by Trevor Hancock
The quality of hospital food has long been the butt of comedians' jokes. More recently, hospitals have also been criticized for serving fast food. One recent U.S. survey, for example, found that 38% of top U.S. hospitals - six of the 16 "Honor Roll" hospitals listed by US News & World Report's 2001 ranking of "America's Best Hospitals" - have fast-food franchises on site. Gottlieb and Shaffer found that more than 25% of 47 U.S. children's hospitals had fast-food franchises within them .
Meanwhile, a 1997 report from Toronto's Food Policy Council entitled "If the Health Care System Believed You Are What You Eat," suggested that we need to transform hospital food service systems into facilities providing healthy food choices and local food.
In response to these criticisms, as well as out of a genuine concern for the welfare of their patients, a growing number of hospitals have started to focus more on the healthfulness of the food they serve. For example, Planetree hospitals, which are committed to creating healing environments for their patients and healthy workplaces for their staff pay particular attention not only to the quality of the food they serve but the nurturing role of food "as a source of pleasure, comfort and familiarity" during a stressful period of hospitalization. Many Planetree hospitals, for example, have small kitchens on each floor where family members can cook favourite foods for their loved ones and nutritionists can demonstrate healthy food preparation, while volunteers fill the halls with the smell of fresh baked goods every morning.
In the U.K., two Scottish hospitals recently won the Healthy Choices Award from Scotland's Health Education Board, while in Wales a hospital in Powys, working with the Soil Association, now provides organic milk for its patients in spite of the difficulties imposed by World Trade Organization regulations that prevent organizations from specifying local produce. This latter example begins to show the links between healthy food and food that is produced in an environmentally sustainable manner - and the challenges involved in being environmentally and socially responsible!
Given the growing concern with the potential health impacts of pesticide residues, particularly for children, and the fact that as a result of eco-toxicity and the contamination of food chains, we get 75 to 90% of our daily dose of persistent organic pollutants such as dioxins from food, serving organic food as much as possible makes sense. Of course, there are many important environmental benefits from producing food organically.
Perhaps the most advanced example of organic food service in hospitals is found in Vienna, where currently about 20% of the food served in the hospitals is organic. There, studies have shown that a move from 0 to 30% organic food results in a 17% increase in the cost of food, which only translates into a 0.1% increase in the overall costs of care; a move to 50% organic food results in a 30% increase, or less than 0.2 % of overall costs of care. In addition, there are significant energy benefits for society as a whole from not having to practice energy-intensive agriculture or move food over long distances (Klausbruckner 2001).
Environmentally-friendly food service not only includes serving organically grown food whenever possible, it also means paying attention to the environmental impact of food preparation and service, and the disposal of food wastes. The U.S. Environmental Protection Association has produced a guide to operating a green cafeteria. Among the key points are the following:
* using permanent china and stainless steel service-ware to minimize generation of waste;
* offering monetary discounts for those who bring their own re-usable coffee mugs;
* using starch-based cafeteria-ware, which has several beneficial environmental characteristics: it is compostable, biodegradable, and uses less energy to produce than paper or polystyrene containers;
* using 100% recycled unbleached napkins, which are compostable;
* recycling plastic and glass bottles and aluminum cans.
Such an approach is compatible with modern hospital operations, as can be seen in the case of the Itasca Medical Center in Grand Rapids, MI. This 108-bed community hospital switched from single-use to re-useable salad plates and dessert bowls for a net savings of $3,500 per year (Canadian Centre for Pollution Prevention 1996).
Food waste forms a significant proportion of a hospital's waste stream, as shown by a 1990 environmental audit of the Ottawa General Hospital, which found that it formed 17% by weight of hospital waste (Canadian Centre for Pollution Prevention 1996). Guidance on management of food wastes can be found at the website of the California Integrated Waste Management Board, which suggests the following order for food scraps management: (1) prevent food waste, (2) feed people, (3) convert to animal feed and/or rendering, and (4) compost.
Food scrap management can even be turned into organic produce at little or no cost to a hospital, as illustrated by The Medical Center Hospital of Vermont. This hospital prepares 3,000 meals a day. And every day, it trucks hundreds of kilograms of kitchen waste (not food from anyone's plates) to a compost site managed by a non-profit group dedicated to organic food production (thus avoiding landfill charges). The 80 tonnes of food wastes that the hospital sent to compost in 1993 was transformed into 40 tonnes of compost and in return the hospital received 10 tonnes of fresh organic produce at a wholesale price of $6,000 (Raver 1994).
Finally, a comprehensive approach to sustainable food services in hospitals is provided by the U.K. government's Sustainable Development Commission which has recently produced a comprehensive report on sustainable food procurement for the NHS. The interim report proposes that "in the NHS, procurement policies should promote health. Trusts should be required to procure food in a way that impacts positively on long-term health outcomes"
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About the Author
Dr. Trevor Hancock is Hospital Quarterly's Environmental Editor. He is Chair of the Board of the Canadian Association of Physicians for the Environment and a founder of the Canadian Coalition for Green Health Care. He can be reached at greendoc@telus.net.
Monday, February 2, 2009
Friday, January 16, 2009
Physicians, Thou Shalt Ration: The Necessary Role of Bedside Rationing in Controlling Healthcare Costs
Peter A. Ubel MD
HealthcarePapers
Vol. 2 No. 2 2001 | Physician Rationing
Abstract:
Physicians are often asked to be "gatekeepers," determining their patients' access to medical therapies and technologies. At the same time, most physicians have been taught that they should act as patient advocates, pursuing patients' best interests regardless of cost. This paper reviews moral arguments ethicists have made for and against "bedside rationing." It argues that healthcare rationing is appropriate in order to help control healthcare costs, and that rationing decisions made at the bedside by physicians must be part of the rationing system. A system that attempts to control costs by mandating an elaborate set of rules would be burdensome, and many physicians would find ways around the rules anyway.
Physicians are deeply conflicted about their roles in cost-containment. Some of the conflict has to do with discomfort over the concept of "rationing," but they are also in conflict about much deeper issues. The author argues that patients can do with less than the "best" treatment and physicians must come to terms with this. Finally, healthcare systems need to signal physicians that it is acceptable for them to offer "less" to their patients in order to serve the greater good.
Ms. Johnson comes to her physician with symptoms of gastric reflux (GERD). Her doctor gives her a prescription for cimetidine, even though he knows omeprazole would be better at relieving her symptoms. He thinks the cost of this other medication is too high for it to be the initial treatment.
In an old Mel Brooks movie,Moses is seen coming down from the mountains with three stone tablets. He announces to his people in a stentorian thunder: "I come down with a copy of God's Fifteen . . ."- he fumbles one of the tablets, and it falls to the ground - ". . . er,Ten Commandments for how to live a good life."
This is pure speculation, but I would guess that somewhere on that broken tablet was a commandment that read: "Physician, thou shalt not ration!" I base my speculation on the tone many people take when debating the appropriateness of bedside rationing by physicians. Opponents of bedside rationing argue vehemently that physicians should never ration from their patients. For example, in a New England Journal of Medicine editorial, Howard Hiatt (1975) wrote: "A physician must do all that is permitted on behalf of his patient." In a similar vein, Dr. Norm Levinsky, chair of medicine at Boston University, has written that: "Physicians are required to do everything they believe may benefit each patient without regard to cost" (Levinsky 1984). Hiatt and Levinsky's statements are consistent with the traditional moral view that physicians should advocate for their patients without regard to costs. This view is treated almost as a theological truth in the United States. But I am a heretic. I think that it is sometimes appropriate for physicians to ration healthcare from their patients in order to help control healthcare costs. In this article, I briefly describe the "theology" of bedside rationing - why so many people think bedside rationing is immoral. I also discuss why I am a heretic. I think any method of controlling healthcare costs is doomed to fail, unless it is joined by some relaxation of physicians' advocacy duties. Finally, I discuss linguistic confusion about bedside rationing.Many people debate the appropriateness of bedside rationing without ever defining what they mean; this leads to disagreements about the morality of bedside rationing among people whose moral values are actually the same.
Theology 101: the Immorality of Bedside Rationing
Opponents of bedside rationing contend that it violates physicians' moral duties to advocate for patients' interests. In addition, they believe that bedside rationing would erode trust between patients and their physicians. Moreover, they hold that bedside rationing creates savings that do not necessarily go toward improving patient care for other patients. I elaborate on each of these objections below.
It has been long argued that physicians have a "fiduciary duty" to advocate for patients' interests (Morreim 1989). A fiduciary is someone who acts on behalf of those who otherwise may not be able to pursue their interests (Hall 1997). Physicians are seen as fiduciaries for patients because they have more knowledge than patients do. Patients may not know what is in their best interests or may not be able to pursue their best interests without a physician's help. Physicians also have fiduciary duties because patients are often dependent on them. Patients are emotionally dependent on physicians because their illnesses make them vulnerable; in addition, patients are legally dependent on physicians, who have been given powers to order medications and perform procedures that other people can not do. Finally, physicians' fiduciary duties arise because healthcare issues are often high stakes. These high stakes distinguish the doctor-patient relationship from otherwise parallel relationships, such as between an auto mechanic and a client. An auto mechanic has more knowledge about cars than a typical person and may have tools to repair a car that the average person could not afford. Although auto mechanics have moral duties, such as to be honest with their clients, their duties are not fiduciary, because the stakes are not high.
People often feel strongly about physicians' advocacy duties towards patients because they recognize that patients need to trust their physicians in order to receive good care (Goold 1998). Many aspects of healthcare depend on trusting interactions between patients and their providers. Patients who do not trust their healthcare provider may not tell the provider about the symptoms they are experiencing, or may not tell about high-risk behaviour they are engaging in. If worried that physicians were rationing healthcare from them, patients might lose trust in their physicians. Consequently, the quality of healthcare that physicians can provide to their patients would erode.
Some opposition to bedside rationing arises because of concern about who would really benefit if physicians rationed healthcare from their patients (Asch et al.; in submission). In the case presented in the introduction, a physician prescribed a less expensive medicine to a patient with reflux in order to save money. But whose money was being saved? If the patient would not have incurred most or all of the increase in costs of the more expensive medicine, then who benefits from this rationing decision? Many people think the money will simply go to a greedy insurance company or to the CEO of a managed-care company. These people contend that there is no moral justification for withholding the best care from patients, given that the money saved by bedside rationing will not necessarily benefit patients.
For these and other reasons, the traditional moral view is that physicians need to do what is in patients' best interests regardless of cost. But, as I stated above, I do not hold that view. Below I will describe why I oppose the traditional view of physicians' moral duties. First, however, I need to define what I mean by "bedside rationing."
Defining My Terms
Bedside rationing is a subset of healthcare rationing; in other words, it is one of many ways to ration healthcare. For the purposes of this article, I hold that healthcare rationing occurs whenever the healthcare system, or "society," allows patients to receive less than the most beneficial healthcare service. If a patient receives treatment A because of resource constraints, when a more expensive treatment, B, would have been better, then treatment B has been rationed from the patient. This rationing could have occurred because of bedside rationing - a clinician might have decided to prescribe A rather than B; or it could have occurred through market forces - the patient could have been asked to pay for either A or B and, thus, chose A; or it could have occurred through any number of other mechanisms.
The definition I have proposed for healthcare rationing is consistent with how most health economists define the term. I have defended this definition elsewhere (Ubel and Goold 1998). Nevertheless, there is no single "best" way to define a complex term like healthcare rationing, nor is it crucial for me to convince you that the definition I propose is the best. Instead, I put forward this definition as a way to clarify the term as I discuss why I believe bedside rationing is morally acceptable.
Before discussing why I believe bedside rationing is an acceptable method of rationing healthcare, I need to note a fact that is perhaps obvious. If healthcare rationing is unacceptable, then bedside rationing is unacceptable. In other words, those who argue that healthcare should not be rationed not only disapprove of bedside rationing but also would disapprove of any other method of rationing healthcare. I will not argue against this view here. Others have argued convincingly, I believe, that there is a need to ration healthcare (Hall 1997; Callahan 1990; Eddy 1994). The proliferation of new technologies being offered to patients with a wide range of illnesses has made it impossible to offer every patient the best possible healthcare services in existence. Each day, new medications become available that, if they were free, would probably be offered to hundreds of thousands of patients. These medications are so expensive, however, we often hesitate to provide them to everyone that would benefit. Cholesterol medications, for example, are slowly diffusing towards a broader group of patients, but if they were as free as water, many people at relatively low risk of coronary heart disease might start taking them. To make this discussion manageable, then, I will ask readers to assume that some amount of healthcare rationing is necessary to help control healthcare costs. The question for this article then is whether any amount of this rationing ought to be done at the bedside by clinicians. In other words, is bedside rationing a legitimate form of healthcare rationing?
Not surprisingly, it is helpful to begin with a definition of bedside rationing. Susan Goold and I have argued that three conditions are necessary for a clinical action to qualify as bedside rationing: (1) the patient must be given less than the best available healthcare, (2) the best healthcare must be withheld in order to save societal resources, and (3) the physician (or clinician) must have control over the healthcare decision (Ubel and Goold 1998). For example, in the reflux case described in the introduction, the physician prescribed the less expensive reflux medicine in order to save society money. Hence, the case was an example of bedside rationing. A subtle change in the case, however, would change this classification. If the patient was responsible for the difference in cost of these two medicines, the decision would not necessarily qualify as bedside rationing, because the physician could potentially be ordering the less expensive medicine to save money for the patient. (In such a situation, the physician ought to talk with patients about how they want to spend their money.) Another change in the case would also eliminate it as an example of bedside rationing. If the patient's health plan required physicians to prescribe less expensive reflux medicines before prescribing expensive ones, the doctor's prescription would not be at her discretion and the health plan would be rationing the expensive medicine from the patient, not the physician.
To better understand what I mean by bedside rationing, it is helpful to think of alternative ways to ration healthcare. Healthcare can be rationed by ability or willingness to pay. Healthcare can also be rationed by formulary committees who decide that expensive reflux medicines are no longer available to all patients. A health plan may decide not to offer lung reduction surgery to its patients, and a government insurer may decide to limit PET scanners for its citizens. These are examples of administrative level healthcare rationing, but not examples of bedside rationing.
Can the Cost of Reflux Treatments Be Contained without Bedside Rationing?
Imagine a healthcare system that is trying to reduce the use of expensive proton pump inhibitors (PPIs), such as omeprazole, in patients with reflux disease. Imagine at the same time that all the physicians in this healthcare plan have vowed never to ration at the bedside. How would this healthcare system go about reducing the use of PPIs?
To begin with, if this healthcare plan did nothing to control PPI use and physicians were committed to providing the best possible care to their patients without regard to cost, then physicians would almost never prescribe the less expensive reflux medicines. PPIs are simply better reflux medicines than the less expensive H2 blockers. Some people might reject the idea that offering less expensive reflux medicines to patients is an example of rationing (Asch and Ubel 1997). They might argue that many patients do just as well with H2 blockers as with PPIs. For these patients, then, no benefit has been withheld if they receive H2 blockers first; if no benefit has been withheld, then no bedside rationing has occurred. This reasoning is faulty, however, because it utilizes an after-thefact evaluation to judge a prior-to-thefact decision. Prior to prescribing a reflux medicine, physicians do not know whether H2 blockers or PPIs will work better for a particular patient. However, patients' chances of successful reflux treatment will be significantly greater with PPIs. Indeed, if money were no object, there would be no reason (in most patients) to prescribe an H2 blocker instead of a PPI.
Because PPIs are superior to H2 blockers but more expensive, the healthcare plan has to find a way to keep physicians from prescribing them if it wants to save money on reflux medications. One way to do so would be to require that all patients undergo a trial of H2 blockers before receiving PPIs. How would such a requirement work? First, the health plan would need a system for documenting whether patients had already been on H2 blockers, so that they could receive PPIs after the H2 blockers failed. The system would also need to track whether patients had received H2 blockers from other healthcare plans prior to transferring to their new plan. In addition, it would need to develop a system whereby physicians could appeal and prescribe PPIs for patients who had taken H2 blockers on the outside or who had some "contraindication" (some medical reason they could not take H2 blockers). Preparing for such exceptions and appeals costs money. The health plan would need to spend money to develop information systems that could monitor the program. This in itself has resource implications and would have to be weighed against the amount of money that would be saved by reducing PPI prescriptions.
But the system would have to be even more complex than I have indicated, or it would create some clinical problems. For example, PPIs are important medicines for treating patients who have non-reflux related stomach problems caused by the bacterium H. pylori. Would physicians be able to prescribe PPIs for such patients? In addition, should the system be prepared to allow exceptions for patients who come in with "severe reflux symptoms"? If so, how should we define severe reflux disease? Once these exceptions are made, how would they be monitored?
I am trying to show, through examples, that rule-based rationing is problematic because the rules can very quickly become unmanageable. Perhaps just as important, rule-based rationing systems are susceptible to physician "gaming"- physicians interpret rules in ways that benefit their patients (Morreim 1991). A notable example of gaming is occurring in the state of Oregon, which, since the mid-1990s, has been trying to reduce its Medicaid expenditures through an explicit rationing plan. Medicaid is a U.S. healthcare program for poor people and is paid for by a combination of federal and state monies. Oregon was having a hard time keeping its Medicaid expenses in line while trying to maintain coverage for all the poor people who needed healthcare. One solution, as formulated by then legislator (and now governor) John Kitzhaber, was for Oregon to specify which healthcare services it would offer to Medicaid patients and which ones it would not. The state hoped to save money by withholding Medicaid services that were deemed less important than other services (Garland 1992). The savings garnered by not paying for such services could then be used to offer Medicaid to more patients.
Despite good intentions, the Oregon Medicaid rationing plan has not saved a dime, because physicians have found ways to get around the rules (Kilborn 1999). For example, if patients have multiple diagnoses below the funding line, physicians will get reimbursed for their treatment. Consequently, when patients come in with "below-the-line diagnoses," physicians almost always find several other "below-the-line" diagnoses in order to get reimbursement for their treatments. Through this and other loopholes, physicians have found ways to make sure patients get the treatments that are best for them. Indeed, physicians are notoriously good at gaming healthcare systems to get benefits for their patients. Thus, to the extent that healthcare plans try to tie physicians' hands to control healthcare costs, physicians wriggle free of the ropes.
What about a Simpler Type of Rule to Control Spending?
So far, I have discussed several rule-based methods of reducing PPI prescriptions. I have argued that these rules need to become more elaborate in order to control healthcare costs, but they can still often be overcome by physician gaming. How about a simpler rule: require gastroenterologist approval of every PPI prescription. Would this simpler rule control costs? Such a rule would have several advantages over more complex rules. It would allow for clinical judgments to be made about which patients really needed PPIs. No committee would need to create an official definition of "severe reflux disease." Instead, clinicians talking to each other on the phone could decide whether a patient really needed a PPI prescription. Such a rule allows for clinical judgments based on the specifics of individual patients. This contrasts with previous rules, which were meant to be applied to all patients.
Despite its advantages, this type of rule has pitfalls too. Most important, it could potentially overwhelm gastroenterologists with pages and phone calls about PPI prescriptions. At one institution where I worked, this plan was rapidly defeated when gastroenterologists told primary-care physicians to write down that they had GI approval any time they wanted to prescribe a PPI. The gastroenterologists were so fed up with receiving phone calls about PPI prescriptions that they found a way to defeat the system.
Let us shift our attention away from reflux disease for a bit and consider a common diagnostic test that has significant expense - CT scans.Who should be able to order a CT? Should all primary-care physicians be able to do so without prior approval? What about primary-care nurse practitioners? At one institution where I worked, nurse practitioners could order CT scans (and MRI scans, for that matter, a significantly more expensive test) without discussing this with a radiologist or primary-care physician. I saw patients who presented with new onset shoulder pain who were referred for MRIs by clinicians without anybody asking a radiologist if that test was indicated. In my clinical judgement, this is a wasteful practice. But how do we keep it from happening?
Healthcare systems could require that all CT scans and MRI scans be approved by radiologists. As with the gastroenterology example described above, however, such a policy would potentially overwhelm radiologists with such requests. Moreover, in many cases, primary-care practitioners have every reason to know that a scan is indicated.
Although it makes some sense to require clinicians to speak with radiologists before ordering extremely expensive radiology tests, I have concerns about a system that requires such conversations. First, such a system ignores many less expensive tests that, nevertheless, are ordered frequently enough that they cost healthcare systems a lot of money. Think of all the plain film x-rays that are ordered for low-back pain and for routine screening of lung fields that have almost no clinical value. Second, such a system imposes burdens on radiologists and other physicians who must now find time in their busy days to speak with each other, even in circumstances where the correct radiology test to order is obvious. This not only takes up these clinicians' time, but also ultimately costs healthcare systems money, because radiologists and other physicians are highly paid professionals. Third, the systems create a layer of bureaucracy in order to document that conversations have occurred between radiologists and other clinicians. Bureaucracies create hassles. Just as important bureaucracies cost money.
Instead of Bureaucratic Rules or Time-Consuming Approval Requirements, Why Not Give Physicians Feedback about Their Utilization?
There are alternatives to forcing clinicians to call each other on the phone to get approval for every lab test, radiology test, and expensive medication they want to order. One alternative is to give clinicians feedback, every few months or so, about how much they utilize expensive diagnostic tests in comparison to their peers. Research has shown that such feedback reduces physicians' utilization (Berwick and Coltin 1986; Schectman et al. 1991). Physicians hate feeling like they are outliers; they do not want to rely on expensive tests more than other physicians do.
Such feedback systems deserve a role in helping control healthcare costs. They do not require burdensome rules, but they do not avoid bedside rationing. If physicians are only interested in patients' best interests, they will completely ignore how their utilization patterns compare to other physicians. In fact, in a world without bedside rationing, they will continue to order what they think is best for their patients. Those who order fewer CTs and MRIs may have reason to wonder if they are ordering too few tests.
What about Avoiding Bureaucratic Rules by Implementing Capitation or Other Financial Incentives?
Asking physicians to bear some financial risk for the tests and medicine they order for their patients has also been shown to control healthcare costs. Under such "capitated" healthcare systems, physicians are given a certain amount of money to take care of their patients (Hillman 1990). Some percent of the money they spend caring for their patients is then taken from their salary. This encourages physicians to order fewer tests and referrals.
Many people have raised moral objections to capitation-reimbursed systems. I do not plan to discuss these arguments here. Instead, I want to make a simple point: capitation systems only control healthcare costs by encouraging bedside rationing. If patients' best interests were all that mattered, most clinical decisions would be unaffected by capitation: clinicians would still do what is best for their patients, regardless of costs.
What about Rationing with Practice Guidelines?
Some colleagues of mine in Michigan recently published an article on the cost effectiveness of performing routine retinal screening exams for diabetic patients (Vijan et al. 2000). The standard of care, up to now, has been to make sure that all diabetic patients have ophthalmology examinations each year to screen them for diabetic eye disease. My colleagues argued that annual screening is unaffordable for patients with mild diabetes; such a screening rarely prevents blindness, compared to screening every two to three years.
If physicians only worried about patients' best interests, they would ignore my colleagues' work, because annual screening would still prevent more cases of blindness than less frequent screening. However, it is likely that in the near future, leading diabetes organizations will change their recommendations on how to screen patients with mild diabetes and recommend screening every other year in low-risk patients. These guidelines will probably have a significant influence on physicians' referral practices.
If physicians begin to follow diabetes society "guidelines" for how often to screen people for retinal disease, they will be engaging in bedside rationing. However, I expect that many physicians will not realize that they are rationing at the bedside when they follow these guidelines (Asch and Ubel 1997). I happen to think these guidelines are signals from society about how much money they want physicians spending to prevent rare illnesses. The decision is, however, still ultimately up to individual clinicians. Such guidelines will have no effect on clinical practice unless physicians are willing to ration at the bedside.
How Do I Justify My Heretical Support of Bedside Rationing?
As hinted above, I have a major concern with healthcare systems that ration without any reliance on bedside rationing: these rationing systems will be burdensome. I scratched the surface in discussing how a healthcare system might try to reduce the use of PPIs. I did not even begin discussing the similarly burdensome rationing mechanisms the system would need to control the use of expensive hypertension medicines, reduce subspecialty referrals, decrease the use of marginally beneficial lab tests, reduce the length of outpatient visits, or reduce the frequency with which physicians order follow-up appointments. A system that controls healthcare costs by creating elaborate rules around all these varied types of clinical decisions would be a bureaucratic nightmare and a clinical disaster.
Those who want to control healthcare costs must decide how they will trade off between blunt, obtrusive rules that completely delineate physicians' behaviours and some amount of bedside rationing that encourages physicians to reduce their use of marginally beneficial healthcare services (Welch 1991).
When I say I am in favour of bedside rationing, I mean the following: at times physicians need to relax their advocacy duties and give their patients less than the best possible healthcare services in order to save money for society. The entire rationing burden should not fall on physicians' hands. There is an appropriate role for administrative rationing mechanisms. In fact, many of the "burdensome rationing rules" I discuss above would be made much less burdensome if we could rely on physicians to occasionally ration at the bedside. For example, a healthcare system could ask physicians to prescribe H2 blockers whenever possible before prescribing PPIs. Such a guideline, handed down by a healthcare system or by a respected medical society, would help physicians remember that H2 blockers are still good medicines for many patients and that society needs to control healthcare costs by reducing the use of expensive PPIs. At the same time, this guideline would allow physicians to use their judgment about when to make exceptions to the guideline.
No system that relies completely on administrative rationing mechanisms will succeed in reducing healthcare costs. In addition, a system that relies heavily on willingness and ability to pay to ration healthcare is morally questionable (for reasons I will not go into here). Thus, the best way to ration healthcare is to have a mixture of administrative rationing mechanisms and clinicians engaging in bedside rationing, with a touch of willingness to pay on the side.
I recognize that there are moral problems with bedside rationing. The problems cannot be eliminated, but they can be reduced. For example, we need to make sure that physicians ration in ways that do not greatly reduce patient trust. I think this is achievable.We also need to do what we can to make sure that money saved by healthcare rationing (bedside or other) goes towards appropriate ends. The goal of healthcare should not be to maximize profits. We need to find ways to help physicians ration at the bedside so that they will not do it haphazardly or in a discriminatory manner. At the same time, we must judge bedside rationing the same way we judge democracy - by comparing it to the alternatives. In this case, the alternatives include burdensome rationing rules, many of which physicians would bend in their patients' favour, and increased use of out-of-pocket expenses to ration healthcare, which favours wealthy patients over others. Bedside rationing has weaknesses, but I think its weaknesses are worth accepting in order to avoid the weaknesses of alternative ways to ration.
What Do Physicians Think of Bedside Rationing?
I have all too briefly discussed the theology behind opposition to bedside rationing and the heresy of relying on bedside rationing to help us control healthcare costs.What do most physicians think about these issues? Do physicians hold to the good old religion and oppose bedside rationing or are they joining heretics like me in accepting its necessity?
Sorting out physicians' attitudes towards bedside rationing is tricky, in part because of linguistic confusion about what it means to ration at the bedside. When physicians disagree about bedside rationing, they could potentially be having one of two kinds of disagreement: (1) they could be disagreeing about the appropriateness of having physicians do less than the best for their patients, or (2) they could be disagreeing about the meaning of the word rationing. That is, physicians might agree with each other that it is appropriate to withhold PPIs from patients, but disagree about whether this is an example of bedside rationing. As an analogy, consider two people who are looking at an insect. In one case, they agree that the insect is a moth, but disagree about whether it is beautiful or ugly. This is similar to agreeing about what it means to ration at the bedside while disagreeing about whether such rationing is justifiable. In another case, imagine they agree that the insect is beautiful while disagreeing about whether it is a moth or butterfly. This is analogous to agreeing that bedside rationing is acceptable - that doing less than the best for patients is acceptable - while disagreeing about whether this is an example of bedside rationing.
To sort out these two ways of disagreeing about bedside rationing, David Asch and I presented 1,000 general internists in the United States with a vignette in which a hypothetical physician offers a less expensive and less effective colon cancer screening test to a patient in order to save money for society (Ubel 2000).We asked physicians whether the physician who ordered the less expensive colon cancer screening test was acting "appropriately" and whether that physician was performing "healthcare rationing."We found that physicians generally agreed that it was appropriate for the hypothetical physician to offer the less effective test to the patient. In fact, only 20% of physicians felt that ordering the less expensive colon cancer screening test was inappropriate. Physicians were completely divided about whether such a decision was an example of healthcare rationing. Forty percent thought it wasn't, 40% thought it was, and 20% had no idea. This suggests that physicians generally support the idea of making cost-quality trade-offs at the bedside. They are comfortable offering a decent screening test to someone, even though a slightly better and significantly more expensive test is available. They are not sure whether to call such a thing "bedside rationing."
This disagreement among physicians about what qualifies as bedside rationing should not surprise us. As I stated above, there is no single way of defining complex terms such as rationing or bedside rationing. And besides, when we conducted this survey, my elegant definition of bedside rationing had not yet been published! More important, rationing is a loaded term. People may support the concept of rationing without wanting to label it that way. I do not have a problem with that. I personally like to use the term rationing, because I think it forces people to consider the moral implications of their decisions. Other euphemisms might be easier to swallow, but they might make us less likely to notice when we are ingesting rotten food.
Nevertheless, I am happy to define rationing in different ways, if that is what people want to do. Instead, what is more important to me is that physicians recognize that they do not currently pursue patients' best interests without regard to costs. I can find examples for almost any physician I know in which they are forgoing a marginally beneficial test or referral because of its expense. Different physicians have different thresholds, but I would guess even Norm Levinsky does not order a thyroid screening test on every patient he sees every few months. If money were irrelevant, even he would order more thyroid tests. Physicians have not done a good job of recognizing that they are making trade-offs between cost and quality. By failing to recognize these trade-offs, they are probably not doing a very good job of making them. If clinicians recognized the trade-offs they made every day, they could begin to look across their entire practices and see when they were trading off too much quality for not enough cost savings, and when they were not trading off enough.
Conclusion
Heated debates about the morality or immorality of bedside rationing have been missing the point.We are so worried about the loaded term "rationing" or about old-fashioned moral ideals that were developed in a time when healthcare costs were not nearly as high as they are that we are not facing up to the new reality.We need to control healthcare costs, and physicians must play a crucial role in helping society do so.
Society is still coming to grips with resource constraints in medical care, especially in the United States. Not surprisingly, many people are not sure who they think ought to be making rationing decisions. Clinicians are equally confused; they do not want to bear a disproportionate share of decision-making over rationing. On the other hand, most clinicians do not want to practise healthcare amid a sea of burdensome rules that limit their abilities to take care of patients.
Whether or not clinicians call it "rationing," they need to recognize that they have a crucial role in helping to control healthcare costs. The best way to control costs is for clinicians to relax their advocacy duties in conjunction with other rationing mechanisms. Clinicians need to recognize that patients can do with less than the best. Physicians need to come to grips, individually if not as a group, with what services they can withhold from patients. And finally, healthcare systems need to find ways to signal to physicians that it is okay to do less than the best for their patients in order to serve the greater good of the population.
About the Author
Peter A. Ubel, MD
Veterans Affairs Health Services Research and Development
Michigan Program for Improving Healthcare Decisions
Division of General Internal Medicine, University of Michigan
Dr. Ubel is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar, recipient of a career development award in health services research from the Department of Veterans Affairs, and recipient of a Presidential Early Career Award for Scientists and Engineers (PECASE).
READERS (with personal or institutional subscriptions) can access detailed commentary here.
Commentaries are by:
The Tragedy of the Medicare Commons?
Peter H. Barrett
Rationing Healthcare: The Appeal of Muddling Through Elegantly
David J. Hunter
Cutting Healthcare Costs without Rationing at the Bedside: Preserving the Doctor-Patient Fiduciary Relationship
Saul J.Weiner and Charles L. Rice
Bedside Rationing by Physicians: The Case Against
Arthur Schafer
The Need Is to Prioritize, Not Ration
Val Rachlis
Physicians Must Participate in Establishing Standards of Care
Gregory Powell
Advocacy and Rationing Are Compatible
Claude Gratton and Margaret Keatings
Final Response
The Author Responds: Putting Bedside Rationing Back into Perspective
Acknowledgements
The author acknowledges Julie L. Lucas for her assistance in manuscript preparation. References
Asch, D.A., et al. When Money Is Saved by Reducing Health Care Costs, Where do Physicians Think That Money Goes? (in submission).
Asch, D.A. and P.A. Ubel. 1997. "Rationing by Any Other Name." New England Journal of Medicine 336:1668-71.
Berwick, D.M. and K.L. Coltin. 1986. "Feedback Reduces Test Use in a Health Maintenance Organization." JAMA 255(1): 1450-54.
Callahan, D. 1990. What Kind of Life: The Limits of Medical Progress. New York: Simon and Schuster.
Eddy, D.M. 1994. "Health System Reform:Will Controlling Costs Require Rationing Services?" JAMA 272: 324-28.
Garland, M.J. 1992. "Rationing in Public: Oregon's Priority-Setting Methodology." In Rationing America's Medical Care: The Oregon Plan and Beyond, M.A. Strosberg, et al., eds.Washington DC: Brookings Institution.
Goold, S.D. 1998. "Money and Trust: Physician Incentives and the Doctor-Patient Relationship." Journal of Health, Politics, Policy, and Law 23(4): 687-95.
Hall ,M.A. 1997. Making Medical Spending Decisions: The Law, Ethics, and Economics Of Rationing Mechanisms. New York: Oxford University Press.
Hiatt, H.H. 1975. "Protecting the Medical Commons: Who Is Responsible?" New England Journal of Medicine 293: 235-41.
Hillman, A.L.. 1990. "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments." Annals of Internal Medicine 112(12): 891-93.
Kilborn, P.T. 1999. "Oregon Falters on a New Path to Health Care." New York Times. p. A1.
Levinsky, N.G. 1984. "The Doctor's Master." New England Journal of Medicine 311(24): 1573-75.
Morreim, E.H. 1989. "Fiscal Scarcity and the Inevitability of Bedside Budget Balancing." Archives of Internal Medicine 149: 1012-15.
Morreim, E.H. 1991. "Gaming the System: Dodging the Rules, Ruling the Dodgers." Archives of Internal Medicine 151: 443-47.
Schectman, J.M., E.G. Elinsky, and L.G. Pawlson. 1991. "Effect of Education and Feedback on Thyroid Function Testing Strategies of Primary Care Clinicians." Archives of Internal Medicine 151: 2163-66.
Ubel, P.A. 2000. Pricing Life: Why It's Time for Health Care Rationing. Cambridge,MA: MIT Press.
Ubel, P.A. and S.D. Goold. 1998. "'Rationing' Health Care: Not All Definitions Are Created Equal." Archives of Internal Medicine 158: 209-14.
Vijan, S., T.P. Hofer, R.A. Hayward. 2000. "Cost- Utility Analysis of Screening Intervals for Diabetic Retinopathy in Patients with Type 2 Diabetes Mellitus." JAMA 283(7): 889-96.
Welch, H.G. 1991. "Should the Health Care Forest Be Selectively Thinned by Physicians or Clear Cut by Payers?" Annals of Internal Medicine 115(3): 223-26.
HealthcarePapers
Vol. 2 No. 2 2001 | Physician Rationing
Abstract:
Physicians are often asked to be "gatekeepers," determining their patients' access to medical therapies and technologies. At the same time, most physicians have been taught that they should act as patient advocates, pursuing patients' best interests regardless of cost. This paper reviews moral arguments ethicists have made for and against "bedside rationing." It argues that healthcare rationing is appropriate in order to help control healthcare costs, and that rationing decisions made at the bedside by physicians must be part of the rationing system. A system that attempts to control costs by mandating an elaborate set of rules would be burdensome, and many physicians would find ways around the rules anyway.
Physicians are deeply conflicted about their roles in cost-containment. Some of the conflict has to do with discomfort over the concept of "rationing," but they are also in conflict about much deeper issues. The author argues that patients can do with less than the "best" treatment and physicians must come to terms with this. Finally, healthcare systems need to signal physicians that it is acceptable for them to offer "less" to their patients in order to serve the greater good.
Ms. Johnson comes to her physician with symptoms of gastric reflux (GERD). Her doctor gives her a prescription for cimetidine, even though he knows omeprazole would be better at relieving her symptoms. He thinks the cost of this other medication is too high for it to be the initial treatment.
In an old Mel Brooks movie,Moses is seen coming down from the mountains with three stone tablets. He announces to his people in a stentorian thunder: "I come down with a copy of God's Fifteen . . ."- he fumbles one of the tablets, and it falls to the ground - ". . . er,Ten Commandments for how to live a good life."
This is pure speculation, but I would guess that somewhere on that broken tablet was a commandment that read: "Physician, thou shalt not ration!" I base my speculation on the tone many people take when debating the appropriateness of bedside rationing by physicians. Opponents of bedside rationing argue vehemently that physicians should never ration from their patients. For example, in a New England Journal of Medicine editorial, Howard Hiatt (1975) wrote: "A physician must do all that is permitted on behalf of his patient." In a similar vein, Dr. Norm Levinsky, chair of medicine at Boston University, has written that: "Physicians are required to do everything they believe may benefit each patient without regard to cost" (Levinsky 1984). Hiatt and Levinsky's statements are consistent with the traditional moral view that physicians should advocate for their patients without regard to costs. This view is treated almost as a theological truth in the United States. But I am a heretic. I think that it is sometimes appropriate for physicians to ration healthcare from their patients in order to help control healthcare costs. In this article, I briefly describe the "theology" of bedside rationing - why so many people think bedside rationing is immoral. I also discuss why I am a heretic. I think any method of controlling healthcare costs is doomed to fail, unless it is joined by some relaxation of physicians' advocacy duties. Finally, I discuss linguistic confusion about bedside rationing.Many people debate the appropriateness of bedside rationing without ever defining what they mean; this leads to disagreements about the morality of bedside rationing among people whose moral values are actually the same.
Theology 101: the Immorality of Bedside Rationing
Opponents of bedside rationing contend that it violates physicians' moral duties to advocate for patients' interests. In addition, they believe that bedside rationing would erode trust between patients and their physicians. Moreover, they hold that bedside rationing creates savings that do not necessarily go toward improving patient care for other patients. I elaborate on each of these objections below.
It has been long argued that physicians have a "fiduciary duty" to advocate for patients' interests (Morreim 1989). A fiduciary is someone who acts on behalf of those who otherwise may not be able to pursue their interests (Hall 1997). Physicians are seen as fiduciaries for patients because they have more knowledge than patients do. Patients may not know what is in their best interests or may not be able to pursue their best interests without a physician's help. Physicians also have fiduciary duties because patients are often dependent on them. Patients are emotionally dependent on physicians because their illnesses make them vulnerable; in addition, patients are legally dependent on physicians, who have been given powers to order medications and perform procedures that other people can not do. Finally, physicians' fiduciary duties arise because healthcare issues are often high stakes. These high stakes distinguish the doctor-patient relationship from otherwise parallel relationships, such as between an auto mechanic and a client. An auto mechanic has more knowledge about cars than a typical person and may have tools to repair a car that the average person could not afford. Although auto mechanics have moral duties, such as to be honest with their clients, their duties are not fiduciary, because the stakes are not high.
People often feel strongly about physicians' advocacy duties towards patients because they recognize that patients need to trust their physicians in order to receive good care (Goold 1998). Many aspects of healthcare depend on trusting interactions between patients and their providers. Patients who do not trust their healthcare provider may not tell the provider about the symptoms they are experiencing, or may not tell about high-risk behaviour they are engaging in. If worried that physicians were rationing healthcare from them, patients might lose trust in their physicians. Consequently, the quality of healthcare that physicians can provide to their patients would erode.
Some opposition to bedside rationing arises because of concern about who would really benefit if physicians rationed healthcare from their patients (Asch et al.; in submission). In the case presented in the introduction, a physician prescribed a less expensive medicine to a patient with reflux in order to save money. But whose money was being saved? If the patient would not have incurred most or all of the increase in costs of the more expensive medicine, then who benefits from this rationing decision? Many people think the money will simply go to a greedy insurance company or to the CEO of a managed-care company. These people contend that there is no moral justification for withholding the best care from patients, given that the money saved by bedside rationing will not necessarily benefit patients.
For these and other reasons, the traditional moral view is that physicians need to do what is in patients' best interests regardless of cost. But, as I stated above, I do not hold that view. Below I will describe why I oppose the traditional view of physicians' moral duties. First, however, I need to define what I mean by "bedside rationing."
Defining My Terms
Bedside rationing is a subset of healthcare rationing; in other words, it is one of many ways to ration healthcare. For the purposes of this article, I hold that healthcare rationing occurs whenever the healthcare system, or "society," allows patients to receive less than the most beneficial healthcare service. If a patient receives treatment A because of resource constraints, when a more expensive treatment, B, would have been better, then treatment B has been rationed from the patient. This rationing could have occurred because of bedside rationing - a clinician might have decided to prescribe A rather than B; or it could have occurred through market forces - the patient could have been asked to pay for either A or B and, thus, chose A; or it could have occurred through any number of other mechanisms.
The definition I have proposed for healthcare rationing is consistent with how most health economists define the term. I have defended this definition elsewhere (Ubel and Goold 1998). Nevertheless, there is no single "best" way to define a complex term like healthcare rationing, nor is it crucial for me to convince you that the definition I propose is the best. Instead, I put forward this definition as a way to clarify the term as I discuss why I believe bedside rationing is morally acceptable.
Before discussing why I believe bedside rationing is an acceptable method of rationing healthcare, I need to note a fact that is perhaps obvious. If healthcare rationing is unacceptable, then bedside rationing is unacceptable. In other words, those who argue that healthcare should not be rationed not only disapprove of bedside rationing but also would disapprove of any other method of rationing healthcare. I will not argue against this view here. Others have argued convincingly, I believe, that there is a need to ration healthcare (Hall 1997; Callahan 1990; Eddy 1994). The proliferation of new technologies being offered to patients with a wide range of illnesses has made it impossible to offer every patient the best possible healthcare services in existence. Each day, new medications become available that, if they were free, would probably be offered to hundreds of thousands of patients. These medications are so expensive, however, we often hesitate to provide them to everyone that would benefit. Cholesterol medications, for example, are slowly diffusing towards a broader group of patients, but if they were as free as water, many people at relatively low risk of coronary heart disease might start taking them. To make this discussion manageable, then, I will ask readers to assume that some amount of healthcare rationing is necessary to help control healthcare costs. The question for this article then is whether any amount of this rationing ought to be done at the bedside by clinicians. In other words, is bedside rationing a legitimate form of healthcare rationing?
Not surprisingly, it is helpful to begin with a definition of bedside rationing. Susan Goold and I have argued that three conditions are necessary for a clinical action to qualify as bedside rationing: (1) the patient must be given less than the best available healthcare, (2) the best healthcare must be withheld in order to save societal resources, and (3) the physician (or clinician) must have control over the healthcare decision (Ubel and Goold 1998). For example, in the reflux case described in the introduction, the physician prescribed the less expensive reflux medicine in order to save society money. Hence, the case was an example of bedside rationing. A subtle change in the case, however, would change this classification. If the patient was responsible for the difference in cost of these two medicines, the decision would not necessarily qualify as bedside rationing, because the physician could potentially be ordering the less expensive medicine to save money for the patient. (In such a situation, the physician ought to talk with patients about how they want to spend their money.) Another change in the case would also eliminate it as an example of bedside rationing. If the patient's health plan required physicians to prescribe less expensive reflux medicines before prescribing expensive ones, the doctor's prescription would not be at her discretion and the health plan would be rationing the expensive medicine from the patient, not the physician.
To better understand what I mean by bedside rationing, it is helpful to think of alternative ways to ration healthcare. Healthcare can be rationed by ability or willingness to pay. Healthcare can also be rationed by formulary committees who decide that expensive reflux medicines are no longer available to all patients. A health plan may decide not to offer lung reduction surgery to its patients, and a government insurer may decide to limit PET scanners for its citizens. These are examples of administrative level healthcare rationing, but not examples of bedside rationing.
Can the Cost of Reflux Treatments Be Contained without Bedside Rationing?
Imagine a healthcare system that is trying to reduce the use of expensive proton pump inhibitors (PPIs), such as omeprazole, in patients with reflux disease. Imagine at the same time that all the physicians in this healthcare plan have vowed never to ration at the bedside. How would this healthcare system go about reducing the use of PPIs?
To begin with, if this healthcare plan did nothing to control PPI use and physicians were committed to providing the best possible care to their patients without regard to cost, then physicians would almost never prescribe the less expensive reflux medicines. PPIs are simply better reflux medicines than the less expensive H2 blockers. Some people might reject the idea that offering less expensive reflux medicines to patients is an example of rationing (Asch and Ubel 1997). They might argue that many patients do just as well with H2 blockers as with PPIs. For these patients, then, no benefit has been withheld if they receive H2 blockers first; if no benefit has been withheld, then no bedside rationing has occurred. This reasoning is faulty, however, because it utilizes an after-thefact evaluation to judge a prior-to-thefact decision. Prior to prescribing a reflux medicine, physicians do not know whether H2 blockers or PPIs will work better for a particular patient. However, patients' chances of successful reflux treatment will be significantly greater with PPIs. Indeed, if money were no object, there would be no reason (in most patients) to prescribe an H2 blocker instead of a PPI.
Because PPIs are superior to H2 blockers but more expensive, the healthcare plan has to find a way to keep physicians from prescribing them if it wants to save money on reflux medications. One way to do so would be to require that all patients undergo a trial of H2 blockers before receiving PPIs. How would such a requirement work? First, the health plan would need a system for documenting whether patients had already been on H2 blockers, so that they could receive PPIs after the H2 blockers failed. The system would also need to track whether patients had received H2 blockers from other healthcare plans prior to transferring to their new plan. In addition, it would need to develop a system whereby physicians could appeal and prescribe PPIs for patients who had taken H2 blockers on the outside or who had some "contraindication" (some medical reason they could not take H2 blockers). Preparing for such exceptions and appeals costs money. The health plan would need to spend money to develop information systems that could monitor the program. This in itself has resource implications and would have to be weighed against the amount of money that would be saved by reducing PPI prescriptions.
But the system would have to be even more complex than I have indicated, or it would create some clinical problems. For example, PPIs are important medicines for treating patients who have non-reflux related stomach problems caused by the bacterium H. pylori. Would physicians be able to prescribe PPIs for such patients? In addition, should the system be prepared to allow exceptions for patients who come in with "severe reflux symptoms"? If so, how should we define severe reflux disease? Once these exceptions are made, how would they be monitored?
I am trying to show, through examples, that rule-based rationing is problematic because the rules can very quickly become unmanageable. Perhaps just as important, rule-based rationing systems are susceptible to physician "gaming"- physicians interpret rules in ways that benefit their patients (Morreim 1991). A notable example of gaming is occurring in the state of Oregon, which, since the mid-1990s, has been trying to reduce its Medicaid expenditures through an explicit rationing plan. Medicaid is a U.S. healthcare program for poor people and is paid for by a combination of federal and state monies. Oregon was having a hard time keeping its Medicaid expenses in line while trying to maintain coverage for all the poor people who needed healthcare. One solution, as formulated by then legislator (and now governor) John Kitzhaber, was for Oregon to specify which healthcare services it would offer to Medicaid patients and which ones it would not. The state hoped to save money by withholding Medicaid services that were deemed less important than other services (Garland 1992). The savings garnered by not paying for such services could then be used to offer Medicaid to more patients.
Despite good intentions, the Oregon Medicaid rationing plan has not saved a dime, because physicians have found ways to get around the rules (Kilborn 1999). For example, if patients have multiple diagnoses below the funding line, physicians will get reimbursed for their treatment. Consequently, when patients come in with "below-the-line diagnoses," physicians almost always find several other "below-the-line" diagnoses in order to get reimbursement for their treatments. Through this and other loopholes, physicians have found ways to make sure patients get the treatments that are best for them. Indeed, physicians are notoriously good at gaming healthcare systems to get benefits for their patients. Thus, to the extent that healthcare plans try to tie physicians' hands to control healthcare costs, physicians wriggle free of the ropes.
What about a Simpler Type of Rule to Control Spending?
So far, I have discussed several rule-based methods of reducing PPI prescriptions. I have argued that these rules need to become more elaborate in order to control healthcare costs, but they can still often be overcome by physician gaming. How about a simpler rule: require gastroenterologist approval of every PPI prescription. Would this simpler rule control costs? Such a rule would have several advantages over more complex rules. It would allow for clinical judgments to be made about which patients really needed PPIs. No committee would need to create an official definition of "severe reflux disease." Instead, clinicians talking to each other on the phone could decide whether a patient really needed a PPI prescription. Such a rule allows for clinical judgments based on the specifics of individual patients. This contrasts with previous rules, which were meant to be applied to all patients.
Despite its advantages, this type of rule has pitfalls too. Most important, it could potentially overwhelm gastroenterologists with pages and phone calls about PPI prescriptions. At one institution where I worked, this plan was rapidly defeated when gastroenterologists told primary-care physicians to write down that they had GI approval any time they wanted to prescribe a PPI. The gastroenterologists were so fed up with receiving phone calls about PPI prescriptions that they found a way to defeat the system.
Let us shift our attention away from reflux disease for a bit and consider a common diagnostic test that has significant expense - CT scans.Who should be able to order a CT? Should all primary-care physicians be able to do so without prior approval? What about primary-care nurse practitioners? At one institution where I worked, nurse practitioners could order CT scans (and MRI scans, for that matter, a significantly more expensive test) without discussing this with a radiologist or primary-care physician. I saw patients who presented with new onset shoulder pain who were referred for MRIs by clinicians without anybody asking a radiologist if that test was indicated. In my clinical judgement, this is a wasteful practice. But how do we keep it from happening?
Healthcare systems could require that all CT scans and MRI scans be approved by radiologists. As with the gastroenterology example described above, however, such a policy would potentially overwhelm radiologists with such requests. Moreover, in many cases, primary-care practitioners have every reason to know that a scan is indicated.
Although it makes some sense to require clinicians to speak with radiologists before ordering extremely expensive radiology tests, I have concerns about a system that requires such conversations. First, such a system ignores many less expensive tests that, nevertheless, are ordered frequently enough that they cost healthcare systems a lot of money. Think of all the plain film x-rays that are ordered for low-back pain and for routine screening of lung fields that have almost no clinical value. Second, such a system imposes burdens on radiologists and other physicians who must now find time in their busy days to speak with each other, even in circumstances where the correct radiology test to order is obvious. This not only takes up these clinicians' time, but also ultimately costs healthcare systems money, because radiologists and other physicians are highly paid professionals. Third, the systems create a layer of bureaucracy in order to document that conversations have occurred between radiologists and other clinicians. Bureaucracies create hassles. Just as important bureaucracies cost money.
Instead of Bureaucratic Rules or Time-Consuming Approval Requirements, Why Not Give Physicians Feedback about Their Utilization?
There are alternatives to forcing clinicians to call each other on the phone to get approval for every lab test, radiology test, and expensive medication they want to order. One alternative is to give clinicians feedback, every few months or so, about how much they utilize expensive diagnostic tests in comparison to their peers. Research has shown that such feedback reduces physicians' utilization (Berwick and Coltin 1986; Schectman et al. 1991). Physicians hate feeling like they are outliers; they do not want to rely on expensive tests more than other physicians do.
Such feedback systems deserve a role in helping control healthcare costs. They do not require burdensome rules, but they do not avoid bedside rationing. If physicians are only interested in patients' best interests, they will completely ignore how their utilization patterns compare to other physicians. In fact, in a world without bedside rationing, they will continue to order what they think is best for their patients. Those who order fewer CTs and MRIs may have reason to wonder if they are ordering too few tests.
What about Avoiding Bureaucratic Rules by Implementing Capitation or Other Financial Incentives?
Asking physicians to bear some financial risk for the tests and medicine they order for their patients has also been shown to control healthcare costs. Under such "capitated" healthcare systems, physicians are given a certain amount of money to take care of their patients (Hillman 1990). Some percent of the money they spend caring for their patients is then taken from their salary. This encourages physicians to order fewer tests and referrals.
Many people have raised moral objections to capitation-reimbursed systems. I do not plan to discuss these arguments here. Instead, I want to make a simple point: capitation systems only control healthcare costs by encouraging bedside rationing. If patients' best interests were all that mattered, most clinical decisions would be unaffected by capitation: clinicians would still do what is best for their patients, regardless of costs.
What about Rationing with Practice Guidelines?
Some colleagues of mine in Michigan recently published an article on the cost effectiveness of performing routine retinal screening exams for diabetic patients (Vijan et al. 2000). The standard of care, up to now, has been to make sure that all diabetic patients have ophthalmology examinations each year to screen them for diabetic eye disease. My colleagues argued that annual screening is unaffordable for patients with mild diabetes; such a screening rarely prevents blindness, compared to screening every two to three years.
If physicians only worried about patients' best interests, they would ignore my colleagues' work, because annual screening would still prevent more cases of blindness than less frequent screening. However, it is likely that in the near future, leading diabetes organizations will change their recommendations on how to screen patients with mild diabetes and recommend screening every other year in low-risk patients. These guidelines will probably have a significant influence on physicians' referral practices.
If physicians begin to follow diabetes society "guidelines" for how often to screen people for retinal disease, they will be engaging in bedside rationing. However, I expect that many physicians will not realize that they are rationing at the bedside when they follow these guidelines (Asch and Ubel 1997). I happen to think these guidelines are signals from society about how much money they want physicians spending to prevent rare illnesses. The decision is, however, still ultimately up to individual clinicians. Such guidelines will have no effect on clinical practice unless physicians are willing to ration at the bedside.
How Do I Justify My Heretical Support of Bedside Rationing?
As hinted above, I have a major concern with healthcare systems that ration without any reliance on bedside rationing: these rationing systems will be burdensome. I scratched the surface in discussing how a healthcare system might try to reduce the use of PPIs. I did not even begin discussing the similarly burdensome rationing mechanisms the system would need to control the use of expensive hypertension medicines, reduce subspecialty referrals, decrease the use of marginally beneficial lab tests, reduce the length of outpatient visits, or reduce the frequency with which physicians order follow-up appointments. A system that controls healthcare costs by creating elaborate rules around all these varied types of clinical decisions would be a bureaucratic nightmare and a clinical disaster.
Those who want to control healthcare costs must decide how they will trade off between blunt, obtrusive rules that completely delineate physicians' behaviours and some amount of bedside rationing that encourages physicians to reduce their use of marginally beneficial healthcare services (Welch 1991).
When I say I am in favour of bedside rationing, I mean the following: at times physicians need to relax their advocacy duties and give their patients less than the best possible healthcare services in order to save money for society. The entire rationing burden should not fall on physicians' hands. There is an appropriate role for administrative rationing mechanisms. In fact, many of the "burdensome rationing rules" I discuss above would be made much less burdensome if we could rely on physicians to occasionally ration at the bedside. For example, a healthcare system could ask physicians to prescribe H2 blockers whenever possible before prescribing PPIs. Such a guideline, handed down by a healthcare system or by a respected medical society, would help physicians remember that H2 blockers are still good medicines for many patients and that society needs to control healthcare costs by reducing the use of expensive PPIs. At the same time, this guideline would allow physicians to use their judgment about when to make exceptions to the guideline.
No system that relies completely on administrative rationing mechanisms will succeed in reducing healthcare costs. In addition, a system that relies heavily on willingness and ability to pay to ration healthcare is morally questionable (for reasons I will not go into here). Thus, the best way to ration healthcare is to have a mixture of administrative rationing mechanisms and clinicians engaging in bedside rationing, with a touch of willingness to pay on the side.
I recognize that there are moral problems with bedside rationing. The problems cannot be eliminated, but they can be reduced. For example, we need to make sure that physicians ration in ways that do not greatly reduce patient trust. I think this is achievable.We also need to do what we can to make sure that money saved by healthcare rationing (bedside or other) goes towards appropriate ends. The goal of healthcare should not be to maximize profits. We need to find ways to help physicians ration at the bedside so that they will not do it haphazardly or in a discriminatory manner. At the same time, we must judge bedside rationing the same way we judge democracy - by comparing it to the alternatives. In this case, the alternatives include burdensome rationing rules, many of which physicians would bend in their patients' favour, and increased use of out-of-pocket expenses to ration healthcare, which favours wealthy patients over others. Bedside rationing has weaknesses, but I think its weaknesses are worth accepting in order to avoid the weaknesses of alternative ways to ration.
What Do Physicians Think of Bedside Rationing?
I have all too briefly discussed the theology behind opposition to bedside rationing and the heresy of relying on bedside rationing to help us control healthcare costs.What do most physicians think about these issues? Do physicians hold to the good old religion and oppose bedside rationing or are they joining heretics like me in accepting its necessity?
Sorting out physicians' attitudes towards bedside rationing is tricky, in part because of linguistic confusion about what it means to ration at the bedside. When physicians disagree about bedside rationing, they could potentially be having one of two kinds of disagreement: (1) they could be disagreeing about the appropriateness of having physicians do less than the best for their patients, or (2) they could be disagreeing about the meaning of the word rationing. That is, physicians might agree with each other that it is appropriate to withhold PPIs from patients, but disagree about whether this is an example of bedside rationing. As an analogy, consider two people who are looking at an insect. In one case, they agree that the insect is a moth, but disagree about whether it is beautiful or ugly. This is similar to agreeing about what it means to ration at the bedside while disagreeing about whether such rationing is justifiable. In another case, imagine they agree that the insect is beautiful while disagreeing about whether it is a moth or butterfly. This is analogous to agreeing that bedside rationing is acceptable - that doing less than the best for patients is acceptable - while disagreeing about whether this is an example of bedside rationing.
To sort out these two ways of disagreeing about bedside rationing, David Asch and I presented 1,000 general internists in the United States with a vignette in which a hypothetical physician offers a less expensive and less effective colon cancer screening test to a patient in order to save money for society (Ubel 2000).We asked physicians whether the physician who ordered the less expensive colon cancer screening test was acting "appropriately" and whether that physician was performing "healthcare rationing."We found that physicians generally agreed that it was appropriate for the hypothetical physician to offer the less effective test to the patient. In fact, only 20% of physicians felt that ordering the less expensive colon cancer screening test was inappropriate. Physicians were completely divided about whether such a decision was an example of healthcare rationing. Forty percent thought it wasn't, 40% thought it was, and 20% had no idea. This suggests that physicians generally support the idea of making cost-quality trade-offs at the bedside. They are comfortable offering a decent screening test to someone, even though a slightly better and significantly more expensive test is available. They are not sure whether to call such a thing "bedside rationing."
This disagreement among physicians about what qualifies as bedside rationing should not surprise us. As I stated above, there is no single way of defining complex terms such as rationing or bedside rationing. And besides, when we conducted this survey, my elegant definition of bedside rationing had not yet been published! More important, rationing is a loaded term. People may support the concept of rationing without wanting to label it that way. I do not have a problem with that. I personally like to use the term rationing, because I think it forces people to consider the moral implications of their decisions. Other euphemisms might be easier to swallow, but they might make us less likely to notice when we are ingesting rotten food.
Nevertheless, I am happy to define rationing in different ways, if that is what people want to do. Instead, what is more important to me is that physicians recognize that they do not currently pursue patients' best interests without regard to costs. I can find examples for almost any physician I know in which they are forgoing a marginally beneficial test or referral because of its expense. Different physicians have different thresholds, but I would guess even Norm Levinsky does not order a thyroid screening test on every patient he sees every few months. If money were irrelevant, even he would order more thyroid tests. Physicians have not done a good job of recognizing that they are making trade-offs between cost and quality. By failing to recognize these trade-offs, they are probably not doing a very good job of making them. If clinicians recognized the trade-offs they made every day, they could begin to look across their entire practices and see when they were trading off too much quality for not enough cost savings, and when they were not trading off enough.
Conclusion
Heated debates about the morality or immorality of bedside rationing have been missing the point.We are so worried about the loaded term "rationing" or about old-fashioned moral ideals that were developed in a time when healthcare costs were not nearly as high as they are that we are not facing up to the new reality.We need to control healthcare costs, and physicians must play a crucial role in helping society do so.
Society is still coming to grips with resource constraints in medical care, especially in the United States. Not surprisingly, many people are not sure who they think ought to be making rationing decisions. Clinicians are equally confused; they do not want to bear a disproportionate share of decision-making over rationing. On the other hand, most clinicians do not want to practise healthcare amid a sea of burdensome rules that limit their abilities to take care of patients.
Whether or not clinicians call it "rationing," they need to recognize that they have a crucial role in helping to control healthcare costs. The best way to control costs is for clinicians to relax their advocacy duties in conjunction with other rationing mechanisms. Clinicians need to recognize that patients can do with less than the best. Physicians need to come to grips, individually if not as a group, with what services they can withhold from patients. And finally, healthcare systems need to find ways to signal to physicians that it is okay to do less than the best for their patients in order to serve the greater good of the population.
About the Author
Peter A. Ubel, MD
Veterans Affairs Health Services Research and Development
Michigan Program for Improving Healthcare Decisions
Division of General Internal Medicine, University of Michigan
Dr. Ubel is a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar, recipient of a career development award in health services research from the Department of Veterans Affairs, and recipient of a Presidential Early Career Award for Scientists and Engineers (PECASE).
READERS (with personal or institutional subscriptions) can access detailed commentary here.
Commentaries are by:
The Tragedy of the Medicare Commons?
Peter H. Barrett
Rationing Healthcare: The Appeal of Muddling Through Elegantly
David J. Hunter
Cutting Healthcare Costs without Rationing at the Bedside: Preserving the Doctor-Patient Fiduciary Relationship
Saul J.Weiner and Charles L. Rice
Bedside Rationing by Physicians: The Case Against
Arthur Schafer
The Need Is to Prioritize, Not Ration
Val Rachlis
Physicians Must Participate in Establishing Standards of Care
Gregory Powell
Advocacy and Rationing Are Compatible
Claude Gratton and Margaret Keatings
Final Response
The Author Responds: Putting Bedside Rationing Back into Perspective
Acknowledgements
The author acknowledges Julie L. Lucas for her assistance in manuscript preparation. References
Asch, D.A., et al. When Money Is Saved by Reducing Health Care Costs, Where do Physicians Think That Money Goes? (in submission).
Asch, D.A. and P.A. Ubel. 1997. "Rationing by Any Other Name." New England Journal of Medicine 336:1668-71.
Berwick, D.M. and K.L. Coltin. 1986. "Feedback Reduces Test Use in a Health Maintenance Organization." JAMA 255(1): 1450-54.
Callahan, D. 1990. What Kind of Life: The Limits of Medical Progress. New York: Simon and Schuster.
Eddy, D.M. 1994. "Health System Reform:Will Controlling Costs Require Rationing Services?" JAMA 272: 324-28.
Garland, M.J. 1992. "Rationing in Public: Oregon's Priority-Setting Methodology." In Rationing America's Medical Care: The Oregon Plan and Beyond, M.A. Strosberg, et al., eds.Washington DC: Brookings Institution.
Goold, S.D. 1998. "Money and Trust: Physician Incentives and the Doctor-Patient Relationship." Journal of Health, Politics, Policy, and Law 23(4): 687-95.
Hall ,M.A. 1997. Making Medical Spending Decisions: The Law, Ethics, and Economics Of Rationing Mechanisms. New York: Oxford University Press.
Hiatt, H.H. 1975. "Protecting the Medical Commons: Who Is Responsible?" New England Journal of Medicine 293: 235-41.
Hillman, A.L.. 1990. "Health Maintenance Organizations, Financial Incentives, and Physicians' Judgments." Annals of Internal Medicine 112(12): 891-93.
Kilborn, P.T. 1999. "Oregon Falters on a New Path to Health Care." New York Times. p. A1.
Levinsky, N.G. 1984. "The Doctor's Master." New England Journal of Medicine 311(24): 1573-75.
Morreim, E.H. 1989. "Fiscal Scarcity and the Inevitability of Bedside Budget Balancing." Archives of Internal Medicine 149: 1012-15.
Morreim, E.H. 1991. "Gaming the System: Dodging the Rules, Ruling the Dodgers." Archives of Internal Medicine 151: 443-47.
Schectman, J.M., E.G. Elinsky, and L.G. Pawlson. 1991. "Effect of Education and Feedback on Thyroid Function Testing Strategies of Primary Care Clinicians." Archives of Internal Medicine 151: 2163-66.
Ubel, P.A. 2000. Pricing Life: Why It's Time for Health Care Rationing. Cambridge,MA: MIT Press.
Ubel, P.A. and S.D. Goold. 1998. "'Rationing' Health Care: Not All Definitions Are Created Equal." Archives of Internal Medicine 158: 209-14.
Vijan, S., T.P. Hofer, R.A. Hayward. 2000. "Cost- Utility Analysis of Screening Intervals for Diabetic Retinopathy in Patients with Type 2 Diabetes Mellitus." JAMA 283(7): 889-96.
Welch, H.G. 1991. "Should the Health Care Forest Be Selectively Thinned by Physicians or Clear Cut by Payers?" Annals of Internal Medicine 115(3): 223-26.
Monday, January 5, 2009
How Well Protected Are Canadian Research Participants: Who Knows?
| From Dorothy Pringle, the Editor-in-Chief of the Canadian Journal of Nursing Leadership: |
| The human research enterprise in Canada is large and growing. It spans a wide range of fields that includes political science, sociology, anthropology, education, social work, nursing, epidemiology and medicine among others. Funding comes from many different sources, including the charitable research foundations such as the Heart & Stroke Foundation and the Canadian Cancer Society, hospital foundations, the three national funding councils - the Canadian Institutes of Health Research (CIHR), the Social Sciences & Humanities Research Council (SSHRC) and the Natural Sciences and Engineering Research Council (NSERC) - and the major provincial funding organizations in Nova Scotia, Quebec, Alberta and British Columbia among many others. Not all research is funded. This is particularly true of the humanities and student research across all disciplines. |
| In Canada, all research on human subjects must be approved by a research ethics board (REB). The major funding bodies will not release funds until an REB has approved the study. In Canada, the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans (TCPS) (Medical Research Council of Canada, 1998) dictates research ethics. It was developed over the 1990s by the Tri-Council Working Group under the auspices of the three national funding councils (the Medical Research Council preceded CIHR as the health research council signatory) and was finally adopted in 1998. By December of that year, all institutions that conducted research were expected to be in compliance with its tenets, or be in the process of becoming so. Since that time, many organizations have invested significant dollars in staff and in information technology to enhance their capacity to undertake credible reviews. Research ethics offices in universities and hospitals, in particular, have grown in size and expertise to respond to the increase in studies that have to be reviewed and to demonstrate the increased expectations of accountability. So, is there a problem, and if there is, what is it? The answer is, we don't know, and the existing system does not make it possible for us to know. The current state of research participant protection in Canada has evolved over time and in response to the numerous policies and expectations set by Canadian and international research funding bodies and other authorities. These policies are not necessarily congruent, and it is virtually impossible to be in compliance with all of them. In fact, the TCPS pertains only to research conducted through funding from the three national research councils, although most organizations stretch that to apply to most of the research coming to their REBs. There are no standards for education in research ethics for investigators, graduate students undertaking research, REB members and chairs, or research participants; for example, some REBs have no members with expertise in law, privacy legislation or qualitative research yet are reviewing proposals that require some or all of these competencies. There are no standards for the operation of research ethics offices in terms of resources, compensation for or acknowledgement of REB members' work, and length of terms for REB members. Proportionate review is still a thorny issue, particularly for researchers in the social sciences and humanities, who believe, with some justification, that the TCPS is biased toward medical or health sciences research. They contend that the level of risk to participants in most of their research studies is much lower than that of medical research in which participants' health and well-being may be jeopardized, and their studies do not require the same scrutiny accorded medical research. The TCPS addresses this and calls for risk to be judged appropriately to the circumstances of the research, but REBs are left to develop their own standards on this issue. Researchers proposing studies that involve collecting data in several (and sometimes dozens) of sites face a requirement for their research proposals to be approved by an REB in each site; this can take months and even years. On the other hand, while there are gaps in policies, concerns about under- and overzealous application of policies that do exist, and angst about multiple REB approvals, Canada has not seen the major breaches in research ethics that have arisen and cost lives in other jurisdictions. In the United States, some universities have had their entire medical research program shut down and all federal funding withdrawn because of grievous breaches to research ethics. However, there is the shared view that "the governance of research in Canada is fragmented and uneven - many players overseeing many other players through the use of many instruments" (Experts Committee 2008: 23) and, at the same time, no way of knowing how well research participants in Canada are protected. Various groups have been and currently are trying to address these issues. The Interagency Advisory Panel on Research Ethics (PRE) was created in 2001 by the three federal funding councils to continue to elaborate the TCPS policies. The PRE has been working for several years on revising the TCPS, including the section on proportionate review, and is supposed to release its revisions for consultation before the end of 2008. Unfortunately, work from the PRE has been slow in developing, and the panel must live with the fact that its sponsors are in conflict of interest when it comes to developing policies to cover research that they fund. This requires an arms-length relationship. NCEHR, the National Council on Ethics in Human Research, is a voluntary organization of individuals with an interest in promoting research ethics and protecting research participants. It is funded by CIHR, Health Canada, the PRE and The Royal College of Physicians and Surgeons of Canada (RCPSC). NCEHR, which has been on the scene since 1989, has developed well-regarded educational programs and a site-visit program for organizations to assist in improving their participant protection programs. Additionally, in 2003 NCEHR proposed an accreditation program that it would operate. However, NCEHR has not been able to secure funding for the proposed program, is frequently limited in its reach by lack of funding, and faces the same problem as the PRE in that its funds come in part from the body that funds research, reducing its arms-length status. SSHRC proposed a type of oversight program, called a public assurance system, as a way of dealing with its constituency's problems with the TCPS. This program was never embraced because it was seen as having "no teeth." In frustration, after a meeting called by NCEHR in June 2005 to review the penultimate draft of its report describing its proposed accreditation program, The Royal College of Physicians and Surgeons convened a meeting to try to deal with the lack of progress in developing an oversight program for research ethics. It invited Health Canada, the three funding councils, the Association of Universities and Colleges of Canada (AUCC) and subsequently eight other organizations including the Association of Faculties of Medicine of Canada to form a "coalition" of sorts, called the Sponsors' Table. The main raison d'être was to establish an expert committee to look into a range of governance models for the oversight of ethics in human research and to explore issues including implementation and funding" (as cited in Moving Ahead, 2008, p. 15) The Experts Committee (of which I was a member) had among its members scientists from the humanities, social and health sciences, including those who investigated research ethics as their area of scholarship, research ethics program administrators and legal experts, and was chaired by the late Arthur Kroeger, a highly respected former federal deputy minister (Experts Committee 2008). The committee's mandate was to provide advice on developing a system for human subject research participant protection in Canada that would address the issues of concern. After nine months of meeting and consulting, the committee prepared a draft report, circulated it for consultation, revised it and submitted the final report, Moving Ahead, to the Sponsors' Table at the end of March. A sad note is that Arthur Kroeger died shortly after the report was completed. The Expert Committee acknowledged both the strengths and weaknesses in the Canadian system but reached the conclusion that a new, independent organization was required that would take responsibility for the oversight of research ethics programs, including policy development, the establishment of educational standards, and the development and operation of an accreditation program for participant protection programs in Canada. These three functions were seen as interdependent, with one influencing the other. It was proposed that the Canadian Council for the Protection of Human Research Participants be established under the Canadian Corporations Act so that it would be at arm's length from all funding bodies. Because of fiscal realities, it was further proposed that the implementation of the Council be staged, with accreditation coming first, then policy, then education. The Sponsors' Table has acted on some of these recommendations; it has established working groups on policy, education and accreditation and has secured funding to support them. It has not embraced the recommendation of the independent Council at this time, but neither has it rejected it, noting that a number of operational issues must be resolved first. It is not clear under whose auspices an accreditation program would operate or how the most concerning aspects of conflict of interest related to policy and accreditation would be resolved. In the view of the Experts' Committee, it is appropriate for the Sponsors' Table to further the development of an oversight system but it is inappropriate for it to operate such a system. It does not have broad representation of organizations and it perpetuates the problem of conflict of interest because the funding councils are among its members. Nursing has not been a major player in this national drama. Nursing organizations are not represented at the Sponsors' Table, whereas organizations representing physicians are, and The Royal College of Physicians and Surgeons has played a leadership role. This is not acceptable. Nurses are now major participants in the research enterprise in this country. Nurse executives are responsible for knowing that the REBs under their auspices are staffed appropriately, have the requisite expertise among the members and are conducting appropriate proportional reviews. Deans and directors of graduate programs need to ensure that their students acquire the knowledge of research ethics that will allow them to conduct ethical studies as students, and as investigators following graduation. Nurse researchers use and are dependent on having robust and highly ethical participant protection programs available to them to review and approve their research proposals. All of us - researchers, nurse clinicians, nurse administrators and nurse citizens - need to have confidence in these same research participant protection programs. We cannot at this time. It is essential that nursing get involved, first by securing representation on the Sponsors' Table. At least one (but it could be more) of the national nursing organizations needs to take the lead on this, with a representative that is knowledgeable about issues related to research participant protection programs. Let's step up to the plate on behalf of all those individuals who contribute to nursing and all other types of research. About the Author Dorothy Pringle, OC, PhD, Editor-in-Chief References The Experts Committee for Human Participant Protection in Canada. 2008. Moving Ahead: Final Report, Ottawa. Medical Research Council of Canada. 1998. Tri-Council Policy Statement. Ethical Conduct for Research Involving Humans. Ottawa. |
Is the PHR Just a Tool for the Wealthy and Healthy?
Neil Seeman |
| Is the PHR like the "executive physical"? Some have suggested that personal health records (PHRs) - a system whereby patients enjoy custodial rights to their secure health data anytime, anywhere - is a privilege that appeals just to the wealthy, healthy or "worried well." |
Where's the Evidence?From what I can tell, there is very little substance to this argument in the current peerreviewed literature. Yet I have heard it from those unimpressed by travelling PHR corporate merchants.One often-cited study, by Weingart and colleagues (2006), found that "younger, healthier patients are most likely to make use of this technology." But that study looked at one portal, PatientSite, used at a Boston teaching hospital (Beth Israel Deaconess) and affiliated community practices. It had a small sample size, and the authors acknowledged that "results may not be generalizable to other portals or health care systems, practices, or patients." Most important: patients were eligible to enrol in PatientSite only if one of their physicians had enrolled, and recruitment efforts had focused on primary care doctors. The Weingart study, important as it was, looked at data from 2000-2004; consumer behaviour, especially among those suffering from chronic illness, has changed since then. And the new model of the PHR is available to anyone, anywhere, whether or not his or her physician is enrolled. A Tool for the Rich?The notion that only the wealthy will benefit from PHRs can be easily dismissed; the same argument was made against the telephone, the television and the toaster, yet all these innovations are now taken for granted by the middle class and all but the very poorest among us. PHRs through Google or Microsoft HealthVault are free to anyone, and at least 75% of Canadians have Web access from home. I predict (although it is hazardous to make predictions in healthcare) that in five years, the percentage of Canadian homes without regular PHR engagement will be lower than 2% (about the same proportion of homes without a television).Just as Wikipedia re-invented the encyclopaedia and the Web decimated newspaper ad revenues, the ubiquitous PHR will re-invent our relationship with the health system. Keep in mind that Facebook, now the third-most popular website in Canada, was in its infancy five years ago; change occurs rapidly in the world of Web-based consumer engagement. In a recent paper in Healthcare Quarterly, Kevin Leonard and colleagues (2008) make the analogy to automated teller machines (ATMs). Most of us can remember a time when there were no ATMs, when all transactions required long teller queues. And now, as former US House Speaker Newt Gingrich once pointed out at an OHA keynote address, who among us - be honest - has not fidgeted while waiting in a two-minute ATM line? Banking expectations have radically changed, for the rich and poor alike. Just for the Healthy?Let us deal more seriously with another argument: the idea that the PHR - as proselytized by Google Health, Microsoft HealthVault, Revolution Health and more than 200 smaller competitors - is a gimmick so that the already healthy can maintain their health. After all, PHRs do not keep people away from emergency rooms or from acute care when they're really sick.We heard this argument against Health Savings Accounts (HSAs). The two arguments, however (and the supporting data), are different. HSAs, according to their most partisan defenders, reconnect the patient and the provider with the true cost of care. And patients thereby start to make wiser decisions - or so the argument goes. We gain insights like: "Whoa, we have increased our use of generic medications, we should shop around for the best deals." Or, "Maybe an MRI costs a little bit more at this hospital versus that hospital." And so, according to this theory, we start to use the health system more strategically, perhaps through a high-deductible, catastrophic plan, the deductible being a cash account that accrues interest-free. Yet the HSA is hardly a panacea. If crafted unwisely, it potentially creates more burden for providers and payers, and can lead to increased spending on wealthy consumers to the detriment of the poor. Although this is a very different issue from that of PHRs, it is instructive. In the case of the PHR, there is every reason to assume that the highestintensity users of PHRs will be those suffering from chronic disease - a swath of society that transcends socio-economic class. Research has shown that chronic disease communities thrive exceptionally well on social networking sites. Remarkably, these communities, on sites such as Facebook and MySpace, are more active than celebrity or sports communities (Seeman 2008a). Bottom line: the healthy (and their providers) go to Google for generic health information; the poor, the rich, the middle class - those with chronic disease - seek out, on a daily basis, more niche-oriented Web communities, like diabetesmine.com. The same phenomenon will occur with the PHR. My own more recent research has shown that the "stickiest" health-related blogs cater to niche, chronic illness populations (Seeman 2008b). The users, chronic illness sufferers, will serve as free ambassadors and champions for tools like Microsoft HealthVault and other PHR platforms, building their own specialized add-on applications, which will then position them to blog about their own PHR experience. A Whatcom County, Washington, consortium that developed a PHR as part of a Robert Wood Johnson Foundation project implemented in 2002 found that chronically ill patients became a kind of PHR sales force, enlisting friends and family to join (Sprague, Lisa. 2006). There is no reason (other than anti-corporate animus) to suggest that poor people have a lesser understanding of their chronic health conditions than do the wealthy or middle class, or that they have a harder time communicating their issues to a PHR. (PHRs can offer multi-lingual, real-time translation, though admittedly, the technology needs to improve.) Conversely, the people most likely to flock to PHRs are historically underserved and stigmatized populations who now make greater use of online communities than do others. This includes the mentally ill (including young men who are unaccustomed to talking about their mental illness) and populations who are physically dislocated, such as Aboriginal peoples. In a survey by the Markle Foundation (2005), people who perceived themselves as healthy were less likely than all other groups to use a PHR. As one PHR entrepreneur advised me, "The problem with the PHR is that the healthy ignore them, so that many marketing schemes look to make them appealing to disease-specific clusters of patients." The Real Role of PHRsKeep in mind that the PHR is not intended to solve poverty, a multi-factorial problem, or other more systemic drivers of chronic illness. It is meant to improve consumers' understanding of health issues; to give them more access to and autonomy over their health; to support more timely, appropriate preventive services; to support home monitoring for chronic diseases; to support the continuum of care; to avoid duplicate testing; to increase access to providers via e-visits; and to reduce adverse drug interactions and allergic reactions.
John Snow and the PHRAs many have noted, engagement requires more than usability. The platform applications, whether via Google or Microsoft or other tools, must provide sustained value. But my instinct is that the PHR is akin to John Snow and the water pump. During the cholera outbreak in 1854 in London, Dr. Snow analyzed the geography of water supply and mortality patterns in Soho and found a disproportionate number of cholera cases within a few blocks of a single water pump on Broad Street. At his behest, the pump was removed. This action has been hailed as one of the first public health interventions of the modern era. Although Snow's microscopic examination of a sample of the Broad Street pump water was not conclusive, his studies of the pattern of disease were convincing enough to persuade the local council to disable the pump. The same can be said about PHRs. The evidence is hardly conclusive, but we do know that consumers are keen to engage with the Web and share secure personal health information that they own. The burden of proof against the PHR should lie with those who challenge consumers' good judgment.A related side note: In a future column, I look forward to tackling another myth about the PHR: that it threatens privacy rights. Lawyers, not consumers, are saying this. Consider this statement by Nicolas Terry (2008): "personal health records are dangerously flawed adjuncts to or substitutes for provider-centric records, and while lacking many of the touted quality or cost-reduction benefits of oft-criticized electronic health records they pose substantially higher levels of risk regarding security, privacy, and confidentiality." Sure, identity theft and privacy risks are always legitimate concerns, and there is a role for government to play in ensuring the security of electronic personal health information. But law should be in the service of innovation that matters to chronic disease sufferers throughout the world. (To be continued…) About the Author Neil Seeman is Senior Resident, Health Strategy Innovation Cell Massey College, University of Toronto Adjunct Professor of Health Services Management Ryerson University Toronto, ON References Leonard, K., D. Wiljer and S. Urowitz. 2008. "Yes, Virginia, There Are System Benefits to Be Gained from Providing Patients Access to Their Own Health Information." Healthcare Quarterly 11(4): 64-68. Retrieved January 4, 2009. < http://www.longwoods.com/product.php?productid =20094&cat=563&page=1 >. Markle Foundation. 2005 (October). "Attitudes of Americans Regarding Personal Health Records and Nationwide Electronic Health Information Exchange." Retrieved January 4, 2009. < http://www.markle.org/downloadable_assets/ 101105_survey_summary.pdf > Seeman, N. 2008a. "Web 2.0 and Chronic Illness: New Horizons, New Opportunities." ElectronicHealthcare 6(3): 104-10. Retrieved January 4, 2009. < http://www.longwoods.com/product.php?productid =19506&cat=524 >. Seeman, N. 2008b. "Inside the Health Blogosphere: Quality, Governance and the New Innovation Leaders." ElectronicHealthcare 7(3): 101-8. Retrieved January 4, 2009. < http://www.longwoods.com/product.php?productid =20298 >. Terry, N.P. 2008 (August 22). "Personal Health Records: Directing More Costs and Risks to Consumers?" Social Science Research Network. Retrieved January 4, 2009. < http://ssrn.com/abstract=1248768 >. Weingart, S., D. Rind, Z. Tofias and D.Z. Sands. 2006. "Who Uses the Patient Internet Portal? The PatientSite Experience." Journal of the American Medical Informatics Association 13: 91-95. Retrieved January 4, 2009. < http://www.jamia.org/cgi/content/abstract/13/1/91 >. Sprague, Lisa. 2006. "Personal Health Records: The People's Choice?" Lisa, Nation Health Policy Forum Issue Brief - No. 820. Retrieved January 4, 2009. < http://www.nhpf.org/pdfs_ib/ IB820_PHRs_11-30-06.pdf > |
Monday, December 22, 2008
A Man for All Sections: Physicians, Heed Thy Hobbes
| Steven Lewis |
| I dunno, maybe it's the season, but I feel especially moved by the plight of doctors at the bottom of the medical politics food chain. Ontario emergency room docs are just the latest in a long line of disgruntled groups crying foul over the agreement negotiated by their medical association. That agreement got the support of 79% of Ontario doctors, but most ER docs said no. Now they're mobilizing to pursue distributive justice by other means. |
| Unfairness in the relative income distribution of physicians is not an occasional aberration, a minor side effect of an otherwise exemplary allocation process. It is the inevitable outcome of a fierce competition within a guild that does most of its bare-knuckled work behind closed doors. Fee schedules are complex and no well-intentioned amateurs - the kinds who sit at the table on behalf of their peers - can possibly master the game with equal panache. Over time, power shifts and accretes, some groups gain the upper hand, and income disparities proliferate. There are winners and losers - all relative of course, since every full-time physician's income is at least upper-middle class. Provincial medical associations are the certified bargaining agents for all doctors - even for doctors who choose not to join. In general, the association and the government negotiate a total amount of money for physician compensation, and most of the details get worked out by the doctors themselves. Sometimes the government targets a top-up here, a fee code adjustment there, but overall, the physician categories - called sections - duke it out for shares of the booty. The mystery is not the injustices that follow, but why habitually shafted specialties, from primary care to rheumatology to geriatrics, stay with the medical herd. We outsiders don't really know - the doctors don't air their reasoning to outsiders - but we can speculate. First, they are a profession, and professions love nothing more than self-regulation and self-management। They might prefer the irritations of internal decisions to the prospect of subjecting the guild to external scrutiny and meddlesome guidance. Who ya gonna trust: your peers, or the bureaucrats? We are a band of brothers (and sisters), are we not? We look after our own - imperfectly, but we get you. Stay with us, and we'll harder for you next time. To continue reading please click here. |
Monday, December 15, 2008
Spare the Policy, Spoil the Profession
| Steven Lewis |
| The jig is up: Canada's publicly financed health care system does not reliably deliver safe, high quality, efficient care - and this after doubling spending in the past decade. Patient-friendly it isn't; the convenience of providers comes first. Need primary care after 5 p.m.? Go to emergency. Got four complaints? Make four appointments. Every serious analysis comes to the same conclusion: the system needs a major refit to improve access, quality, and value for money. |
| Yet we remain a nation of demonstration projects, taking two steps backward for every step forward. Of the many obstacles to transformative change, one looms larger than all the others: organized medicine. For the better part of 40 years organized medicine has more often than not stood in the way of efforts to re-engineer health care. It has pursued its own interests with brilliant success, and passed them off as the public interest. It has secured more money, the right to saturate one jurisdiction or specialty with doctors and neglect others, largely autonomous and unaccountable practice, and separate and unequal access to the councils of state and the boardrooms of health organizations. Don't blame organized medicine for the way it behaves; blame us, meaning the citizenry and the governments we elect. We're the enablers. Predictably, the system suffers: the documented shortcomings in safety, access and quality speak for themselves. More surprisingly, doctors are suffering too. Their own surveys unearth a litany of miseries, fantasies about leaving practice within a couple of years (they don't even when they say they will), overwork, ennui. So if it's not working for us, and it's not working for them, why does nothing change? We owe the doctors of Canada a serious apology for spoiling a noble profession. By kowtowing to organized medicine, we end up with collective agreements and policies that entrench the status quo and keep Canadian health care in the dark ages. Doctors who have nothing to do with medical politics nonetheless bear the consequences of the positions taken by their representatives. The culture of self-centeredness and privilege erodes idealism and produces generations of cynics who chafe under the rules of the game but lack the will to change them. Here are the main errors for which we need to atone: First, we have erred in how we pay most doctors, and for letting medical politics determine what and who are worth more and worth less. Allowing organized medicine to divide up the pie has distorted care patterns, undercompensated many doctors, obscenely enriched others, and pitted group against group. The doctors who use their hands outearn those who use their brains. The ophthalmologist who does 20 cataract procedures in a day earns more than the one who figures out 20 complex eye disorders in a week. The dermatologist's pay leaves the rheumatologist's in the dust. We stand by in learned helplessness as the medical associations concoct a reward system that produces ten times as many paediatricians as geriatricians, a steady abandonment of primary care, and a generation of doctors practicing at the low end of their capacities. Second, we should apologize for letting doctors practice in the 21st century with the tools of Bob Cratchit. Governments sign collective agreements that condone quill pen medicine - we're at the bottom of the G7 pack in adoption of the electronic medical record. Quality improvement tools and techniques are optional. There is no obligation to undergo practice profiling and recertification. Most doctors have no clue about the quality and effectiveness of what they deliver - and those that think they do are almost certainly wrong. The inevitable result: medical practice harms 10% of patients in hospitals; there is routine prescribing of dangerous dosages and drug combinations to the elderly; there is widespread failure to diagnose and effectively manage the most common and straightforward chronic diseases; primary health care patients get all of the evidence-based care they need only about half the time; and the list goes on. Research shows that the longer doctors practice, the more they decline. We would never neglect the career development of our pilots, car mechanics, or workers in fast food restaurants the way we have neglected the professional competence of doctors. And instead of organized medicine imploring governments and health organizations to analyze patients' anonymized data, feed back the results, and help doctors with QI, the CMA President makes ominous speeches about privacy. Third, it's been a mistake to leave unchallenged the attribution of access problems to shortages of doctors, and inflate medical school enrolments by two-thirds in re-sponse. Instead, we should have mandated strategies that could dramatically improve access right now, such as advanced access scheduling. Millions of Canadians can't get to see their family doctor the same week they call for an appointment while everyone in England, can and does in 48 hours. Do the process re-engineering, optimize the division of labour among professions, and then assess whether there are shortages, and if so, of what. And recognize that expanding enrolments in medical school won't solve the shortage of specialists in the disciplines that internal medical politics has consigned to the bottom of the income ladder. Fourth, we have erred in adopting organized medicine's view that all doctors' prob-lems, dissatisfactions, and anxieties are soluble in cash. When doctors tell us they can't be on call 24/7/365 in rural areas, we empathize and come to the table to help find a solution. Nurse practitioners? No thanks. Group-based practice? Can't sell it to the members. How about a hundred thousand bucks extra? Sounds good! So we inflate doctors' incomes to do the same things that sap their energy, ruin their home life, and keep them on a treadmill to depression, substance abuse, and burnout. Shame on us. Fifth, we've blundered in letting medicine dwell in splendid isolation atop the heap of the health professions. We allow the guild to keep competent others out of the sand box: nurse practitioners are threatening, let's go for physician assistants. The pharmacist who knows more than the doctor about pharmacotherapy remains a diffident subordinate instead of a true partner. The other guilds follow medicine's lead, and we wonder why interprofessional collaborative practice goes nowhere. If being separate and unequal made doctors happy and the system better, fine. But the job satisfaction survey data show the unhappy consequences of letting organized medicine get in the way of its own members' well-being. Fifth, we owe a mea culpa for letting organized medicine's media grandstanding, government-baiting, hyperbole, and fearmongering go unchallenged. Because we do not hold organized medicine to a higher standard of discourse and accountability, its rhetoric becomes bolder and it comes to believe its own propaganda, that every misdeed or wait list is everyone's fault but doctors'. We've turned organized medicine into expert blackmailers: more money, more machinery, a bonus here, a new medical school there. Attend a committee meeting? Pay us. Become true partners in the hard job of running the system? Nah, we like being independent contractors, not integrated team players. Staff the ER? Pay us fee-for-service, an hourly rate on top of that, a shift bonus on top of that. Set up shop in the poor part of town where the need is greatest and unmet? Charter of Rights! Freedom! We fed the beast and stood by as medical altruism and decency became entombed in a hard shell of self-serving cynicism. No one wins. Our biggest mistake is failing to demand more of both organized medicine, and individual doctors. We admit only superior students into medical school. We put them through intensive training (but not much education in citizenship, and how systems work). We then turn a blind eye to huge variations in practice and never evaluate them seriously. And because this is a proven recipe for substandard quality, we let organized medicine persuade us that the remedy is to pay extra for mere competence - participating in chronic disease management collaboratives, following the occasional clinical practice guideline. This is our fault and our folly. Lord Acton would have expected as much: Power corrupts, and we have given organized medicine too much power. The dysfunction is intergenerational: we have not sufficiently protected and nurtured opportunities for new generations to chart a different path. We have given medicine autonomy without accountability, and increased its allowance while its grades declined and it acted out at the table. Small wonder that practice is anarchic and error abounds. We didn't bring organized medicine up right, and we have only ourselves to blame for its values and behaviour. Apology is a precursor to reconciliation and recovery. We need to recognize our mistakes and become the partners organized medicine deserves to restore its dignity as a profession that advances the public interest and justice for its members. Collectively physicians are worse than the sum of their parts, and that harms all of them, and us. Our mistake has been to give organized medicine what it wants. It is time to give it what it needs, and help it understand the difference. About the Author Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the health care system needs to get a lot better a lot faster. |
Wednesday, December 3, 2008
Show Me the Way to Stay Home
| Nursing Leadership (CJNL), 21(4) 2008: 29-32 Show Me the Way to Stay Home Lynn M. Nagle |
| As the health system continues to evolve through the implementation of the electronic health record and other information technology initiatives, it is imperative that governments undergo a paradigm shift and recognize the need for strategic investment in home care (CHCA 2008a:7). Among my closest baby boomer contemporaries, recent life experiences have revealed an increasingly pervasive challenge - maintaining the independence of aging parents. As one of the major issues facing middle-aged Canadians today, the provision of emotional, material, and physical support and care to this cohort takes a toll on family caregivers. The lay caregivers of Canada save taxpayers millions annually by avoiding the cost of institutional care. Although given comparatively less airplay these days, there is also tremendous cost avoidance afforded to the healthcare system because of home-based, family-delivered care for chronically ill children and young adults. A significant number of Canadians are doing their bit to supplement the gaps in service: family and friend caregivers constitute up to 80% of the care delivered in the home (Canadian Home Care Association [CHCA] 2008b). More than 10 years ago, it was estimated that 2.85 million Canadians were caring for a family member with long-term illness (Cranswick 1997), equating to more than $5 billion of unpaid labour annually (Fast et al. 2002). Given the country's demographic trends, one can only surmise what those figures might be in 2008. 'Twas ever thus that a majority of families assume responsibility for certain aspects of care for their loved ones, but limited attention is afforded these contributions. |
| Approximately 900,000 Canadians access home care on a regular basis (CHCA 2008a). Home care is the fastest-growing sector in healthcare, and it is predicted that between 1996 and 2046 the number of people needing it will double (Home Care Sector Study Corporation 2003). It has long been a cornerstone of Canadian healthcare, but sadly, home care gets short shrift when it comes to public funding. In a study of the long-term care systems of 19 OECD countries, Canada was found to invest 0.17% of its GDP in such systems compared with the overall average of 0.35% (Organisation for Economic Co-operation and Development [OECD] 2005). Why is there not greater equity with other sectors in the funding of home- and community-based care? It seems obvious there are some potentially significant financial benefits to be derived by investing in community and home care services that keep Canadians out of high-cost institutions. With shorter hospital lengths of stay and higher discharge acuities than ever before in our history, where is the infrastructure to support recovery at home? Interestingly enough, a tremendous amount of rhetoric is directed to the need to focus on primary care, chronic disease management and aging at home. How can any jurisdiction effectively deliver on these agendas without some concomitant investment in community-based supportive technologies? We certainly do not have an endless supply of health human resources to deliver on the services needed to support same. Is it realistic for any jurisdiction to expect that without information and communication technology (ICT) investments, effective home and community support can be achieved? Assistive technologies to support individuals and family caregivers exist (e.g., remote monitoring of chronic disease and smart devices for those with dementias and sensory impairments), but are they widely utilized? Surely the cost of such supportive technologies would significantly offset the costs associated with short-term hospitalization or long-term institutionalization. Grim forecasts of pending shortages of health professionals, particularly nurses, should provide compelling enough reason to consider technology solutions to optimize efficiency and effective use of resources in every sector. Equipped with point-of-care technologies, nurses in the community could access client data and information from other providers and settings, collaborate with other members of the healthcare team on-line and ultimately contribute to improved clinical outcomes. Estimates suggest that access to remote technologies could extend nurses' capacity to visit more clients (up to 3-4 times more) and maximize access to this increasingly scarce commodity (Thobaben 2000). As the nursing profession is also aging, it behoves jurisdictions to consider deploying solutions to further support nurses in the delivery of home and community care. A recent publication by the CHCA (2008a) included several recommendations directed to investment in ICTs and other technologies to support the delivery of community-based care for lay and professional caregivers alike. In particular, the need to link community care, including primary healthcare teams and home care, to other sectors is highlighted as essential to enable "improved integration, communication and collaboration" (CHCA 2008a). Financial investments in ICTs to support the provision of home and community services remain relatively insignificant when compared with those being directed to other sectors. While infrastructure supporting the advancement of electronic health records in institutions has been emerging as a priority in every Canadian jurisdiction, few have recognized the need to move beyond institutional brick and mortar to the communities where the greatest amount of care is delivered by professionals and family caregivers. In our technology-obsessed society, one cannot help but wonder why more solutions are not being deployed to support and sustain the unsung heroes of home- and community-based care delivery. The current delivery of community-based care is undervalued and not integrated with the rest of the healthcare system, yet it is on the verge of becoming the single most important point of service delivery. The recent launch of the Canada Health Infoway-funded "VON Caregiver Portal" ( www.caring-connect.ca) is an excellent demonstration of the capacity to lend support to hundreds of thousands of Canadians seeking information and solace from others in comparable circumstances. As all providers of care (read "my generation") are also aging, relying entirely on families and communities to keep citizens out of hospitals will not be sufficient. The demographics, the statistics and the trends tell a clear story - community- and home-based care, while not a panacea, can go much further still in offsetting the continuing escalation of healthcare costs. I look forward to an acknowledgement by "the system" that there is merit in extending the reach of supportive ICTs. That acknowledgement will be clear when there is an increase in public funding for supportive infrastructures and technologies. If given the choice, I want to age "at home" rather than "in the home." How about you? About the Author Lynn M. Nagle, RN, PhD Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; Senior Nursing Advisor, Canada Health Infoway References Canadian Home Care Association (CHCA). 2004. Home Care: a National Health Priority (Position Statement). Ottawa, ON: Author. Retrieved October 17. 2008 < www.cdnhomecare.ca/media.php?mid=357 > . Canadian Home Care Association (CHCA). 2008a. Integration through Information Communication Technology for Home Care in Canada. Ottawa: ON: Author. Canadian Home Care Association (CHCA). 2008b. Portraits of Home Care in Canada. Ottawa, ON: Author. Cranswick, K. 1997. Canada's Caregivers. Canadian Social Trends Backgrounder, Ottawa, ON: Statistics Canada. Fast, J., L. Niehaus, J. Eales and N. Keating. 2002. A Profile of Canadian Chronic Care Providers, a Report Submitted to Human Resources and Development Canada. Alberta: University of Alberta, Research on Aging Policy and Practice. < www.ales2.ualberta.ca/hecol/rapp/ > . Home Care Sector Study Corporation. 2003. Canadian Home Care Human Resources Study - Technical Report. Ottawa, ON: The Home Care Sector Study Corporation. < www.cdnhomecare.ca/media.php?mid=1035 > . Keefe, J. and P. Fancey. 1998. Home Care in Canada: an Analysis of Emerging Human Resource Issues. Final Report. Halifax: Mount St. Vincent University. Organisation for Economic Co-operation and Development. 2005. Long-Term Care for Older People. Paris: Author. < http://oberon.sourceoecd.org.ezproxy. library.uvic.ca/vl=2717272/cl=17/nw=1/ rpsv/cgi-bin/fulltextew.pl?prpsv=/ij/ oecdthemes/99980142/v2005n11/s1/p1l.idx > . Thobaben, M. 2000. "Change and Growth in Home Care: Telehealth Care." Home Care Provider 5(2): 47. |
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