Posted in Ethics Forum on December 5th, 2016 by MMS Communications – Comments Off on IM-16 Ethics Forum: Challenges of the Employed Physician
As more physicians become employed, and more attention is paid to cost control in health care, physicians are faced with ethical challenges: should a physician’s care and treatment of a patient take into consideration cost controls, or should a physician do everything in his or her power to care for the patient without regard to cost?
Dr. James Sabin
The main presenter for this session was James E. Sabin, M.D., Clinical Professor of Population Medicine and Psychiatry at Harvard Medical School and Director of the Harvard Pilgrim Health Care Ethics Program. As Director of the Harvard Pilgrim Health Care Ethics Program, Dr. Sabin is responsible for a nationally recognized, highly innovative organizational ethics program firmly based in a managed care system. He was joined by Karen Wood, M.D., of Harvard Vanguard, and Andrew Levin, M.D. , who practices in Holyoke, Mass.
Discussion centered on the conflicts inherent in practicing medicine as an employed physician and the employed physician’s role as a steward of health care resources. Dr. Sabin’s presentation included a focus on the American Medical Association’s Code of Ethics, which defines the ethical responsibilities for physicians and physician-administrators. Among the topics of conversation were how to help physicians apply, and patients accept, cost-conscious medical practice; how to achieve access and affordability for all patients; and how to recognize the need to share resources and the inevitable need for limits on care. More information on organizational ethics in health care is available from Dr. Sabin’s blog.
Posted in Ethics Forum, Primary Care on May 5th, 2016 by MMS Communications – Comments Off on Ethics Forum: Patient Experience and Satisfaction
A growing part of the ever-changing healthcare landscape is measuring patient satisfaction. Hospitals and physicians, more and more, are being rated and ranked based on a patient’s experience – what they think of the care they get from their individual physician, what they think of their stay in a particular hospital. Reputations are at stake, as are reimbursements and payments.
Surveys and publication of patient satisfaction with providers of all kinds are growing in number. And they’re here to stay.
That was part of the message from the MMS Ethics Forum on Thursday, May 5 presented by the Committee on Ethics, Grievances, and Professional Standards as part of the 2016 MMS Annual Meeting.
The Forum, entitled Patient Satisfaction Surveys: Utility and Unintended Consequences, featured presentations from Thomas Lee, M.D., Chief Medical Officer of Press Gainey and former CEO for Partners Community HealthCare, Inc., and Allen Kachalia, M.D., J.D., a general internist and Chief Quality Officer at Brigham & Women’s Hospital. Below, are the main points from their presentations.
Dr. Thomas Lee
Dr. Lee recognized that patient measurement can lead to unwanted changes or unintended consequences, but also acknowledged that not measuring patient experience means “giving up on the idea of improvement.” The challenge, he said, was “to invest thought, time and energy in preparing people to receive data [of measurement], and it’s a challenge worth taking on.”
Patients are afraid, he noted, not just of their diseases or the therapies they may have to undergo, but of the lack of coordination by the medical community, that, as he bluntly stated, “we don’t have our act together” in caring for patients.
Dr. Lee, however, ended on a positive note. The keys to proper and well-accepted measurements, he said, are within our control: better care coordination, more empathy, and improved communication with the patient. The good news, he said, is that those drivers of patient satisfaction are consistent with the professional values of physicians.
Dr. Allen Kachalia
Dr. Allen Kachalia said that legitimate issues exist in accurate measurement. The rankings are based on inexact science, response rates are generally too low, financial incentives are motivating the wrong behaviors, and measurement is one more item for physicians to manage. Yet his message was clear: patient satisfaction and the public reporting of patient experiences are here to stay. “All of us want to be the best,” he said, “but there’s no way to know if we are the best without measurement.” The key, he said, is to balance patient experience with quality of care. Physicians must “embrace measurement and be transparent,” Dr. Kachalia stressed, and “offer solutions to the poor metrics” that exist in measurement today.
Posted in Ethics Forum, Interim Meeting 2015 on December 4th, 2015 by MMS – Comments Off on MMS Ethics Forum: Big Data Offers Big Promise, But Big Concerns As Well
By Richard P. Gulla
It’s called Big Data. Its creation has spawned new companies and new professions, and it’s rapidly enveloping the health care industry.
The basic idea of Big Data is simple: amassing huge amounts of all kinds of information, analyzing it, and then applying that analysis to achieve the goal of improving health care systems and health care for patients.
Still in its infancy, Big Data’s promise looms large. Yet it arrives not without major ethical concerns. And those concerns provided the focus for the MMS Ethics Forum, presented by the Committee on Ethics, Grievances, and Professional Standards as part of the Society’s Interim Meeting of its House of Delegates.
While Big Data offers promise, it’s also filled with what the experts call “ethical tensions:” how to use the data; the obstacles that limit the data gathering (such as HIPAA); ownership of the data; privacy laws; consent of its use; and the misuse of data, through discriminatory actions or denials of insurance coverages.
Each of the expert’s presentations was wide ranging, but here are some highlights:
Ameet Sarpatwari: Big Data is characterized by the ‘five V’s: Variety, used for disparate purposes; Volume, enormous amounts of information that’s gathered; Velocity, data accumulated at near real-time; and Veracity, determining the validity of the information.
The raw ingredients of Big Data in healthcare are several: insurance claims, electronic health records, wearable sensors, social media, and biological registries. Its uses include systems improvement in care, precision medicine (the new movement to personalized medicine), comparative effectiveness (which drugs, procedures, treatments work better than others), and medication adherence by patients.
Joe Kimura: Big Data at Atrius entails finding the answers to many questions. What is appropriate or not appropriate in the search for data? How does a physician practice use information to do better? How does the data help us learn? How do we measure things that matter to use? Above all, the goal is to use the information to make more timely decisions to help patients.
Kyu Rhee: The essence of Big Data at this time is IBM’s Watson, now being used more and more in health care applications. It is humanly impossible to know all the data you need to know, and the goal of IBM Watson Health is to translate Big Data into Big Insights and Big Solutions. In compiling data, Watson can read 800 million pages a second, which means the potential of cutting the time from research to practice in medicine is enormous. But in using such data, physicians must be part of the conversation, and be “at the table” in the decision-making process – vital for the profession and the care of patients.
While the each of the experts shared his unique perspective of Big Data, they all agreed on one principle: that physicians and patients must be at the forefront of Big Data and the goals it can achieve.
The opioid epidemic continues to grow, here in Massachusetts as well as the nation. In its latest tally, the state has recorded more than 1,000 opioid-related deaths in 2014, 33 percent higher than just two years earlier.
In announcing the figure on Wednesday, Governor Charlie Baker cited research showing that four out of every five heroin addicts got hooked on opioids through pain medications, many starting with legally prescribed medicine, according to a report by The Boston Globe.
While some point to the overprescribing by physicians as part of the problem, the opioid epidemic – and what can be done to reduce the abuse – has been a priority topic for physicians. The MMS’s 2015 Public Health Forum focused on the topic, and Dr. Richard Pieters’ President’s Report to MMS members delivered earlier today recounted some of the Society’s accomplishments in addressing the issue.
Today’s MMS Ethics Forum continued the Society’s emphasis on the topic. Presented by the Committee on Ethics, Grievances, and Professional Standards, the 2015 forum explored the ethical and legal consideration in pain management. Among the topics included were responsible prescribing, the complexity of pain as a clinical issue , and the ethical problems associated with undertreatment and overtreatment, and the balance between a physician’s obligations to the patient and obligations to public health.
Participants include Seven Adelman, M.D., director of Physician Health Service; Dr. Richard Pels, Director of Graduate Medical Education at Cambridge Health Associates; and Mark Eisenberg, M.D., Unit Chief of Adult Medicine at Massachusetts General Hospital-Charlestown Health care Center.
Since its introduction some ten years ago, Pay-for-Performance (P4P) has been the object of much confusion, conversation and scrutiny in the medical industry.
Such programs have raised a host of practical questions: What criteria do you use to objectively judge performance? How do you develop incentives for accomplishment and penalties for falling short? What principles do you use to guide such programs?
Practical considerations aside, the payment system has also raised some important ethical questions, and those were the focus of the Ethics Forum at the 2014 MMS Interim Meeting on Friday, December 5 presented by the Committee on Ethics, Grievances and Professional Standards.
Offering their perspectives on the topic of Ethics of Pay for Performance were Alyna T. Chien, M.D., M.S., a pediatrician at Boston Children’s Hospital and the lead investigator in four different projects focusing on the effectiveness of payment and quality incentives, and Sachin H. Jain, M.D., M.B.A., Chief Medical Information and Innovation Officer at Merck and Lecturer in Health Care Policy at Harvard Medical School.
“We are in a revolution,” said Dr. Chien, “as the entire organization of medicine is changing, progressing to one of integrated health care.” She noted that most incentives move from the payer to the hospital or physician practice, and that most of the data regarding the impact of P4P programs exists at the organizational level. There’s little data on how it works at the individual physician level.
Dr. Chien believes these performance programs can have one of three effects in delivering care: a neutral effect, where the status quo is preserved; a narrowing of care, where more attention is paid to quality and more programs are tailored to patients; or a widening of care, where gaps will occur between rich and poor and physicians will selectively pick their patients.
Dr. Jain acknowledged that the public perception of the profession has changed and that physicians should be at “a point of soul searching and questioning where we are in society.” He offered a scenario of physicians as either “knights” (motivated by altruism and being the ultimate champion of the patient), “knaves” (driven by self-interest and financial gain), or “pawns” (pushed by rewards and penalties of the system in which they operate).”
While he pointed out that such a framework can also be applied to others (for example, patients, health plans, pharmaceutical companies, nurses, and hospital executives), Dr. Jain believes organized medicine has focused too much on reimbursement and that physicians are perceived not to be trusted to do what’s right unless there’s a carrot or stick approach.
“We are losing our more intrinsic value in favor of pay-for-performance,” Dr. Jain says, “and the intrinsic motivation of doing what’s right for the patient must be preserved. It is what differentiates us from other professions. It is what tells others that we will do the right thing whether we get paid or not.”
His prescription is direct: a proper system of reimbursement must offer a reasonable salary, reject incentive contracting, focus on clinically meaningful measures, make it easy for physicians to do the right thing for patients, and find ways to honor and reward the intrinsic motivation of what’s best for the patient that most physicians have.
The accountable care organization (ACO), loosely defined as a group of providers that accepts responsibility for the total care of a patient and is accountable for high quality care and the cost of care, is a rapidly growing concept whose aim is to reduce the rising costs of care and improve quality.
While the emphasis on ACOs has focused on cost and outcomes, less attention has been paid to the ethical considerations of delivering care within such a structure. As the ACO continues to evolve, what are the ethical issues that physicians might face as they practice medicine? Do healthcare institutions, as well as individual providers, face ethical issues as organizations? And how might ethical considerations influence payment structures?
These are some of the issues discussed at the Ethics Forum, held on the first day of the 2013 MMS Interim Meeting of the House of Delegates.
Presenting were Susan Dorr Goold, MD, professor at the University of Michigan and Chair of the American Medical Association’s Council on Ethical and Judicial Affairs, and Philip F. Gaziano, MD, chairman and CEO of Accountable Care Associates, a Springfield-Mass. based healthcare management company.
In two presentations over two hours, delegates heard perspectives on the practical and ethical challenges in making a transition to an ACO, who providers are accountable to and for what within an ACO while maintaining their first loyalty to the patient, conflicts of interest that may arise, and ways to protect patient autonomy while practicing in an ACO.
Some highlights from the presenters:
Dr. Goold, in a presentation entitled Strengthening Patient-Physician Trust in Accountable Care Organization, examined the elements of personal and organizational accountability that lead to strong physician-patient relationships. Professionals, organizations and patients all have a responsibility in strengthening trust, she said: professionals with a duty to “seek trust from patients” based on openness and honesty, patients by being truthful and to trust wisely, and organizations as “moral characters” in modern society.
Dr. Gould also outlined the challenges to trust in physicians (patient expectations, requests, and demands) and health care institutions such as hospitals and payers (safety of personal information, treatment decisions, fair and prudent use of resources). She concluded with the notion that physicians and healthcare institutions have “moral responsibilities in health care” to include advocacy, competence, fairness, and honesty, among others.
Dr. Gaziano’s Ethical Considerations in Accountable Care Organizations focused on the payment considerations with ACOs, comparing fee-for-service to global payments (payments based on Relative Value Units) to Quality Value Units, a new designation created by his firm that provides the advantages of tracking and reporting in real time, predictive value, and the tracking of quality and budgets. He also addressed physician concerns: why ACOs are different from earlier cost-saving attempts like HMOs and opportunities within the new system of ACOs such as payments and managing budgets.
The overriding refrain in medical care over the last several years has been persistent if nothing else: “the continuing cost of medical care is unsustainable.” The subsequent calls for “cost-conscious medicine” have been ringing louder and more frequently. The trend is inevitable, as governments at all levels, businesses of all sizes, and individuals who buy coverage struggle with strained budgets and rising costs.
The efforts for cost control in the Commonwealth culminated this year with Chapter 224, the cost-containment law passed earlier this year by the legislature.
So what might be the impact on physicians? How should physicians react? And what could it mean for patient care?
Some answers came from the 2012 Interim Meeting’s Ethics Forum, Serving Two Masters – What Practicing Cost-Conscious Medicine Means for Patient Care and the Public Trust.
Presenters included James E. Sabin, M.D., Clinical Professor in the Departments of Population Medicine and Psychiatry at Harvard Medical School and Director of the Harvard Pilgrim Health Care Ethics Program, and Martin Samuels, M.D., Professor of Neurology at Harvard Medical School and Neurologist-in-Chief and Chairman of the Department of Neurology at Brigham and Women’s Hospital and Co-Chair of Partners Neurology.
Over nearly two hours, the physicians offered their perspectives on the issue and the direction that physicians might take in today’s practice environment of ever-increasing fiscal constraints. Some excerpts from their presentations:
Dr. Sabin – “Implementing cost-conscious medicine will take time and will not be easy…the biggest impediment is more emotional than intellectual…We must involve patients and the public in our deliberations and policy-making…They will only trust the concept of cost-conscious medicine if they believe the quality of care is preserved and the savings will be used for good purpose.Physicians are the crucial players in this endeavor, we can be spoilers or leaders….It is our responsibility to make it work.”
Dr. Samuels – “The important question is which master do we serve? … Simultaneously considering the interests of society and the individual patient represents an irresolvable conflict of interest… Overutilization is expensive and dangerous….Errors are unavoidable, despite our best efforts, and without errors, we have no progress…Believe in the concept that physicians are required to do everything that they believe may benefit each patient, without regard to costs or the societal considerations…because the best individual care is cost effective.”
Since starting his popular online portal KevinMD.com in 2004, Pho’s site has become one of the most influential medical sites on the Internet, with 7 million page views annually.
He pointed to research that shows 8 out of 10 web-using patients polled looked online for health information, but only a quarter of them checked the accuracy of the information. An estimated 86 percent of doctors also said they go online for health information.
Patients are often overwhelmed, confused, and frightened by what they find, Pho said.
“What they see online affects health decisions before they even see a doctor,” he said. “It’s up to physicians to un-scare our patients. Doctors can’t lose the online PR battle or we will lose out status as health care authorities.”
Pho shared the stage with Arthur R. Derse, M.D., J.D., Director of the Center for Bioethics and Medical Humanities, and professor of Bioethics and Emergency Medicine at the Medical College of Wisconsin.
Derse discussed how frequently younger physicians are incorporating social media into their own lives. He cited a study indicating 65 percent of recent medical graduates were on Facebook and one-third of them had used the forum to reveal their sexual orientation, an episode of alcohol consumption, or a religious viewpoint.
About 33 percent of those doctors polled said they had received a friend request from a patient. Of that group, 75 percent turned down the request – a recommended practice, Derse said.
Social media is a good thing, but has downsides, said Derse.
Derse told the audience of a cautionary tale involving a photo of doctors volunteering in Haiti smiling while posing with automatic weapons. In that case, the photo –- later circulated on Facebook –- embarrassed those involved, he said.
Unprofessional images have caused some health care workers to be disciplined by their employers, or even fired, he said.
Calling relations between industry and academic medicine “essential to our mission of translating scientific advances into improved health care,” Eugene Braunwald, M.D., explained the latest conflict-of-interest (COI) policies at Partners Healthcare System at Thursday’s MMS Ethics Forum.
Dr. Braunwald is a world-renowned cardiologist, Harvard professor, and faculty dean for academic programs at Partners.
Here’s a summary of several Partners COI guidelines. Those who willfully violate them receive warnings and then face dismissal for further lapses, Dr. Braunwald said.
All gifts to Partners physicians are prohibited, including meals, unless the meals occur in the course of non-marketing business activities
Free drug samples will be distributed to patients through a centralized outlet. Physicians will not be permitted to keep drug samples received from industry reps
All visits by industry representatives must be preceded by a written invitation specifying the purpose and duration of the visit
Partners is developing a process to monitor financial interests held by physicians in companies that make products the physician prescribes or uses in clinical practice
In any industry-sponsored educational program or fellowship, there must be more than one sponsor, and no single sponsor can contribute more than 70 percent of the funding
All Partners faculty are barred from participating in industry-sponsored “speakers’ bureaus” and from “ghostwriting” for industry
“Institutional officials” at Partners (e.g., presidents, senior VPs, and department chairs) may not receive more than $5,000 a day for work with an outside board of directors that does business with Partners and they may have no equity stake in such companies.
Dr. Braunwald noted that these policies represent a “series of compromises” that were often “challenging to reach consensus on.”
Asked by the outgoing MMS President, Mario Motta, M.D., whether the tightened rules were hurting efforts to recruit physicians and researchers, Dr. Braunwald said, “Yes, but most all academic centers are changing their COI rules.” He did concede that he’s heard “some grouching” from Partners faculty about the changes.