Goodbye to the old; hello to the new

Dear Readers -

Shortly after I started this blog my friend Dan Callahan, President Emeritus of the Hastings Center, suggested that we develop it under the wing of the Center. This was a very appealing idea. The Hastings Center is a recognized and highly respected "brand" in the world of ethics and health policy. While the Center is small, the staff has far more technical skill and media knowledge than I do. Dan, Shep Nuland (Professor of Surgery Emeritus at Yale), Mary Crowley (Director of Communications at the Hastings Center), and I worked together for a few months to develop the concept, gather a group of supporters for the venture, and solve a few technical glitches.

We launched the new blog - Over65 - in August. I encourage anyone who gets to this site to visit. I thought "Seniors for Medicare Reform" was a great idea when I started in in January. "Over65" is a way better idea. I'm excited to be working on it.

This will be the last post on "Seniors for Medicare Reform."

Best to all

Jim

Doctors Die Differently

Many years ago, my late father received a recommendation for carotid artery surgery. He had no symptoms, but his physician was concerned about kinking and possible narrowing of the artery. I described the situation to a vascular surgeon colleague. He thought the recommendation was questionable. I encouraged my father to talk further with his physician about the procedure In their discussion the physician said - "I'm a worrier - I would do this for myself. But now that I hear more about your values, I don't think you should do it."

This exchange should have occurred before the recommendation was made. But the physician was commendably self aware and honest. (The artery never caused problems. My father died years later, at 89, of other causes.)

 When I was in clinical practice, patients sometimes asked me what I would do if I were in their situation. I thought this was a reasonable question. Interest in how our physicians care for themselves is more than idle curiosity. Their choices don't establish "truth." But knowing how they handle their own care and the values they bring to bear on their choices is useful "data" for our own reflection.

In a recent Wall Street Journal article - "Why Doctors Die Differently" - Dr. Ken Murray, a retired Assistant Professor of Family Medicine at the University of Southern California, tells how a physician mentor and a cousin both chose "low tech" end of life care for themselves. Dr. Murray cites a study of elderly graduates from Johns Hopkins Medical School that supports his anecdotes - a large majority would refuse a range of life-sustaining treatments. Here's how Dr. Murray puts it:

It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.

Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).

Dr. Murray speculates that when patients ask their physicians how they would handle their own end of life care, we physicians are reluctant to answer. Though I haven't seen any research on the issue, his guess could well be right. End of life care involves the most personal choices we make, and physicians may hesitate to (a) reveal their own values and (b) exert too much influence.

But good medical care requires conversations of this kind. All too often overly intrusive end of life care happens by default. As a symptom of our pathological political culture, a proposal to reimburse primary care physicians for discussing our values for end of life care with us elicited (a) an accusation of "government death panels" from duplicitous politicians and (b) a mini-epidemic of public paranoia.

Why ICDs Shouldn't Always be Replaced

The implantable cardioverter-defibrillator (ICD) can save lives by recognizing a life threatening heart arrhythmia and immediately shocking the heart back to a normal rhythm. More than 100,000 are implanted each year.

ICD batteries last an average of five years. Here's how the Mayo Clinic talks about battery life:

The lithium battery in your implantable cardioverter-defibrillator can last up to seven years. During your regular checkups, which should occur every three to six months, your doctor or nurse will check the battery. When the battery is nearly out of power, your old shock generator is replaced with a new one during a minor outpatient procedure.

Notice how the final sentence suggests that replacement will automatically be done. There's no reference to the patient's preferences. The implication is that once an ICD is implanted, it will be with us until we die.

An article in the January 26 New England Journal of Medicine - "Time for a Change - A New Approach to ICD Replacement" challenges that assumption. Health status and life circumstances may have changed since implantation such that sudden death from an arrhythmia now looks like a blessing, not a curse.  Or our experience with the ICD may make us not want to replace it.

The authors describe how in our all-too-often fragmented system of care no one physician is responsible for helping the patient decide whether the battery should be replaced. The care system goes onto automatic pilot. As the Mayo Clinic says - the "old shock generator is replaced with a new one during a minor outpatient procedure."

The authors' recommendations are so obviously sensible it's surprising they aren't routine:

1. A comprehensive medical evaluation should be done before ICD replacement.
2. There should be clear and full communication among the entire medical team.
3. The patient's preferences, past experience with the ICD, and advance care planning, should be explicitly included in decision making.
4. Replacement should only be done if the patient wants it to be done!

I haven't been part of decision-making about an ICD, but I have observed how medicine can go onto automatic pilot. At the end of my first stepmother's life (my father was a three-time widower) she was suffering from terrible shortness of breath. She was put onto a ventilator for comfort. Over a day or two the coma she was in from cancer that had spread to the brain deepened. The ventilator, which initially had relieved suffering, was now prolonging the dying process. I pointed this out to her children (my step-sibs) and they authorized withdrawal of the ventilator, allowing their mother to die peacefully, unattached to any machines.

Not automatically replacing ICDs will save money, but it's not death panel rationing. Ascertaining what our true wishes are and following them is the right way to practice medicine!

Should We Accept Kidney Donation from our Children?

I've been looking into the phenomenon of organ donation from children to parents. Since I believe our national approach to Medicare injures future generations on behalf of us in the over 65 cohort, I wanted to see how we're dealing with the most tangible form of intergenerational transfer - organ donation.

Here's what the Handbook of Kidney Transplantation has to say about donation from children to parents:

Parents often are reluctant to turn to their children as potential donors, yet as those parents age, it becomes less and less likely that a donor from their own generation will be available. It is useful to point out to parents that their grown children are adults who are capable of making independent decisions; that the welfare of the donor will be protected in the evaluation and donation period; and that, if they exclude their children as donors, they may be preventing them from enjoying the psychological gain of helping a beloved parent. Older patients will often insist that they would have been prepared to donate to their own parents while simultaneously expressing reluctance to permit their own children to donate to them.

To my eye, the author evinces an unseemly rush to persuade us that it's right to cannibalize our children's bodies. He treats reluctance to accept kidney donation as an irrational stance. And with regard to the donor, he minimizes concern for physical and psychological risk, and envisions only "psychological gain [from] helping a beloved parent."

By way of contrast, Sharon Kaufman, professor of anthropology at UCSF, has written a wonderfully thoughtful article based on interviews with kidney recipients over 65 and their donors - Aging bodies and kinship matters: The ethical field of kidney transplant. She demonstrates that attitudes range from what I would call "entitlement" (in effect, "I have a right to your kidney so that I can go on living") to a view that transfer of body parts from child to parent is wrong (in effect, "if you need a kidney I should give it to you, but absolutely not the other way around").

Here's a vignette from a patient who ultimately accepted a child-to-parent donation:

The children talked me into it. I said, I’m not taking my daughter’s kidney! But other family members persuaded me. You know, I kind of went along with my older daughter’s insistence, and we didn’t say too much one way or another, whether I wanted to or not. But I was hopeful that I could get a cadaver—right up to the night I was hospitalized. My point was, I didn’t want to take an organ from my child. If it were the other way around, I would have gladly given my kidney to one of them, but because it was coming as a hand-me-up sort of thing, I thought about it a lot. It didn’t feel like it was the right thing to do. Help should go the other way, from parent to child. I, really, there were periods of time I just really didn’t want to do it. There was no real point in time where I decided I wanted to have it done. I just went along with the flow. I was going along for the ride because things were being arranged for me.

The clinical and ethical issues will vary from family to family. Parental age matters. A 50 year old still raising children who dies from kidney disease is "abandoning" dependents and missing out on half of adult life. An 80 year old has lived a full life span. I don't know how others would assess the ethics of taking a child or grandchild's kidney at that age. In my view it would represent monstrous narcissism.

The fact that the 2010 Handbook of Kidney Transplantation discusses child-to-parent transplantation as if the only moral issue was clearing away impediments to going ahead suggests the degree to which the technological imperative to do what is technically possible to do has gone onto automatic pilot. Organ donation from a child to a parent demands careful medical, psychological and ethical attention. It deserves better than the superficialities the Handbook offers.

Don't Let Medicare Undermine the Health of Future Generations!

Zeke Emanuel, who is becoming the national educator-in-chief about health care in his new role at the University of Pennsylvania, preaches an excellent sermon in today's New York Times - "What We Give Up for Health Care."

Zeke's point is obvious, but, amazingly, it's one our political process has been oblivious to: what we spend on health care we can't spend for other purposes. That creates an ethical imperative to consider opportunity costs for health care expenditures. The proper question is - "does this health care expenditure create more human benefit than other possible expenditures?" - rather than the one we typically ask - "does this health care expenditure produce any benefit for the patient, no matter how small the benefit or how high the cost?" Zeke shows how health care costs have acted as an economic cancer, invading and obliterating investments we would otherwise make in wages (which have been stagnant or declining), education, and other crucial components of our lives.

As important as medical care can be, income and education are also crucial determinants of health. When we reduce wages to pay for health insurance, and reduce educational investments at every level to pay for Medicare and Medicaid, we're reducing overall health and well-being. The real "death panel" is our reflexive investment in medical interventions that produce minimal or no benefit at the cost of investments that would do more for us!

Zeke argues that "liberals" should be as concerned about health care costs as "conservatives" are:

There is an inevitable trade-off between rising health care costs and things liberals really care about, like access to college and good wages for working Americans. We cannot have it all. The health care reform act will help us save — mainly by changing how physicians and hospitals are paid and delivering better care to our most expensive patients. But more can be done: for starters, we could speed up the implementation of payment reform, stop Medicare payments for tests and treatments that provide no benefit and endorse competitive bidding for medical goods and services.

The premise of this blog is that many of us in the Medicare age group - whether we're "liberal" or "conservative" - share a concern about the future, and don't want current Medicare expenditures to undermine the health and well-being of future generations.

Avoiding overtreatment, and the moral imperative to consider opportunity costs, should be our relentless advocacy focus!

Changing End-of-life Care

When I told my colleague, dear friend, and mentor, Gordon Moore, about this new blog, he showed me the draft of a proposal he had written for Medicare reform. Gordon and I have worked together and exchanged ideas regularly for more than 30 years, so it's not surprising that we agree that we in the Medicare generation are key for reforming the program and reducing its costs. He gave me permission to print what he'd written and to tweak it for length:

To my fellow Medicare recipients, 

I am a retired general practicitioner, now on Medicare.  Like many of you, I am feeling guilty and at the same time defensive about the claim that Medicare expenditures threaten the economic well-being of America.   Defensive because I feel I have earned the right to have good medical insurance as I get older.   But guilty because I know that the growth rate of Medicare does, indeed, threaten the future of our children and grand children.

As I watch the partisan fighting in Congress, I have become increasingly dubious that our government will be able to solve the problem of Medicare costs.  Both sides have staked out positions that block compromise. We are in a stalemate that threatens the nation’s future.

I have concluded that only we Medicare recipients are capable of stepping up to the plate and resolving this dilemma.   I am reminded of Pogo’s famous comment that ‘we have met the enemy and he is us.’

So how could we solve this problem? One answer is that we individually volunteer to remove Medicare expenditures that are wasteful. The greatest waste is in end-of life care.  We spend almost 30% of the Medicare budget on care that ends with death in a year or less.  As a doctor, I saw time and again the relative futility of aggressive medical care in the last months of life.  Not only did I know that such care was vanishingly unlikely to prolong life by any meaningful length, but I also watched the quality of life plummet as aggressive medical care led to hospitalization, loss of function, and prolonged pain and suffering. 

I promised myself that, like Elizabeth Edwards, at a certain point when my doctor calculated that the odds of meaningful survival were low, I would choose to be at home with my family, to receive hospice services for comfort only, and die in dignity. 

How would we know that the time had come to make such a choice?  As a primary care physician, I almost always knew the odds that intensive care would no longer help.  And yet I was relatively ineffective in helping many of my patients accept that conclusion.  Part of the problem is that most doctors find it hard to accept that there is nothing more that they can do to produce a cure.  And for most patients and families, insurance makes care seem “free,” so why not do “everything”?

But we are discovering that this care isn’t free.  It’s just that we are asking our children and grandchildren to pay for our expenditures by reducing the prospects for their own lives.  I’m very uncomfortable with the idea that our end of life care is hurting the generations that follow us, especially “care” that is associated with a miserable quality of life and maximum distraction when our real need is to be comfortable and at peace to come to our own terms about dying.   

So I have been thinking about whether we could start a campaign to reduce the expenses of our own end of life care.  If most or all of us committed ourselves to ask our doctors to inform us when the odds of recovery or significant prolongation of quality of life had dropped below a specific figure (like 1 in 5 or 1 in 10) and if we further committed to asking that all but supportive comfort care be stopped, we could make a significant dent in Medicare’s risking costs.  

But this prospect makes me confront a major barrier to my own participation - that the savings would disappear into relieving our sovereign debt.  That would feel like paying taxes - at best it's a duty, at worst it's taking the money from my sacrifice and using it for many things with which I disagree. 

 As I thought about this, I came to the conclusion that were I to relinquish my ‘right’ to unlimited expenditure at the end of life, I would want it put to a good purpose that would be sufficiently specific to make me proud and others grateful.  

My proposal is that we earmark these savings to make the generations that follow healthy and productive, to make it possible for them to achieve the quality of life that my generation has been able to enjoy.  

To do this I propose that we form a National Health Fund to which our individual contribution, calculated actuarially, be made when we forgo high cost/low yield end of life “care.” This fund would be used in the best way we know to assure healthy productive young people capable of contributing to our common good – to combine public health, education and personal care in initiatives to address the major behavioral factors that lead to illness and disability – obesity, lack of exercise, violence, and smoking.  There is little we could do in personal medical care that would deliver as much improvement in the health of our nation.

We Medicare recipients are capable of improving care and reducing costs.  We can be the generation that says ‘it’s not all about me.’ We can lead the way to a new level of civil discourse about the future of America.  Our parents did this for us with their sacrifices during the Great War; isn’t this crisis the war that we can fight to make this country better for our children?

I want to (a) thank Gordon for letting me publish his vision of Medicare reform and (b) invite other readers to send me their best ideas!

Is Death Optional?

An old joke spoofs the way we in the U.S. think about death:

In India, death is seen as a potential step away from reincarnation and towards blissful Nirvana. In Europe, death is seen as an existential tragedy we must face. In the U.S., death is seen as optional!

Last summer, Daniel Callahan, author of "Taming the Beloved Beast: How Medical Technology Costs are Destroying our Health Care System," and Sherwin Nuland, author of "How We Die: Reflections on Life's Final Chapter," (both have written many other books as well) took on the American myth of eternal youth in the New Republic. They argued that "the war against death as the highest priority should give way to a new goal: aiming to bring everyone’s life expectancy up to an average age of 80 years (already being approached), reducing early death, and shifting the emphasis in the direction of improving the quality of life of those in every age group. The highest priority should be given to children, the next highest to those in their adult years (the age group responsible for managing society), and the lowest to those over 80."


This is the kind of discussion we need to have in the U.S. in place of the vacuous tit-for-tat between Republicans and Democrats over who loves Medicare the best and who is out to destroy it. Medicare is an amazing achievement for a society in which many, perhaps a majority, agree with President Reagan that "government is not the solution to our problems; government is the problem." Medicare is cherished by its beneficiaries and by the generation concerned about care for their parents. Medicare's popularity is so deep that it's been known as the "third rail" of American politics since the Clinton presidency. Touch it and you're dead!

Callahan and Nuland could argue for giving priority to children and younger adults because they're both over 80. The ordinarily lethal accusation of being "granny bashers" is hard to pin on grandparents themselves. I'd guess that in a forced choice, a majority of Medicare recipients would agree with Callahan and Nuland's perspective.

Medicare costs must be brought into line with general inflation. But we won't make progress until our political leaders develop more backbone, and that won't happen until they hear from us Medicare constituents ourselves. I think the right starting point for that advocacy process is for those of us in the Medicare age group to demand that Medicare focus more on interventions that promote quality of life and less on costly hi-tech interventions that may forestall death by prolonging deterioration and suffering.

As Callahan and Nuland noted in their article, this will require a heightened political and medical awareness among Medicare recipients, and will engender economic losses for those who currently profit from the way health care is provided. Overtreatment is always bad medicine, but it can be economically rewarding for those who provide it inflict it.

In a followup to the New Republic article cited above, the July 3 New York Times featured a letter on the topic from Dan Callahan along with several responses. Among the responders, Doris Fenig wrote "We are a very strong lobby. We have a very loud voice. Let’s use it...for 'common civic sense.'"

Doris got it right! Her letter was one of the prods for me to start this blog.

[This post is a tweaked version of a post I wrote on my healthcareorganizationalethics blog shortly after the Callahan/Nuland article appeared.]

Going to Heaven with our Stitches in

A team at the Harvard School of Public Health published a disturbing article in Lancet on "The intensity and variation of surgical care at the end of life."

The group studied the 1.8 million Medicare beneficiaries who died in 2008 to determine the frequency of surgery during the last year of life. 32% had an inpatient surgical procedure during their last year. 18% had surgery during their last month. And 8% had surgery during their last week.

This is a population study, so it doesn't tell us how often the surgery was required by the patients' true needs and wishes. But I'd bet dollars to pennies that most readers of this post have seen surgery done in situations where a better informed patient and family would have rejected the proposal.

My beloved late father-in-law, who I wrote about two days ago, was vigorous until he turned 90, at which time angina limited how far he could walk in New York City's Central Park. Early in his life he'd been in the plumbing supply business, so when a revascularization procedure was proposed to him he thought of it as a common sense plumbing repair. He didn't consult with his family before deciding to do it. The result was five months of intractable heart failure before his death.

He was a gentle, fair-minded man and forgave his physicians for a recommendation they shouldn't have made and he shouldn't have accepted: "My doctors were young men. They were thinking about young hearts, not about 90 year old hearts."

Dr. Ashish Jha, leader of the Medicare study, told a similar story from experience at his own hospital:

A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine.

“No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.”

Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.

The man died of a complication from the surgery.

“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea.”

Instead, Dr. Jha said, “we sent him to the O.R.”

The election year concern is with Medicare costs. But the primary problem for my father-in-law and the patient Dr. Jha describes is care, not cost. Overtreatment is a serious problem for Medicare beneficiaries. More appropriate care for folks like my father-in-law and Dr. Jha's patient would have had the secondary benefit of reducing cost. That's better medicine, not "death panel rationing"!

[This post is a slightly modified version of a post I wrote in October on my  healthcareorganizationalethics blog.]

Raising the Age of Medicare Eligibility - First Prize Dumb Idea

This week the Congressional Budget Office released a report on proposals to raise the age of eligibility for Medicare and Social Security.

The CBO concludes that raising Medicare eligibility to 67 would reduce federal spending by $148 billion between 2012 through 2021. By 2030, Medicare's net spending would be reduced by 5% - 4.7% of GDP rather than 5%. Those numbers sound good.

But reducing federal expenditures doesn't reduce the need for medical care. Some lucky folks (I'm in that category) (a) have employment that provides health insurance and (b) are happy to continue working. Some who would rather retire will continue to work, increasing health care costs for their employer (and fellow employees). Some will scramble to find alternatives which will cost them more than Medicare would. And some will become uninsured, at an age when this is progressively risky. Overall costs - to individuals, employers and other government programs would probably go up more than the $148 billion reduction in Medicare outlays.

The CBO does not comment on the fact that employers are not clamoring for ready-to-retire employees to stay on the job simply to avoid being uninsured.

Raising the Medicare eligibility age isn't meaningful cost reduction - it's simply a form of hot potato, dumping the costs into other accounts. It intensifies the fragmentation of our health system, and worsens overall quality of care.

In my view, the proposal is born out of despair about achieving constructive Medicare reform in which health professionals, patients and families collaborate on behalf of improved care (basically more compassion and less technology) and reduced costs. From 35 years of practice in a not-for-profit HMO setting I know this kind of collaboration is possible. But it requires a spirit of cooperation and trust that is not easy to find in our toxic political environment. 

When Will We Die?

The most recent issue of the Journal of the American Medical  Association has an important article, with an accompanying editorial, on the effort to predict life expectancy for patients over 60.

My armchair research (conversation with friends) suggests that our Medicare cohort has two antithetical fears about longevity and medical treatment. Some fear we'll be flogged with aggressive interventions way beyond the point of usefulness. Others fear we'll be consigned to the grave too quickly, and even if not actually buried alive, won't be offered interventions that could reasonably be expected to provide significant quality of life.

I'm on a week's holiday in Puerto Rico. This morning another guest was playing good tennis on the adjacent court. When we chatted later he told me he'd had a total knee replacement two years ago. He enjoys skiing and tennis. He's experienced impressive improvement in the quality of his life.

In contrast, 13 years ago my beloved father-in-law, 90 at the time, experienced angina that limited his walking. His physicians recommended a surgical revascularization procedure. He was an activist, and without telling anyone in the family until the night before he went into the hospital, scheduled the surgery. The results were catastrophic - an extended period of delirium and progressive heart failure. He declined rapidly and died after a few miserable months. Poignantly, his oldest grandson's best friend is a distinguished cardiovascular epidemiologist. Had he been consulted, he would have given a strongly evidence-based recommendation against the procedure.

My father-in-law was a thoughtful, forgiving man. He said  "my doctors were young men [i.e., in their 50s]. They were thinking about young hearts, not about 90 year old hearts."

The article identified 16 systems of prediction that show reasonable accuracy, but none were good enough to be recommended for routine use in practice. The editorial urges physicians to (a) consult readily available life tables (predicted longevity by age, race and gender) and then (b) consider individual factors. Here's the relevant passage:

These calculations could be facilitated through use of an electronic comorbidity and functional status. Lung disease requiring regular use of corticosteroids or supplemental oxygen, New York Heart Association class III or IV congestive heart failure, renal disease requiring dialysis, advanced dementia, inability to walk more than a block, and need for personal assistance with bathing are examples of factors that would reduce life expectancy substantially below the average. The absence of significant comorbid conditions or functional limitations would identify older persons who are likely to live longer than average.

As a starting point, age-, sex-, and race-specific life expectancies (median and interquartile range) can be calculated using data from standard life tables.

The authors have created a remarkable website - ePrognosis - that allows health professionals (identified by self report) to apply relevant tables to their patients. They've also created GeriPal (GERIatrics and PALiative care), a blog for health professionals and others interested in care of the elderly and palliative care. I'm proud that one of the sponsors - Dr. Alex Smith - did his primary care residency in the program I teach in. ( He was a star!)

Conversations based on life tables, individual status, and the patient's guiding values, won't achieve mathematical certainty. But they're crucial elements of wise, compassionate health care decision-making. It was monstrous when politicians branded support for this form of humane medical practice "death panels." We Medicare folks need to fight that form of demagoguery!

An Attack Ad in New Hampshire

Have a look at this TV advertisement attacking NH Representative Charlie Bass for his support of Paul Ryan's Medicare voucher program.

I'd never heard of Representative Bass until the ad came to my attention. The Wickipedia blurb about him suggests that on some issues (abortion rights, environment) he's relatively progressive for a Republican, though he follows party line on the Patient Protection and Affordable Care Act & voted for its repeal.

I have mixed feelings about the ad. I'd like to see Republicans lose their majority in the House. But although I think Paul Ryan's voucher plan is deeply flawed, I think it should be a discussable policy alternative.

The ad reinforces the widely held view of Medicare as a "third rail" of politics. And no matter where we are on the political spectrum, a healthy future - for Medicare and for the U.S. economy - requires opportunity to deal thoughtfully with the need to improve the program and constrain its costs!

Harmful Hospital Errors are Vastly Underreported

In an article by the always informative Robert Pear in yesterday's New York Times we learn that a just-released study from the Inspector General of the Department of Health and Human Services reports that only one in seven errors, accidents, or other events that harm hospitalized Medicare beneficiaries gets recognized and reported. (As of today, the report itself isn't available on line.)


Quality improvement gurus teach that "every defect is a treasure." Sometimes recognizing that avoidable harm has occurred lets us help the involved patient, but there are always important lessons that can prevent repetition and help other patients in the future.


The unreported events were identified from detailed study of hospital records. They included

medication errors, severe bedsores, hospital-acquired infections, delerium from overmedication, and excessive bleeding linked to improper use anticoagulants. The Inspector General calculated that more than 130,000 Medicare beneficiaries experience this kind of injury each month!

What I found most disturbing is the Inspector General's surmise that the primary reasons for the underreporting were (a) not recognizing that avoidable harm had occurred or (b) seeing the incident as so common that it didn't need to be reported.

"Developing a culture of safety" is a common mantra, but we clearly have a long way to go to make it more than an empty cliche.

Fidelity and Stewardship as the Guiding Values for Medicare

I've used this diagram for many years in teaching about the ethics of health care provided to a population within a budget - HMOs, ACOs, VA, public sector mental health, and countries that provide universal coverage. Given the absurdly fragmented system we have in the U.S., it's difficult for patients, physicians and the public to have a sense of the denominator we're part of (the population served under a budget).

I believe the diagram shows the right ethical perspective on Medicare. We want attention to the needs of the individual to predominate in the exam room, but not to the total exclusion of awareness of our responsibilities to others as well as to ourselves. We want attention to the needs of the population to predominate at the policy level, but not to the total exclusion of awareness of the implications of policy decisions on individuals.

Ability to embrace complexity is part of maturity. I'm convinced that if we were able to survey the Medicare population, a large majority would embrace the moral perspective shown in the diagram. Wider endorsement of fidelity to the needs of the individual AND stewardship of shared resources on behalf of the population will provide the ethical basis for doing what we need to do to make Medicare secure for the future.

My aim for this new blog is to encourage my fellow members of the Medicare community to give stronger voice to fidelity AND stewardship as the proper guiding values for Medicare reform.

Two Common Sources of Overtreatment

Experts, most recently former CMS administrator Don Berwick, tell us that 20% - 30% of medical care is "waste." At the very least, "waste" is harmful to all those who pay for Medicare. But often it's directly harmful to the patient as well.

I recently saw a friend at a holiday party. Since we'd last seen each other my friend's spouse had died. (I'm deliberately avoiding gendered pronouns and omitting other identifying details.) My friend contrasted the excellent hospice care with problem-ridden hospital care. Here are two examples of "waste" that were thwarted only by my friend's vigilance.

My friend's spouse ("the patient") was declining rapidly, and was admitted to the hospital. While my friend was attending to some bureaucratic aspects of the admission, the hospitalist ordered a CT and insertion of a "picc line" ("picc" = "peripherally inserted central catheter").

On returning to the patient's bedside my friend pointed out that an identical CT scan had been done four days earlier.

The hospitalist responded - "I don't have it."

My friend replied - "Rather than putting such a sick person through another CT and spending another few thousand dollars, let's get it."

With regard to insertion of the catheter, my friend asked: "what aspect of the plan does it serve?" The answer was - it was an automatic part of a protocol, not tailored to the wishes of the patient and family. When their goals were clarified, the picc line idea was dropped.

I know from my own practice experience that getting test results and records can be difficult. But repeating an identical test four days after it had been done elsewhere is a very expensive workaround that would have imposed avoidable distress on the patient. And although threading a catheter to place near the heart is a fairly routine hospital procedure, it carries risks (such as infection) and burdens (being hooked up to tubing). The hospital protocol should have required clarity about treatment goals before a non-emergency intervention was set into motion.

What struck me about these examples of overtreatment is how mundane they were. The hospitalist meant well. It was important for him to have the information the CT scan would provide, but repeating it wasn't the right way to get it. And having routines can promote patient safety - but only when the routine is tailored to the true situation. In a non-emergency, clarity about the treatment goals of patient and family should be part of the what we routinely expect of ourselves.

How to Make Medicare Go Broke

Zeke Emanuel and Steve Pearson, colleagues I admire greatly, have an Op Ed in today's New York Times that shows how our current way of running Medicare will ultimately send the program down the tubes.

Here's the first paragraph, and the gist, of their argument:

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

Proton beam is a form of radiation that uses atomic nuclei rather than other sources of energy, such as gamma rays, x-rays, or electrons. Proton beams have less scatter, theoretically making it possible to provide more narrowly focused treatment, which, again theoretically, could allow more vigorous treatment of a cancer with less injury to surrounding tissues.

The key word is "theoretically." Proton beam fulfills its promise for relatively rare radiosensitive cancers in children and some rare nervous system tumors in adults. But for its widest use - prostate cancer - there is no evidence for superior outcomes. Medicare payment policy, however, results in a fee of about $50,000, twice as much as equally effective forms of radiation.

Facilities like Loma Linda in California, M.D. Anderson in Texas, Massachusetts General Hospital, University of Pennsylvania, and now two Mayo Clinic sites, are eager to pilot new forms of treatment and to maintain their competitive position in U.S. health care. You can get a sense of how actively marketed proton beam is from the Loma Linda website.

Zeke and Steve identify three alternative Medicare payment policies:

1. Refuse to pay for proton beam except for  diseases where there is solid evidence for clinical superiority. This is what most private insurers do - as an example, see Aetna's detailed policy.
2. Use the option of providing "coverage with evidence development," an approach whereby Medicare would cover proton beam for prostate and other cancers, but only for patients enrolled in a randomized trial comparing the treatment to its alternatives.
3. "Dynamic pricing" - a system whereby Medicare would pay more for proton beam, but only for diseases for which the treatment has been shown to be more effective than the alternatives.

We seniors need to demand that Medicare follow the policies Zeke and Steve argue for. Doing so will (a) protect us from economically-driven recommendations for treatments we don't need, and (b) help to constrain Medicare costs so that (c) future generations can have the same advantages we have. What they propose isn't rationing - it's prudent spending for demonstrated value. That's something we do in our own lives all the time!

[Zeke and Steve's analysis sets in after treatment for prostate cancer has been recommended. Alas, there's lots of reason to believe that many men are treated for cancers that would not have impaired their health or longevity. Overuse of the PSA test is another story for another time, but if you're interested, there's an excellent NPR interview  with Dr. Gilbert Welch, author of Overdiagnosed: Making People Sick in Pursuit of Health.]

The Right Foundation for Medicare Reform

When I recently spoke with a friend about my conviction that U.S. political process needs a voice from Medicare beneficiaries advocating for a progressive and sustainable approach to Medicare, I told him that although I don't have survey data to draw on, I believe that many of us folks in the Medicare generation are worried about the impact of runaway Medicare costs on future generations. We're not all like the belligerent elders in the AARP advertisement who warn politicians - "if you want my vote, don't touch my Medicare."

My friend responded with an aphorism I'd never heard before:

The true meaning of life is to plant trees under whose shade you do not expect to sit.

I do a lot of walking in the woods and love trees, so the aphorism moved me.

I went back to Erik Erickson, to review his interpretation of the stages of life. I discovered that I misremembered his schema. I mistakenly thought Erickson named the healthy approach to aging "generativity." Erickson actually posits that as the virtue for adulthood. "Wisdom" is what he ascribes to the successful 65+ folks. It's opposite is despair.

Erickson may have been on target when he formulated his views 50 years ago, but I think he's wrong for the present. "Wisdom" as he conceptualizes it involves reflecting on the meaning of one's life. That sounds passive and somewhat narcissistic. What I see, and experience, in the Medicare set, is much better described as a quest for "generativity." The question many pose for themselves is - what can I contribute to the world at this phase of life?

Current political dialogue offers two choices for Medicare policy - "don't touch Medicare" or "tinker with the mechanics - raise the age of eligibility or replace Medicare with a voucher to buy insurance."

No one is talking about a cooperative enterprise in which Medicare moves to sustainability via patients and clinicians cooperating to create a more caring, less technological, approach within an overall budget that doesn't saddle the next generations with crushing debt. This kind of patient-physician collaboration promotes the best care for individuals. And at the health system level it will promote the best direction for Medicare reform.

(The aphorism comes from the title of a book by Wes Henderson (1928-2003), a third generation Canadian, about his father Nelson. It's the advice Nelson gave Wes when Wes graduated from high school.)

Seniors for Fair Medicare Reform

I started my first blog - health care organizational ethics - in August 2007. Here's how I described why I was doing it:

Medical ethics has traditionally focused on the individual patient, the individual doctor, and the patient-doctor relationship. But today most care occurs in organizational settings – group practices, HMOs, VA and more. Insurers and other third parties have a huge influence on the exam room. Medicare shapes care for the elderly and disabled. Medicaid does the same for the poor. Hospital cultures and policies affect what sick patients experience, for both better and worse.

All this means that the ethical quality of health care is profoundly influenced by the ethics of organizations. We can’t have ethical health care without ethical organizations.

Organizational ethics is what this blog is all about.

But my 2007 rationale for the "health care organizational ethics" blog overlooked a major problem. Organizations like hospitals and medical practices live in a mega-organization - the disastrously dysfunctional U.S. political system. With regard to Medicare, the "death panel" lies during the health reform "debate" and Republican refusal to confirm Don Berwick as CMS administrator showed just how toxic our political culture has become. This new blog will include politics.

Medicare has been called the third rail of politics. If you touch it, you're done for. A recent AARP advertisement, directed to the ill-fated "super Committee" reinforced the point. It shows an army of folks around my age marching and looking tough, while the narrator/leader intones:

"Washington, before you even think about cutting my Medicare benefits...here's a number you should remember - 50 million. We are 50 million seniors who earned our benefits, and you will be hearing from us, today, and on election day."

Here's what I thought an ethically grounded ad would have said:

"Washington, before you even think about cutting Medicare benefits, think about fairness. We 50 million seniors want to do our part to ensure a healthy future for America. We know that for that to happen, Medicare has to cost less. But we want to be part of a team, and that means everyone sharing the burden, including adding new revenues..."

I don't think politicians will get creative about Medicare until Medicare beneficiaries push them. So far there's been no voice from the many seniors who want to improve the care provided under Medicare and, at the same time, to reduce the costs. We're concerned about ourselves, but whether or not we have children and grandchildren we're also concerned about the health of future generations.

I'm insured through my employer, but I'm Medicare eligible. When I'm insured through Medicare, please tell me to wash my mouth out with soap if I call it "my Medicare." It's not just "mine," it's "ours." My payments into the Medicare fund from 1965 on paid for the care of my elders, including my parents. When I'm a beneficiary, my care will be paid for by the younger generation. Medicare is a matter of communal responsibility, not the private property of the 65+ generation.

Age is supposed to be a source of wisdom. Calling for teamwork and shared sacrifice is what my generation should be advocating for. The AARP advertisement invites definition of us seniors as "greedy geezers." I'm hoping this new "Seniors for Medicare Reform" blog will contribute to developing a strong voice from seniors on behalf of a more clinically sound, ethically justifiable, and fiscally prudent Medicare program.