What does halachah say about how to improve American health care? Not much.

Someone skeptical about halachah might ask, "Does Jewish law have anything useful to say about a public policy debate as complicated and multifactorial as health care?" Unfortunately, after reading the chapter devoted to health care in Rabbi Jill Jacobs' There Shall Be No Needy, I have to say no.

I wanted Jacobs' book to provide halachic metaphors to help me understand better what it means to support health care reform - and, ideally, to help me judge the relative ethical benefits and risks of various alternatives, even in a general way. I don't need halachah to tell me about the necessity of health care, the critical role of the health care provider, or the community's role in providing such care: these are relatively uncontroversial, things that even opponents of health care reform support. Halachah should be a source of Jewish wisdom and  something more than the deployment of righteous cliches. It should provide a particular perspective, not a reinterpretation of universalist principles which can be found in any liberal ethos.

Rabbi Jacobs' chapter is a skillful summary of the general principles of Jewish law regarding the provision of health care to the individual and community. She discusses the well-known arguments about the healer's permission to "interfere" in Divine creation when healing the sick, the need for the physician to be remunerated for their services; and the requirement inumbent on the community to provide for medical care. In an esthetic and moral sense, the passages she cites are useful - as Jacobs herself points out, they serve as a troubling reminder of the inefficiencies of the American health care system. (1)

After these summaries, however, Jacobs seems to get lost. She acknowledges that "today's system presents us with many more players than the doctor, the patient, and the immediate community" and goes out to find what halachah will tell us about these multiple factors. Unfortunately, there isn't much there (when has there been a health care system on earth as fragmented, oversized, and inefficient as ours?), so she has to limit herself to an unsatisfying historical aside on the history of Jewish hospitals and an unsurprising teshuvah by Rabbi Shlomo Goren holding that the Israeli government is required to provide health care. (2)

Jacobs acknowledges in passing that most Americans today receive health care through their employers (though she neglects to mention that veterans and Native Americans also are cared for by a national system), a state of affairs which has no halachic precedent. What then is there to say?

This is where the rubber meets the road. If there are no exact parallels in halachah to the matter at hand, perhaps there are at least useful metaphors, engaging stories, gripping ultimatums, solid philosophies. Jacobs: "From a Jewish perspective...a major problem with the American health care system is the lack of community oversight over the distribution of funds." This is disappointingly tepid and unfocused.

"Community oversight," like Mom and apple kugel, sounds good on its face. (I supported a public option and I think that a single-payer system is the way to go - I assume this is what Jacob is reaching towards with her "community oversight.") But what we need is help with a hard question: what kind of community oversight is needed, and at what level of government? Do we need more state control of apportionment of Medicare and Medicaid, or less (both could be called "community oversight")? Do we need Congressional interference in decisions about comparative effectiveness research? Should the Federal government have a role in deciding what health care should be available to which doctors? Democracy is all about the conflict of different communities, and "the Jewish perspective," at least as Jacobs is presenting it, has nothing whatever to say about these conflicting priorities.

In a concluding chapter which is useful in understanding her overall approach, Jacobs lays out her vision for how Jewish law and tradition should inform public policy (or the "public sphere," as she vaguely calls it). Unfortunately, this vision is not convincing.

Why unconvincing? Her "essential principles" ("the dignity of human life," "the inherent disparity of power" between different classes, and the reciprocal responsibilities of individual and community) are not unique to Judaism. This would not be a problem if halachah provided a unique perspective on issues of public policy - but I don't see any evidence of that here either. How, according to Jacobs, should Jewish law inform our discussions? "Jewish sources should help us to see various sides of an issue,challenge our assumptions, and enable us to formulate a response that takes multiple factors into account." Again, this is nothing we need halachah for - only a liberal cast of mind and general civic virtues of tolerance and open inquiry. (3)

It is not inspiring to say that halachah offers us no guide in some areas of life, but I think that's the case. I will not ask a posek the next time I prescribe an antibiotic and I don't think I need one either when considering various aspects of health care reform. (4) General moral guidelines about the importance of health care are available in halachah, should one choose to seek them there (though they can be found nearly everywhere else in a liberal society). For practical approaches to systematic reform, we should look elsewhere.

Update: See Rabbi Josh Yuter's shiur on the topic here, which I haven't listened to all of yet.

1. Jacobs says that our country's systematic inefficiencies and profit-driven nature "prevents many patients from being able to afford needed medical care." This is undoubtedly true, but another issue - which Jacobs does not explicitly address - is that Americans want too much medical care: too many labs, tests, and procedures, which drive up costs without improving care. This, among many other complications of the health care system, is something which our halachic predecessors simply could not envision, although I am sure one could, by stretching some precedent to the breaking point, find a proof text of use.


2.  Jacobs calls this teshuvah influential, but I suspect she is mixing up the chicken and the egg. Surely more determinative in today's halachic world is the fact that Israel is a democracy. Democracies legislate and administer national health care. Were Israel not a democracy, or not able to administer health care, the Goren teshuvah would be forgotten.


3. In fact, one could argue that Jewish law - in many places - does not place a premium on tolerance or open inquiry. There is the apikores and the min, after all.


4. In this regard, Rabbi Jacobs' philosophy bears a surprising (and disquieting) resemblance to Charedi daas Torah: that rabbis have a variety of expertise which equips them to offer advice even in practical situations far afield from their formal erudition. 

The Ten Contradictions of American Health Care

Uwe Reinhardt at the Health Affairs Blog points out the contradictory wishes of most Americans with regard to health care.

[A]s the policy-making elite stews in its stalemate, the American plebs dreams of a political Messiah willing to build for them a health system that:

1. Lets only patients and their own physicians determine how to respond clinically to a given medical condition, never an insurance clerk or, even worse, government bureaucrats.
2. Limits their families’ out-of-pocket payments for health care to make it “affordable.”
3. Keeps insurance premiums and taxes for health care low.
4. Does not ever ration health care, because that is un-American and practiced only by un-American alien nations with inferior health systems.
5. Does not allow public or private insurers to let “costs” or “cost-effectiveness” ever enter coverage decisions, because that would implicitly put a price on human life which, in America, unlike elsewhere in the world, is priceless.
6. Does not mandate individuals to purchase health insurance, if they do not wish to do so, if for no other reason than that this would be unconstitutional and, therefore, un-American.
7. On the other hand, grants every American the moral right – backed up by a government mandate called EMTALA– to receive critically needed and possibly high cost health care from hospitals and their affiliated doctors, even if they are uninsured and could not possibly pay for that expensive care with their own resources.
8. Controls Medicare spending, which is widely thought to be completely out of control, as long as it does not reduce payments to hospitals or to doctors or to producers of medical technology, or to any other provider of health care.
9. Provides universal health insurance coverage to all Americans, provided it does not mean raising taxes or cutting Medicare spending or raising premiums on healthy Americans.
10. Keeps government out of health care but somehow makes sure that insurance companies do not exploit patients through incomprehensible fine print, no one engages in price gouging – e.g., charge $10 for an aspirin — and no one in health care earns excessive profits (or any at all).

That’s all.

If you read only one article on health care reform...

...then you've probably read it already, or you're never going to at all. But in case you haven't found that one article, hie yourself to The New Republic. There Harold Pollack has some clarity on the relationship between universal coverage and improved mortality

would universal coverage make people tangibly healthier? You betcha.

but says something else even more important:

there are other ways to save thousands of lives that are much more cost-effective than expanding health insurance coverage. We systematically neglect these other opportunities.

How should patients decide which hospitals are best for them?

Johns Hopkins Hospital is consistently named one of the best in the country. I can’t disagree with that; after all, I just started working there as an internist in September. Coincidentally, in the midst of the raging debate around health care reform, the past few months have seen increasing discussion of a small but crucial question: why do some of the best hospitals spend more money than others? If other hospitals named to the best-of lists consistently spend less money than my employer, shouldn’t we be emulating them instead? And how should an individual patient go about deciding which hospitals are the best for them?

Read more at KevinMD.

Ten reasons for health reform (with asterisks next to what Obama's effort might help with)

1. The uninsured.*
2. The uneven delivery of health care, which varies from hospital to hospital, region to region.
3. The money spent on ineffective care, using resources for the sake of those resources' continuing existence.*
4. The general unsustainability of expenditures.
5. The holes in our systems of preventive care*, care for immigrants, and care for non-English speakers.
6. The overabundance of specialists.*
7. The philosophical and ethical failures of the current medico-industrial establishment.
8. It all costs too much & we can't afford it (repetition of 4. for emphasis)
9. Other countries do it better.
10. If we give veterans, the old, and the poor evidence-based medicine (or at least we're starting to try) why can't we do it for everybody?×

Saving money while improving care

At the Health Care Blog, George Lundberg picks the following sources of savings, where comparative effectiveness research can help save money while guiding us to the most effective treatment. His confidence that screening mammography doesn't improve mortality seems misplaced (the data isn't clear, and the studies are difficult), and his jab at oncologists is impolitic, but otherwise this is a worthwhile list.

1. Intensive medical therapy should be substituted for coronary artery bypass grafting (currently around 500,000 procedures annually) for many patients with established coronary artery disease, saving many billions of dollars annually.


2. The same for invasive angioplasty and stenting (currently around 1,000,000 procedures per year) saving tens of billions of dollars annually.


3. Most non-indicated PSA screening for prostate cancer should be stopped. Radical surgery as the usual treatment for most prostate cancers should cease since it causes more harm than good. Billions saved here.


4. Screening mammography in women under 50 who have no clinical indication should be stopped and for those over 50 sharply curtailed, since it now seems to lead to at least as much harm as good. More billions saved.


5. CAT scans and MRIs are impressive art forms and can be useful clinically. However, their use is unnecessary much of the time to guide correct therapeutic decisions. Such expensive diagnostic tests should not be paid for on a case by case basis but grouped along with other diagnostic tests, by some capitated or packaged method that is use-neutral. More billions saved.


6. We must stop paying huge sums to clinical oncologists and their institutions for administering chemotherapeutic false hope, along with real suffering from adverse effects, to patients with widespread metastatic cancer. More billions saved.


7. Death, which comes to us all, should be as dignified and free from pain and suffering as possible. We should stop paying physicians and institutions to prolong dying with false hope, bravado, and intensive therapy which only adds to their profit margin. Such behavior is almost unthinkable and yet is commonplace. More billions saved.

Evidence-Based Lobbying

Leaders of the medical-industrial complex wonder if the Dartmouth research findings might be a touch overblown. I dunno - maybe. But don't we doctors do a lot else based on much less evidence? What fraction of hallowed medical practice is based on no more than class IIb recommendations?

Heck, I'm ready for New York to get less medical money. I don't think the kinds of places I'd rather practice are the ones that are overspending.

Operator, can you please page the Surgeon General on call?

The name of neurosurgeon and health journalist Sanjay Gupta was leaked in early January as Barack Obama’s choice for Surgeon General. His selection has caused controversy, and the formal nomination seems to have been delayed by the search for a Secretary of Health and Human Services after the withdrawal of Tom Daschle. While we’re waiting for Gupta to be confirmed, we can ask: what exactly is the Surgeon General supposed to do, and in this administration whose watchword is change, can the office be more useful?

More in Clinical Correlations.

Does Massachusetts's health care reform work?

As Massachusetts’ Secretary of Health and Human Services, JudyAnn Bigby, MD, is charged with overseeing the health-care program which covers nearly all of the Commonwealth’s residents (nearly 98%) while costing more than anyone expected (about 800 million dollars in 2008). On February 4th, Dr. Bigby spoke at NYU’s Medicine Grand Rounds, where she summarized the approach and accomplishments of Title 58, the health care legislation passed in 2006. The program had several goals: improving access, reforming the insurance market, and (it was hoped) improving outcomes. Bigby gave clear and convincing evidence for the first two goals, while the jury is still out on the third.

More in Clinical Correlations.

Can health care act as an economic stimulus?

I'm scholar Googling and can't find anything. I don't know what the Obama Administration's argument is supporting their inclusion of comparative effectiveness research in the stimulus bill. Obviously I think CER is great a priori, as are EHRs, but neither save money in the short run. Do they stimulate the economy? Beats me - not my field - but I suppose in the sense of creating jobs, sure. (Funding research supports researchers, who buy bread, gasoline, and electricity just like everyone else.)

Note that this is separate from whether prevention and CER give good value for the dollar. Stephen Woolf claims unsurprisingly that they do, writing recently in JAMA. But the real point of his article is this: if you're going to ask whether prevention is worth the cost, you have to ask also whether (say) CTs, MRIs, and the whole whizz-bangery of technologized medicine is worth the cost too:

Throughout health care, the spending crisis requires a comprehensive search for ways to shift spending from services of dubious economic value to those with high cost-effectiveness or net savings. Whether those services are preventive or otherwise is not the point; what matters is prioritizing services that produce the greatest health benefits for the dollars spent. ... As a matter of economic security and ethics, it is inappropriate to debate the economic value of prevention while excusing the rest of medical care from such scrutiny.

Pots of money pretty please for primary care training and diversity programs!

Here's a call to action (read: e-mail petitioning) from the Society for General Internal Medicine. Unfortunately, I don't know explicit criteria for judging the stimulativeness of any given line item, but I would hope curing sick folks (some of whom work and make things!) would rank somewhere pretty high.

Later this week, a joint House-Senate conference committee will meet to reach a compromise on a massive economic stimulus bill. The House version of that bill includes $600 million for primary care health professions training, diversity and nurse education programs. This would double the current level of funding, a long needed beginning to healthcare reform.Unfortunately, the Senate version of the economic stimulus bill does not include funds for these Title VII primary care training programs.

Please contact your two senators and your representative today! Lawmakers need to be convinced that the compromise bill they send to President Obama must include $600 million to help ensure the supply of primary health care providers, namely internal medicine, family medicine, pediatricians, dentists and nurses.

Good things in the stimulus package come in hundreds of millions

Look what Barack Claus brought down the chimney - the Federal Coordinating Council for Comparative Effectiveness Research! This is wonderful news. And I'll even try and convince the skeptics at some point.

A penny of prevention is worth a pound of cure?

I wish Obama all the best, and I'm excited that health care reform is being contemplated as one of the first orders of business after the stimulus package is passed. Prevention is being touted as a big healthcare money saver.

But prevention of what?

1. Prostate cancer by PSA screening. (Whoops, early detection doesn't decrease mortality.)
2. Breast cancer by self-exam. (Whoops, ditto. Mammograms work, though.)
3. Colon cancer by colonoscopy. (Right-sided cancer might not be caught by colonoscopy.)
4. Pneumonia by vaccination. (Whoops, maybe not - except in high-risk groups.)
5. Heart disease in women by estrogen replacement therapy. (We know how that turned out.)
6. Cancer by vitamin ingestion. (Whoops again.)

So not only is prevention very unlikely to save significant healthcare money, but we have to make sure we're actually preventing what we set out to prevent.

"What we do in improving quality can also help us address costs"?

That's what Neera Tanden, a member of Obama's transition team, had to say in this morning's conference call organized by Doctors for Obama, which had over a thousand people listening in.* I wish it were true. 

As I expected, the focus of the call was on outreach and recruitment. Tom Daschle (Obama's pick for HHS Secretary) spent some time talking about the transition team's Change.gov and the umpteen zillion comments that have been offered up there about needed healthcare reform, all of this by way of example of the transparency Obama emphasized during the campaign. "He wants the administration to change the way people interact with their government," said Daschle, "and this is especially true when it comes to healthcare." "We have to have better transparency," he said later - "we can't understand problems until we see them effectively."

The more interesting part of the call was policy, though Daschle averred that no decisions were being made yet: "That's not the role of the transition team, we're working to prepare the president-elect about healthcare options." 

To a question about prevention: "The new paradigm has to be a recognition that prevention has to be a central feature of a new healthcare delivery mechanism. ... But there are serious problems about whether we have the infrastructure to deal with the opportunities that an attention to health and wellness can bring. There need to be more roles for nurse practitioners and physician assistants. We need to make sure we incent people to become general practitioners and family physicians." 

Daschle also talked about improving healthcare delivery ("We have 21st-century operating rooms and 19th-century administrative rooms. The solution to that is electronic medical records and health IT") and quality ("we see an extraordinary lack of best practices and quality of care implemented in procedural ways across the country"). 

To his credit, he did not make the explicit claim (as has been done by others) that improving quality, emphasizing prevention, and implementing efficient delivery of care will reduce health care costs. (I think this claim is difficult to believe.) Nira Tannen made the claim, though: "Making sure our people are healthy will lower long-term costs for everyone and in the meantime ensure that everyone is covered."

To quote Bob Laszewski of the Health Care Policy and Marketplace Blog:

Define quality for me. Then show me a system in which there won't be as many winners as losers--how else do you save 30%? Then I will show you a real health care policy debate and we will see how much consensus we have.

Wellness? Wellness programs today look an awful lot like the voluntary education oriented wellness programs we were selling in 1988 and things are far worse. Prevention? Most of the commonsense steps in prevention were available to us years ago.

We have been avoiding the heavy lifting in health care reform for 16 years. For me, all of these new ideas aren't so much new ideas as one more "Ground Hog day" in the long-running health care debate.

I believe Laszewski over Tannen, though I wish I didn't. The stronger argument for universal care (and perhaps truer to the facts) is to say that covering everyone will cost more money, at the very least in the short term, but (a) it's the right thing to do, because healthcare has become as much a public as a private good; and (b) it's a stimulus to economic growth that people who understand the economy (not me!) say is necessary in times like these.

I should say I was encouraged by the speakers' attention to workforce issues. More primary care physicians, please. But we need more fundamental (re-)thinking about changing healthcare delivery.

*All quotes paraphrased.

The Raucous Baucus Caucus

I skimmed the Baucus policy paper, which is (like the Health Care Policy and Marketplace Blog says) a plan, not a proposal for legislation, with a whole bunch of possibilities that Baucus doesn't really distinguish among. Also, it is a zillion (or 96) pages long. A couple of observations:

Baucus talks a lot about pay for performance plans but never really describes which he prefers, how the current stakeholders will be assuaged, or whether P4P is meant to be the basis for a new payment model - not just a worthy experiment. He also doesn't mention that outcomes improvement via P4P isn't supported by the literature. Then again I didn't expect him to say that. (But maybe he doesn't know that? Senator, a Dr. Berger on the line.)

[edited]

Right on, Max Baucus!

From today's press conference:

We need to train more primary care doctors. I heard only 2 percent of last year's doctors were primary care, because the money wasn't there. We need more medical homes, a more holistic approach to care. There must be a greater role for primary care then there is in America today, and this bill has incentives to do that.

The Emanuels Take Over

If Rahm is chief of staff, does that mean we get health care vouchers from his brother?

For the Sausage Factory: Various Health Care Proposals as Fodder for Compromise

Even in the midst of the presidential campaign, we should remember that there are a number of health care plans other than those proposed by McCain or Obama. Given the vagaries of politics, any given plan is very unlikely to be passed. Thus we should become familiar with the details of a variety of them, since any compromise will look like a hybrid.

More in Clinical Correlations.

Needed renovations, or setting the roof on fire?

Our exposure to health care policy - as part of our primary care curriculum - ran the gamut recently.

Last week we went to Washington to advocate for increased support for the primary care workforce. (In brief: we need more primary care health care providers. There aren't going to be enough of them, especially if we start covering the uninsured. We need to create incentives to help people choose to go into primary care rather than the oversubscribed and overpaid subspecialties.) We spoke to young, fresh-faced, intelligent, and hyperinformed health care staffers of some of the Capitol's most influential senators - they were genuinely friendly and happy to see us.

One senator's office is working on a creative idea left over (so they said) from Hillarycare, a "foundation" to ensure a funding stream for primary care education, training, and loan repayment, paid for by a tax on insurance companies. Of course, no one in the room disagreed with that. Everyone realizes that primary care training needs to be dissociated from the current system, private insurance companies and hospitals included. (Our very friendly lobbyist, paid for by NYU Medical Center and along with us to make sure we didn't say anything stupid, was not very excited to hear about this idea.)

This week (thanks to a colleague of mine, whose father is a fundraiser for the senator in question) we went to the office of the junior senator from New York. We spoke to her for fifteen minutes about the necessity to improve funding for the primary care workforce - she was impressively informed, realistic about the political obstacles, and . . . oh, who am I kidding? We were giddy. We got a picture, too!

On Friday, we visited Jack Resnick, an internist (let's say it: a primary care doctor!) with a practice on Roosevelt Island. "[In Washington,] they're talking about payment reform, which is . . . pffphpht! You have to tear out the guts!" By which he means - you have to alter the incentives so as to drastically reduce hospitalization. It's an open secret that hospitals are not the best places for sick people. They breed infections, deconditioning, delirium, psychosis. Resnick's approach (and the approach of this organization) is to closely monitor the chronically ill patients in his practice, keeping the hospitals at bay by providing patients sophisticated but sensitive care at home. It's more feasible for Resnick because (a) he lives on an island; (b) he's ready to devote himself nearly 24-7 to his patients. But this, he says, is the wave of the future - money saving, intensive, personal primary care for the elderly and chronically ill, taking away money from hospitals where it's not usefully spent (or, rather, uselessly overspent).

Resnick, and the AAHCP (see the link above), are behind the Independence at Home Act, a bill introduced in September which would experiment with cash rewards for house-call physicians that trim Medicare outlays for high-cost patients with multiple chronic conditions.

[revised per comments]

America's Next Top Health Policy Problem

James Knickman, the unassuming and friendly health-policy analyst and CEO of the New York State Health Foundation, talked to our class of third-year primary care residents on Tuesday as part of our health policy course. Here is his list of the Top Ten Health Policy Crises.*

Solutions received by Monday at 7pm will get a free piece of apple-and-honey.

1.The lack of affordable and accessible health care for all Americans.

2. The need to develop methods to decide when to pay for emerging modalities and pharmaceuticals.

3. The need to move resources into prevention and public health.

4. The need to move resources into primary care.

5. How do we care for an aging population?

6. How do we expand physicians' use of evidence-based treatment approaches?

7. Great disparities across ethnic and income groups.

8. Malpractice!

9. Dental care.

10. The lack of health-care professionals.

*Okay, he didn't say "crises," he said "topics." But "crises" is more fun.