. As a child I was often frustrated by my having a greater ability to take things apart than to put them back together again. Now as an adult I hope to gain additional abilities not only to understand but to play and to possibly to help design complex systems. My hope is that the field of Public Administration becomes more of a design science, as I think Herbert Simon suggested.
Saturday, December 25, 2010
Julie Salamon Interview
I am continuing to experiment today to see how this blog can be used. This is part of an interview of Julie Salamon, author of a book titled, Hospital. This is the YouTube link to the same interview. In the interview she talks about the possible consequences of the United States going to a single payer system.
Tomato soup no longer included
I am feeling substantially better this Christmas day, having endured outpatient surgery about a week ago. I have been lucky so far in life not to have required much medical care. Reflecting upon this recent surgery has brought back memories of a surgery experience in Athens, Georgia several decades ago. That was an inpatient experience. The themes are similar, with variations.
In Athens I was visited by a nun and by the assistant to the CEO of the hospital. I think a visit by a nun was common. When the assistant to the CEO entered I had the clear impression that his projected but unspoken question was, "Why are you here?" I was working as a consultant for the hospital across town at the time writing a certificate of need application that involved a competition between the two hospitals. My sense was a possible concern that I might somehow be spying for the other hospital. If that had been the case I certainly had chosen an unlikely implementation of such intent.
I still remember details of that experience decades ago. I remember actually seeing the operating room prior to anesthesia and thinking to myself the title, "A Clean Well Lighted Place" from a short story by Ernest Hemingway. The evening before the anesthesiologist had visited me in my hospital room. The intent of the visit was surely to comfort me but I was not comforted by his coughing. I felt no sense of professional bonding with him. The surgery itself apparently went well. My best memory of the experience was the tomato soup served that evening, and the additional serving of it the kitchen prepared for me later in the evening upon my request.
My recent experience in Albany had similar themes, although it was outpatient surgery. I noticed that a blanket I was given prior to surgery in a preparation room was warm. That was nice. It was the "tomato soup" of this experience. But again I had some issues regarding the anesthesiologist. In the "theater of blue hairnets" I was lead to understand that a particular person would be my anesthesiologist. I was able to briefly tell him of my concerns and felt comforted by his professional manner and understanding. Another caregiver spoke well of him, which I found reassuring. Then when it came time to "roll" again I was approached by another person who appeared to me to be an apprentice. When he said something about anesthesiology I explained that I was not his patient. Apparently the first person I had spoken to had been called out of the room and I had made no reservation for his services! That conversation with the person who appeared to me an apprentice was not following an upward pathway as I tried to express my concerns. Then another person unknown to me appeared who stuck me as being more experienced and I concluded (correctly or not) that he was really my anesthesiologist and that the person I did not intuitively trust was his associate, assistant and/or apprentice. The patient representative who had so efficiently introduced herself and disappeared was nowhere in sight. I was hardly in a position to argue in my blue hairnet as I was rolled around the corner into a corridor, the end of which I did not see. I assume that there was a clean, well-lighted room at the end of the corridor, but was not awake to see it. Thankfully, my surgeon who I trust had visited me prior to my conversations with others described above.
I guess there are three themes here. One, in three decades things have changed but much has remained the same. Two, small things matter. I remember two bowls of tomato soup over thirty years later! I will remember the warmed blanket hopefully for at least another thirty years. Three, relationships matter and there is little time for relationships to take shape in an outpatient surgery. Patients generally get to choose their physicians/surgeons but apparently not their anesthesiologists. It seems to be luck of the draw. I even wonder if surgeons get a voice in the selection of an anesthesiologist. I know this. If I have to have any additional surgery I am going to ask my surgeon if he or she has a preferred anesthesiologist, and if so, try to reserve the services of that person!
In Athens I was visited by a nun and by the assistant to the CEO of the hospital. I think a visit by a nun was common. When the assistant to the CEO entered I had the clear impression that his projected but unspoken question was, "Why are you here?" I was working as a consultant for the hospital across town at the time writing a certificate of need application that involved a competition between the two hospitals. My sense was a possible concern that I might somehow be spying for the other hospital. If that had been the case I certainly had chosen an unlikely implementation of such intent.
I still remember details of that experience decades ago. I remember actually seeing the operating room prior to anesthesia and thinking to myself the title, "A Clean Well Lighted Place" from a short story by Ernest Hemingway. The evening before the anesthesiologist had visited me in my hospital room. The intent of the visit was surely to comfort me but I was not comforted by his coughing. I felt no sense of professional bonding with him. The surgery itself apparently went well. My best memory of the experience was the tomato soup served that evening, and the additional serving of it the kitchen prepared for me later in the evening upon my request.
My recent experience in Albany had similar themes, although it was outpatient surgery. I noticed that a blanket I was given prior to surgery in a preparation room was warm. That was nice. It was the "tomato soup" of this experience. But again I had some issues regarding the anesthesiologist. In the "theater of blue hairnets" I was lead to understand that a particular person would be my anesthesiologist. I was able to briefly tell him of my concerns and felt comforted by his professional manner and understanding. Another caregiver spoke well of him, which I found reassuring. Then when it came time to "roll" again I was approached by another person who appeared to me to be an apprentice. When he said something about anesthesiology I explained that I was not his patient. Apparently the first person I had spoken to had been called out of the room and I had made no reservation for his services! That conversation with the person who appeared to me an apprentice was not following an upward pathway as I tried to express my concerns. Then another person unknown to me appeared who stuck me as being more experienced and I concluded (correctly or not) that he was really my anesthesiologist and that the person I did not intuitively trust was his associate, assistant and/or apprentice. The patient representative who had so efficiently introduced herself and disappeared was nowhere in sight. I was hardly in a position to argue in my blue hairnet as I was rolled around the corner into a corridor, the end of which I did not see. I assume that there was a clean, well-lighted room at the end of the corridor, but was not awake to see it. Thankfully, my surgeon who I trust had visited me prior to my conversations with others described above.
I guess there are three themes here. One, in three decades things have changed but much has remained the same. Two, small things matter. I remember two bowls of tomato soup over thirty years later! I will remember the warmed blanket hopefully for at least another thirty years. Three, relationships matter and there is little time for relationships to take shape in an outpatient surgery. Patients generally get to choose their physicians/surgeons but apparently not their anesthesiologists. It seems to be luck of the draw. I even wonder if surgeons get a voice in the selection of an anesthesiologist. I know this. If I have to have any additional surgery I am going to ask my surgeon if he or she has a preferred anesthesiologist, and if so, try to reserve the services of that person!
Patient Advocacy and Knowledge Management
This Christmas morning I am reading a blog post by Jacqueline O'Doherty titled, Dissecting the role of a patient advocate.
http://www.hospitalimpact.org/index.php/2010/12/22/patient_advocates_guide_patients_through
She writes as if she has real power in the decision making process. It seems to me that a patient advocate is in the midst of a very complex set of participants in which there really is no centralized power. I am thinking of dynamic models of complex adaptive systems that tend over time to switch between multiple patterns called "attractors." The situation was in one attractor prior to the patient's unexpected massive stroke. Then the entire system shifted into a very different attractor. The system has a life of its own, so to speak. No one is really in charge.
Jacqueline O'Doherty writes that she called a meeting attended by every doctor and other major caregiver. She writes that this meeting allowed everyone to understand and be on the same page concerning the patient's diagnosis and prognosis. I remember "calling" such a meeting once years ago when I was a patient advocate for my father. I was only a teenager and found myself alone in a room with perhaps eight physicians and other care providers. I was his family. To the best of my ability I spoke his preferences and values when he could not speak them himself. They took time to explain the situation to me from their professional perspectives. It was quite an amazing experience.
As I think about what Ms. O'Doherty has written I realize that patient advocacy is more than knowledge management. But it seems to me that knowledge management is a major part of it. I don't think it is possible or practical to always call a meeting. Otherwise, physicians and other providers would spend most of every day sitting at a table. It is like a dance in which the music sometimes suddenly changes. It is not a square dance with a caller. I keep remembering Mary Parker Follett writing about supervision and authority. In her view, it is not about which of us leads. It is about how we respond together to what we face. But to understand how this scales up to large numbers of medical providers, insurance companies, administrators, and family members (plus the patient, of course) is quite a challenge.
http://www.hospitalimpact.org/index.php/2010/12/22/patient_advocates_guide_patients_through
She writes as if she has real power in the decision making process. It seems to me that a patient advocate is in the midst of a very complex set of participants in which there really is no centralized power. I am thinking of dynamic models of complex adaptive systems that tend over time to switch between multiple patterns called "attractors." The situation was in one attractor prior to the patient's unexpected massive stroke. Then the entire system shifted into a very different attractor. The system has a life of its own, so to speak. No one is really in charge.
Jacqueline O'Doherty writes that she called a meeting attended by every doctor and other major caregiver. She writes that this meeting allowed everyone to understand and be on the same page concerning the patient's diagnosis and prognosis. I remember "calling" such a meeting once years ago when I was a patient advocate for my father. I was only a teenager and found myself alone in a room with perhaps eight physicians and other care providers. I was his family. To the best of my ability I spoke his preferences and values when he could not speak them himself. They took time to explain the situation to me from their professional perspectives. It was quite an amazing experience.
As I think about what Ms. O'Doherty has written I realize that patient advocacy is more than knowledge management. But it seems to me that knowledge management is a major part of it. I don't think it is possible or practical to always call a meeting. Otherwise, physicians and other providers would spend most of every day sitting at a table. It is like a dance in which the music sometimes suddenly changes. It is not a square dance with a caller. I keep remembering Mary Parker Follett writing about supervision and authority. In her view, it is not about which of us leads. It is about how we respond together to what we face. But to understand how this scales up to large numbers of medical providers, insurance companies, administrators, and family members (plus the patient, of course) is quite a challenge.
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