Reforming healthcare: an ethical perspective

Health care schizophreniaHealth care schizophreniaI don’t care how much it costs, I want the best care available.

It costs what? That’s outrageous!

Everyone in America should have appropriate access to health care.

I am not willing to pay any more taxes, and I don’t want socialized medicine.

Government should fix it.

Let the market fix it.

Here is the real bottom line: The current state of health care is unethical. It is neither just nor fair. There is no morally defensible reason why some

Americans get excellent medical care at costs they can afford and other Americans lose their homes or

go into bankruptcy attempting to secure treatment for a seriously ill loved one. The current proposals being

debated in Congress all go a long way towards making health care in America more just. At the

same time, there is nothing in the current proposals that threatens a patient’s right to choose, a critical

feature of an ethically acceptable health care system.

- Ruth Faden

ethics of health reform

"This historic legislation, for the first time, enshrines a national commitment to guarantee that all of us in

this country have meaningful access to appropriate medical care. As a consequence, our society is now

more just. Our people have a greater prospect of securing for themselves and their families not only

more health, but also more of everything that is essential to human well-being, including personal

security, respect and self determination.“

- Ruth Faden

ethics of health reform

“examination of the issues in healthcare reform would require consideration of much different arguments than already presented.

ethical issues would center on the moral right discussion and would begin with not

“what is best for me” but rather “how should we as a society be acting so that our actions

are morally correct”

- Beverly O’Malley

ethics of health reform

What neither side will admit is that medical rationing is part of the future. We can't afford a system where everybody gets

whatever care they want regardless of cost and effectiveness. The only question is

whether we'll ration intelligently and fairly, or not.

- Beverly O’Malley

ethics of health reform

However, all ethical decision making is structured around values. In order for universal health care to be

embraced by all citizens in the United States, they will first have to agree to the collective value of equity and fairness and embrace the goal of meeting their

collective responsibility to each other while maintaining individual rights and freedoms. That may

prove to be the most difficult obstacle of all.

- Beverly O’Malley

ethics of health reform

When a third party— government, insurer or employer—controls most of the health care funds, that entity

eventually becomes the decision maker, not the patient.

An ethical health care system doesn’t just promise people they will get the care they need, it empowers people so

they can get that care.

- Merrill Matthews. PhD Institute for Policy Innovation

ethics of health reform

What action will bring the most good to the most people?

What action in and of itself is a good act and helps us to fulfill our duties, obligations, and responsibilities to each other?

What action in and of itself shows caring and concern for all citizens?

reform inamerica

employer-sponsored health care1940s

government-sponsored health care

To provide coverage for the elderly as well as poor women and children, Congress enacted Medicare & Medicaid in the mid-1960s.

1960s

The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 requires hospitals to screen and stabilize (treat) every patient who comes to the hospital ED seeking care, regardless of the patient’s ability to pay and regardless of what it costs the hospital to provide the care.

1980s

health care for all…through an unfunded mandate

the affordable care act

2010

3 key myths about health reform

health reform means giving up control of my own healthcare decisions

health reform will control healthcare costs by depriving patients of important but costly medical treatments

health reform will deny older Americans medical treatment at end of life

strategic directions

• coverage• delivery system

reforms• payment reforms• transparency• health IT

• Improve the safety and reliability of America’s health care system

• Engage patients and families in managing health and making decisions about care

• Ensure patients receive well-coordinated care across all providers, settings, and levels of care

• Guarantee appropriate and compassionate care for patients with life-limiting illnesses

• Improve the health of the population • Eliminate waste while ensuring the delivery of

appropriate care

National Priorities Partnership:National Priorities Partnership:Overarching ObjectivesOverarching Objectives

implications for hospitals

• achieve solid hospital-physician (clinical) alignment

• measure, report and deliversuperior outcomes

• reduce costs

• form strategic alliances

implications for physicians• apply evidence-based practices

to achieve best clinical results

• deliver the right care…at the least cost

• coordinate your patients’ care with other providers

• learn to manage risk in partnership with hospital and physician colleagues

Percent Seeing 10 or More Different Physicians during the Last Six Months of Life

Percent of Deaths Occurring In Hospital

Percent of Cancer Patients Dying in Hospital

Percent of Decedents Enrolled In Hospice during the Last Six Months of Life

Guiding Ethical PrinciplesGuiding Ethical Principles

Beneficence- obligation to benefit patient and to further their welfare and interests

Respect for autonomy- protect and defend the informed choices of capable patients

Nonmaleficence- obligation to prevent or minimize risk of harm

Justice- fairness of access to health care

Ethical Obligations of Clinicians

Respect patient’s rights/autonomy and maintain confidentiality

Communicate honestly about patient’s diagnosis, treatment and prognosis

Determine patient’s decision making capacity

Actively participate in informed consent process

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Patient-Centered Care Continuum

Medical Home

Data Management

Chronic Disease Management

Pharmacy

Home Care

Ancillary Providers

Long Term Care

Public Health Agencies Hospice

Hospitals

Palliative Care

LTACH & Acute Rehab

Specialists

Patients

EHR

Population Health

Management

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Conceptual Shift from “Curative Model”

Medicare Medicare Hospice Hospice BenefitBenefit

Life Prolonging CareLife Prolonging Care OldOld

Palliative CarePalliative Care

Bereavement

Hospice CareHospice CareLife ProlongingLife Prolonging

CareCareNewNew

Diagnosis Death

Palliative Care Teams Address 3 Domains

1. Physical, emotional, and spiritual distress

2. Patient-family-professional communication and decision-making

3. Coordinated, communicated, continuity of care and support for practical needs of both patients and families across settings

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‘Mainstreaming’ Palliative Care

Providing palliative care simultaneously with all other appropriate medical treatment

Actively integrating palliative care into care transition programs

Expanding palliative care services and resources across entire care continuum

Demonstrating positive impact of palliative care from a “triple aim” perspective

How Advance Directives and POLST Work TogetherHow Advance Directives and POLST Work Together

Adapted with permission from California POLST Education Program © January 2010 Coalition for Compassionate Care of California

POLST: An outcomes POLST: An outcomes continuumcontinuum

Better informed consent +

Patient’s documented wishes

+Family consensus

Patients’ wishes known & honored =

+Portable MD orders

=

Satisfaction & communication

Risk & Costs=

= Hospice LOS = Hospital

LOS= Pain

management

= Hospice & Palliative Care Utilization

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SC Triple Aim SC Triple Aim PlatformPlatform

Keys to a Healthy South Keys to a Healthy South CarolinaCarolina1. Health care must become highly reliable.

2. Patients must be more engaged.

3. We must deliver compassionate and patient-centered care at the end of life.

4. We must improve health status and reduce health disparities.

5. We must improve efficiency and reduce waste.

6. We must improve coordination of care.

7. Payment models must be reformed and aligned.

SC Coalition for the Care of the Seriously Ill ( SC

CSI)

• Founding Members: SCMA, SCHA, TCC, SC Healthcare Ethics Network, LifePoint, AARP, SC Nurses Association

• Mission: All persons in SC with serious, chronic, or terminal illnesses will have an active voice in the care decision process