The Ethical Case for Health Care Rationing

After writing my last post, I came across a relevant and very interesting article due to be published in this coming weekend's New York Times Magazine. It is written by Peter Singer, the well-known bioethicist.

Singer attempts to make the ethical case for health care rationing in the United States. What I found most intriguing was his argument that health care is already rationed in this country, but it's just done in ways that are much less visible -- and more arbitrary -- than in Britain, for example, where an independent government committee decides how much can be spent per person per treatment. In the US, by contrast, rationing comes in the shape of long waits in emergency rooms (rationing by ability to wait), high co-payments (rationing by ability to pay). Singer goes on to argue that rationing should be practiced transparently and systematically instead of in the current haphazard and arbitrary manner.

It's an intriguing argument and one that is sure to raise the hackles of many who read it. I'm not even sure how I feel about it! But it is certainly worth the read.

On a decidedly less important side note, Singer proposes a rationed, government-based health care plan for all Americans and suggests that it be called Medicare for All. If I may be so bold as to offer a tweak on that name, I think MedicALL has a nice ring to it.

That's it from me. Happy reading.

-- Alexi Nazem

Writing and Publishing Your Work

Interested in writing and publishing your improvement stories and other work? Join us for two great calls on writing and getting your work published!

On Call: Get Your Work Published
Wednesday, July 22, 4-5PM ET

You have a lot to say about the work you do. But getting published is another story. What journals should you target? What do editors look for? Is it even possible for a student to publish independently?

Join Frank Davidoff, IHI's executive editor, and David Stevens, Editor-In-Chief of the journal Quality and Safety in Health Care, demystify the publication process for students. You'll learn:

• How publication works, from start to finish
  
• The most common reasons editors accept and reject submissions
  
• The types of student articles that are most likely to be published
  
• Five major obstacles to writing and publishing--and how to overcome them.

Don't forget to register here.

How to Write Titles and Abstracts
Wednesday, July 29th, 4-5pm Eastern Time
A good abstract is like a good ad. You've got just a minute or two to convince readers that your paper is worth their time. But all too often, authors give their title and abstracts short shrift.

In this free, hour-long web conference, David.P. Stevens, editor of the journal Quality and Safety in Health Care, explains the nuts and bolts of writing a great title and abstract. You'll learn:

• What every abstract should contain
  
• What makes some abstracts compelling- and others just average
  
• Why "Snakes on a Plane" is a better title than "There Will Be Blood"

Bring your questions. No advanced registration is required.

Hope to see all of y'all on these calls!

Is it possible?

I would like to pose a question to all of you:

Can we actually afford a health care system that provides comprehensive, high-quality coverage for everyone?

I ask simply because the entire health care reform debate seems to operate on the assumption that we can but that we just haven't figured out the secret yet. Somewhere, we believe, lurks a solution -- tweak this, restructure that and...voila! Some combination of strategies must work...right?

But is that really true? No matter what kind of cost, quality, and infrastructure improvements we make -- and to be sure there are many -- the leaner, meaner system we end up with will still be massively expensive. Do we have an idea of how much a perfectly built and operated system would cost? Really, how much is it? Does anyone know? Can we afford that cost?

If we cannot afford it, how does that change the parameters of the debate and the shape of the resulting reform? Will we need to change what we expect from our health care? Will we have to revisit the dichotomy of health care as a right vs. health care as a privilege?

Unless we set reachable goals, this reform process will be meaningless and the search for solutions will be fruitless. So, I ask all of you, Is effective, high-quality care for all a reachable goal?

I sure hope it is. I hope that improving quality, cutting out waste, making care more efficient, and emphasizing prevention instead of reactive treatment will make it all possible. I'm betting my career on it!

What do you think?

-- Alexi

Prometheus Payment

In a recent New York Times article, Dr. Pauline W. Chen reviewed a new model for healthcare that will provide a warranty to healthcare consumers by making providers pay if they make an “avoidable mistake." Currently, fee-for-service plans place the cost burden of avoidable mistakes on third party payers.
Proposed by Francois de Brantes, the Prometheus Payment model (http://www.prometheuspayment.org/) offers set fees for providers that would cover all the recommended costs for healthcare specific to a person and their healthcare needs, but costs from avoidable errors are payed in part by the provider (and in part by the third party payer). It offers a “warranty” because it makes the provider financially responsible for avoidable complications.
Despite questions regarding how this model would affect the relationship between providers and patients, Mr. de Brantes concludes that such a model would improve the relationship by creating a system that reinforces quality of care.
In an interview with Dr. Chen, Mr. de Brantes says:

Right now you have hundreds of thousands of dedicated and devoted professionals who want nothing else but to apply their knowledge and skills for the betterment of their fellow human being; yet every day they go to work and the entire system militates against their desires of doing the best for their patients. Right now you have 50 to 80 percent of diabetic patients with an encounter that is caused by an avoidable complication; yet it is not because clinicians aren’t trying their best. The odds are simply stacked against them.

What we are proposing is a system that makes it profitable to do the right thing for patients systematically. Our system is not that complicated, but it will require a significant amount of effort on the parts of everyone.


What are your thoughts on the Prometheus Payment model?

Signs of Hope

I think this blogging is becoming a habit for me. Tell me to stop if you're not digging it! Actually, I'll probably run out of (interesting) things to say even before you make it to your keyboard.

Anyway, the more and more time I spend in the hospital, the more I see little things around that give me hope for the future of the quality and safety movement. It seems as though it's really winning hearts and minds. With luck, that also means that there is also greater willingness to include this kind of teaching in our education. I sure hope so. I think it's so important to the "complete" medical education.

In the meantime, I thought I'd share a couple things I've seen out and about in med school. Take a look at these pictures snapped on various recent rotations. The safety sign is from an underground passageway that lots of people take from the garage to the hospital in the morning. The CA-BSI (catheter-associated bloodstream infection) sign is in the PICU. Great stuff!

Have any of you seen anything similar? Write your story in the comments. Or, if you've got a picture, upload it imgur.com and leave a link in the comments.

Hope everyone is enjoying the weekend.

-- Alexi

Errors Take a Toll on Patients AND Providers

Hey everyone, me again. This blogging thing is addictive.

Another great article from Dr. Pauline Chen in the New York Times. It talks about the toll that errors take on physicians, specifically young physicians-in-training, but I suspect that the phenomenon applies to all health care providers in all fields.

The thrust of the article is that when a physician makes an error it can send him in a downward spiral of more errors, depression, and questioning of self-worth. If I might opine, I think it's the fear of making another mistake that drives this vicious cycle. As a fourth-year med student, I am so close to being thrown head-first into the scary world of residency. And let me tell you, despite a fantastic training in med school and even a good deal of confidence in what I know, I'm terrified that I might hurt one of my patients without the constant supervision I've had in med school. A single mistake threatens to prove my worst fears -- that I really don't know what I'm doing! Raise your hand if you feel the same way.

How can we fix this? Is it better training? Is it simulation? Is it a more welcoming environment? Dr. Chen gives the very vague suggestion that the system -- patients and our teachers -- need to re-calibrate their expectations. But what, really, does that mean? And will that alone work? Share your thoughts in the comments.

- Alexi

Setting Audacious Goals

Hello young improvers!

I'm a long time reader but first time poster to the blog. I came across a great article in this morning's New York Times Op-Ed section that I thought many of us would be interested in. It's a piece written by Paul O'Neill, the former Treasury Secretary turned health care improvement crusader.

In his piece today, O'Neill writes about how, thus far, the goals Washington has set for health care reform have not been "audacious" enough. He states that there is about $1 trillion of annual waste in the health care system and that's what we need to tackle, not the miniscule cost inflation reductions that Obama has wrangled out of the insurance companies. He offers that one great place to start is nosocomial infection reduction, and he points to some star health care improvement leaders -- Gary Kaplan, Brent James, Rick Shannon -- to give us shining examples of what's possible.

Best of all, O'Neill says that the system needs more improvement-minded leaders. That's us guys!

Hope you can check out the article. It's a good read.

- Alexi (Yale Med 2010)