CHW Healthcare Blog

Can We Regulate Compassion?

Here is a new question for our readers: How do we encourage more compassion in health care delivery? Through empowerment or regulation? Can we regulate compassion?

It seems one country is trying. We previously blogged about a report out of the U.K. that the NHS's relentless pursuit of efficiency has resulted in a significant lack of compassion for patients. In response, the NHS is planning to rate nurses in a new Compassion Index:

Health Secretary Alan Johnson told The Guardian newspaper he wants the performance of every nursing team in every ward across England to be scored, with the results displayed on an official website. ... Mr Johnson said he hoped to encourage friendly rivalry between wards over which nursing team could achieve the best ratings. The Government wants to publish each trust's overall nursing quality score, to inform patients when they are choosing where to be treated. The scheme will be piloted and first results are likely to emerge next year, according to the newspaper.

Does something seem off here? This is a system that has prized and rewarded efficiency. The effect of this singular focus, though certainly not planned or advocated for, meant nurses and doctors were incented (pressured?) to provide efficient care, which, as it turned out, was very different from compassionate care. And now, when it is revealed that it's the caring we really prize...we get a more complicated system?

We are in no way suggesting that efficiency and compassion are incompatible. Quite the opposite. We believe we can be more efficient in the care we provide, and that doing so (when it's done well) improves outcomes and gives caregivers more quality time with their patients. But we're hard pressed to see how compassion can be quantified, and it strikes us that most people who go into medicine are, by their very nature, compassionate. Perhaps it's not punishment that's needed, but permission.

"We Will Move Quickly in 2009"

The Senate Finance Committee held its day-long Health Reform Summit yesterday. The overall theme of the meeting was reassuring in that no one doubts that changes need to be made, and soon:

“We will move quickly in 2009,” said Senator Max Baucus, the Montana Democrat who is chairman of the committee. Mr. Baucus suggested that “some kind of federal health board” could help Congress make technical policy decisions. “How in the world am I supposed to know what the proper reimbursement rate should be for a certain procedure?” he asked. (From the New York Times)

"We have a broad consensus that we aren't getting nearly as much as we should for the money," said Mark B. McClellan, President Bush's former director of the Centers for Medicare and Medicaid Services who now heads the new Engelberg Center for Health Care Reform at Brookings. "There's an unprecedented level of agreement that something can be done and that something must be done." (From the Washington Post)

The keynote address was given by Federal Reserve Chairman Ben Bernanke, who didn't offer a prescription for change so much as he put our spending on health care into context. "From the economist's perspective," he said, "the question of whether we are spending too much on health care cannot ultimately be answered by looking at total expenditures relative to GDP or the federal budget. Rather, the question, whatever we spend, is whether we are getting our money's worth."

Cost effectiveness is a common theme we're exploring here, and is the subject of one of the advertisements that launched this blog. We can deliver care more efficiently, which will bring our costs down, but also give us higher quality care. What we must keep in mind, though, is that compassion must also be at the forefront of this debate. Saving money is a laudable goal, but doing so at the expense of human compassion isn't worth it. We're advocating for a system that places the patient experience at the nucleus of the system and builds a high-quality, affordable health care delivery platform around the individual's physical, mental, and spiritual needs.

Longer ER Waits for Mentally Ill

USA Today reports on a study of hospital ERs by the American College of Emergency Physicians. They found that psychiatric patients wait four hours or more to be admitted. Why:

Only half of the 328 hospitals surveyed had psychiatric units. The rest transferred patients, sometimes far from homes and families. Hospitals are closing their units because of inadequate payments from government and insurers, unpaid costs for the uninsured and too few psychiatrists willing to work in hospitals, says James Bentley of the American Hospital Association.

Compassion as a Medical Practice

In a post about Classic Chinese Medicine, blogger Eric Grey offers the following wisdom he received from one of his teachers:

1. To achieve mastery in medicine, we must not only learn from the Classical texts and the wisdom of our teachers, but also allow this information to transform us on a deep level.
2. This transformation will be on many levels. Physically, we will “follow our own advice” and live in accordance with the ways that our teachers lay out for us. Emotionally and spiritually, we will walk the path of the Boddhisattva (i.e., one who embodies purest compassion and service to humanity).
3. This path is one that brings us into line with Shu - opening to our true nature through living the truth of our heart. This in part involves, and is productive of, behavior in line with the Golden rule.
4. This Golden rule indicates that we should treat others as we treat ourselves, or that we should not do to others what we would not have done to ourselves.
5. In some sense, all of this tells us to polish ourselves into the kind of doctors that can serve as great examples for our patients. But, we must also allow our patients to be a mirror for us - when we gaze into that mirror we must always be asking ourselves if we are treating our patients as we would want to be treated in similar circumstances.

When the System Takes Precedence

Here's a story out of Phoenix of a man who, in attempting to obtain basic care for his dying father, experienced first hand what we've discussed on this blog before, and even before that.

This is a story of sympathetic individuals and uncaring institutions. All the nursing staff in the hospice/nursing home provided professional, compassionate care. The hospice pharmacist stayed late to fill the prescription.

What I saw was an inefficient and indifferent bureaucratic system that was unable to economically provide basic health care. It is a system that is obsessed with saving pennies, like a centralized pharmacy center, and oblivious to excessive costs, such as having an emergency room provide routine medical care.

I saw a medical staff hampered by institutional boundaries and paperwork. We endured a for-profit health care company unwilling to provide medical care yet unwilling to relinquish control.

What we have is a system that works very well for products and services. But it doesn't always work well for people. This is the price we pay for creating a system that is focused on the cost of "things" instead of what's right for human beings.

Seeing the Sacred

In today's Eureka Times-Standard hospital chaplain Ken Meece reminds us that "from time immemorial, health care has been a 'sacred encounter' for the persons involved. In ancient as well as modern times, health care has included profound vulnerability, precious hopes and intimate moments shared in the close circle of family and friends and often with strangers."

He goes on to explain that hospital staff were recently asked to "sight" sacred encounters happening around them. Here are a few of theirs:

• being fully present, with body language of attention, interest, caring
• when a patient seeks us out to share something special, a need, a meaningful memory, even loneliness
• watching a little child with his or her parent
• being tired, but still noticing stars, a breeze, the moon or clouds when heading home

Tell us about the sacred encounters you've seen and we'll post them to this blog.

The Canadian Debate

BusinessWeek runs a Pro and Con debate on the Canadian health care system and whether it is a good model for the U.S. to adopt.

Tell us your take on the debate, or add your own ideas by submitting a comment.

"Fundamentally Immoral"

Former U.S. House Speaker Newt Gingrich is advocating insurance mandates for people who earn over $75,000 per year. According to the Associated Press story:

Gingrich called it "fundamentally immoral" for a person who can afford insurance to save money by going without, then show up at an emergency room and demand free care. He said those who can afford insurance and choose not to buy it should be required to post bonds to pay for care they may someday need.

The debate about mandating insurance typically revolves around the expected cost reductions. Those in favor of the mandates say that by increasing the risk pool, costs will go down for everyone (an argument that may, in the short term, prove counter intuitive, as shown by the Massachusetts plan). Critics have said mandates will create a new, expensive bureaucracy to manage, track, subsidize, and penalize those who don't comply with the mandate.

We believe that access to quality, compassionate health care is a fundamental human right. To achieve this moral imperative, all sectors of society need to take responsibility for ensuring that quality care is available. This means individuals, businesses, providers, insurers, and the government. Ultimately, the value of our health care system is not solely about the proportion of the GDP dedicated to it, but also as a vital differentiator of a productive society.

National Health Reform Brewing

Yesterday, we blogged about the Senate Finance Committee hearing on the health care marketplace. There is a full day Health Care Reform Summit scheduled for the Committee on June 16th, which we'll be following closely.

We applaud our nation's leaders for keeping this important issue top of mind, especially in an election year. That the Senate is laying the groundwork through these hearings for the coming effort to reform our nation's health care is reassuring. In Senator Max Baucus's words, they're working to "leave the trivia behind...gain perspective...and try to understand at a deeper level."

The work of health care reform isn't solely about the uninsured. It's about ensuring that anyone in need of medical services is able to access those services when and where they are needed. We are advocating for a national health system that is characterized first and foremost by quality and compassion. As our country debates the adequacy of our health care system, the value of the simple act of caring for a person who is vulnerable should not be peripheral to the debate. It should be the central focus.

Health care is an extraordinarily important social service. As our country evolves and matures, it is important that the significance of the act of care be fully appreciated. How we value health care will determine the structure of how we provide it and who is eligible to receive it.

47 Million and Counting...

The Senate Finance Committed today heard testimony from witnesses in business, insurance, policy, and consumers. The subject, "47 Million & Counting: Why the Health Care Marketplace is Broken."

Witnesses discussed the varying approaches to health insurance, including limited-benefit plans, employer plans, and managing costs within the insurance industry. You can read the full testimony from all the witnesses here.

Of particular note, Ronald Williams, chairman and CEO of Aetna Inc., said:

In sharp contrast to many other parts of the world, people in America demand - and get - routine and rapid access to needed specialty care. It is a useful reminder that there are more than one million people waiting for medical care in Great Britain and more than 800,000 in Canada. It is also important to remember that more than 250 million people in America currently possess health insurance. Disrupting the coverage of hundreds of millions of people does not constitute progress.

It's a point well taken, and one that isn't lost on our readers, as reflected in your comments. We do need to ensure that compassionate care is available to everyone, focusing on the needs of both those with and those currently without insurance. We believe that the solution is out there, and it is uniquely American.