On Saturday, May 17, 2014, I had the pleasure of speaking at a conference in Wooster, Ohio. The conference, titled “The Healthcare Trojan Horse,” was sponsored by the Pro-life Healthcare Alliance and Wayne/Homes Right to Life. Following is the presentation as it was written; the actual talk was abbreviated due to time constraints.—Ione Whitlock
We strongly caution policy makers not to expect that health professionals will be willing and able to capture significant amounts of structured data—unreasonable expectations in this regard are not only likely to compromise patient care (by unduly interfering with physician-patient interactions) but also lead to an anti-EHR response by the physician community.
It was a different story when it came to comments from the hospice and palliative care associations. They rather liked the course the administration is taking. In fact, they recommended that electronic records should collect even more data about patients and their families than was contained in the original plan.
Yes, these are the same hospice and palliative care professionals who are always moaning about the “technological imperative.”
In one section, NCHPC suggests that the controversial POLST form might be used as a model to collect data, to coax “health systems who are not so forward-thinking.” They write (emphasis is theirs):
Goals of care can and should be captured as structured data so that future measures can be developed related to goals of care that will not require laborious chart abstraction … To help imagine what this might look like, we cite the below example from an eMOLST1 form. MOLST forms [a version of POLST] are only appropriate for those very ill individuals with very poor prognoses, but [below is] illustrative of what is possible for goals of care generally. Indeed, forward-thinking health systems are … developing EHRs that can record goals of care. The meaningful use program should include objectives for health systems who are not so forward-thinking in leveraging EHRs in this way.
Generally speaking, advance care planning aids work in a two-step process. Start by assessing the patient’s “values and beliefs” – i.e., how wretched is your quality of life now; how wretched will it be? Are you now, or will you ever be, a burden to loved ones? (multiple choice, the better to pigeon-hole patients):
The next step is to set goals. NCHPC’s sample:
So it appears that organized palliative care is in favor of the Technological Imperative when it aids and abets the Quality-of-Life Imperative.
Here is my question: How often will we be subjected to these types of questions, and from whom?
A quick note on the people who signed the NCHPC letter speaking on behalf of the world of palliative care: Three of the four signatories are Timothy Quill, Diane Meier, and Sean Morrison. “Tim” Quill (as he is known by his friends in the palliative care world) is infamous for helping a patient to commit suicide, and then writing about it. Meier, Quill and Morrison later co-authored a controversial study of (illegal) physician-assisted suicide practices. Shortly thereafter Meier had second thoughts about advocating the legalization of physician-assisted suicide. Coaxing patients out of life-saving treatment on the basis of the quality of life imperative might be another matter.
POLST and other advance directives play an important role in the Community-Based Care Transitions Program (CCTP) and Partnership for Patients discussed in a previous post here at Belbury Review.
In order to reduce hospitalizations within a community, participants in the care transitions demonstration projects generally use one of a handful of “intervention” programs. A few of those interventions appear on a useful diagram that is posted at the Administration on Aging website (see illustration at right). Though the slide was part of a presentation on “Interact” — just one of the interventions — it presents a good summary of some of the others. POLST is one of those interventions.
While some of the care transitions interventions focus on pressuring patients and families to be responsible for proper medication, symptom identification, doctors’ appointments and so forth, a number of the interventions focus on end-of-life decisions, DNRs, and advance care planning. This is particularly true of interventions involving patients in nursing homes who are frail and might request another trip to the emergency room.
“Sometimes when peoples’ hearts stop, doctors and nurses try to delay the dying process … Have you considered whether you would want this or not?”
The rest of the discussion contains carefully chosen “facts” to discourage life-saving measures; facts such as:
The possibility of surviving CPR in a nursing home is very low, and CPR
often results in broken ribs and the need for a respirator (“breathing machine”) in
an intensive care unit.
The Interact tool also discusses “Artificial Hydration/Nutrition” and the supposed dangers of feeding tubes.
These are but a few examples of POLST and end-of-life discussions prompted by the “care transitions” project.
Erik Fromme, MD, is a hospitalist at Oregon Health & Science University who specializes in palliative medicine and is frequent co-author with POLST’s developers. In early 2011 he articulated how POLST and palliative medicine would take a role in “care transitions.” In an article titled “Transitions in End-of-Life Care: the Oregon Trail,” Fromme remarked that “transitions” is a malleable term; useful because it can take on a variety of meanings suitable to meet a number of objectives:
Transitions is a broad term that can refer to moving from one care setting to the next, changing goals of care, changing both care setting and goals (as happens with the transition to hospice care), or even death.
Strong palliative care teams, statewide outreach and education, and programs like POLST allow hospitals and healthcare systems to support patients, families, and clinicians in the inner work of letting go.
Not all of the care transitions interventions focus on “letting go,” but coaching patients and families in end-of-life decisions is a key feature in many contexts.
Here’s a scheme that’s sure to fundamentally transform America’s health care system, from top down and bottom up. The Administration is pairing Alinsky-style organizing with Berwickian rationing, and using your tax dollars to do it.
In a series of YouTube videos posted last fall, Joanne Lynn, MD (right-to-die activist, bioethicist, and wife of Rev. Barry Lynn of Americans United for Separation of Church and State) described a $1 billion “care transitions” project that was established via Section 3026 of the Affordable Care Act (Obamacare).
Lynn explains that “care transitions” means “how you move across settings” in healthcare. The Centers for Medicare & Medicaid Services (CMS) at HHS has been bothered that their clientele — elderly, frail fee-for-service patients — keep going back to the emergency room after they are discharged from the hospital. According CMS, “unnecessary hospital re-admissions” cost roughly $12 billion a year. Supposedly one in five patients returns to the hospital, but Lynn remarks that “in some areas, even higher rates apply; some populations certainly return more often.”
The answer: Use the federal government’s QIO network to establish community-based organizations for health care (re)distribution.
In response to the perceived crisis, CMS is starting with one billion dollars to change health care delivery systems across the country. Lynn says half a billion for “Community-Based Care Transitions Program” (CCTP), and the other half billion goes to “Partnership for Patients.” (Elsewhere, CMS describes CCTP as a sub-project of Partnership for Patients.) Lynn calls CCTP a “marvelously fertile endeavor,” and hopes that the CCTP demonstration project will spawn thousands of coalitions across the country:
“. . . [CCTP is] a very interesting program; half a billion dollars over five years, trying to have leadership organizations in the country – leadership communities, really – figure out how you can build community, . . . reduce therate of hospitalizations and re-hospitalizations, by involving community-based organizations….”
These test sites will be the foundation for a permanent restructured delivery system over the next few years.
Though the coalitions are local, the federal government determines which organizations are allowed on the team. Lynn says that to qualify for funding, the lead organization must be
“. . . a community-based organization which has adequate representation of the provider stakeholders and adequate representation of the consumers on its board – so it’s a very special organization – Medicare has determined that public organizations like a Department of Health can qualify, and that Area Agencies on Aging can qualify, but you’ll have United Way agencies and others that might be able to do this …
The end result will be a coalition with clout.
The coalition will have its own board and will funnel large amounts of money. The organization is paid a flat rate per person, but then the organization decides how to allot the funds, determining which patients will receive more services, and which patients will get less. Lynn explains:
The community-based organization is the one that will get paid; they must be working with one or more hospitals. It’s an advantage to be working with hospitals with high re-admission rates. You submit an application that gives a blended rate, that says for every patient in our target population, we will be paid a certain amount, and then we will figure out, within ourselves, the patients that need a whole lot of services, and the patients who need less.
Joanne Lynn is not just a random observer. Lynn is an insider. She spent about a year advising CCTP’s headquarters in Colorado. During the mid- to late-‘90s she collaborated with Donald Berwick and his Boston-based Institute for Healthcare Improvement in projects aimed at decreasing hospital admissions by increasing the use of living wills and other advance directives. (Not surprisingly, before he left CMS, Donald Berwick was one of CCTP’s principal champions.) Lynn is probably best known for devising “Medicaring,” a program that manipulates Medicare reimbursements to discourage chronically ill patients from requesting life-saving measures.
Lynn recognizes that developing coalitions across the country will be tricky. She warns that people will be suspicious at first. She advises,
You need to build a level of trust, and then you need to govern by consensus, probably, for a while; and then figure out . . . what’s the governing board really going to look like; are we going to incorporate; are we going to be able to take on grants or funding; are we going to be able to take on the management of any records, or monitoring the situation, or speaking to the public? You have to think a couple years down the road.
This is where the Alinsky-style organizing comes into the picture.
Organizing for Health is spearheaded by Marshall Ganz and his department at Harvard’s Kennedy School of Government. From the Organizing for Health website:
Building on experience with Marshall Ganz, known for his campaigns with Cesar Chavez and California’s migrant grape workers in the 1970s, and Barack Obama’s 2008 grassroots presidential campaign, Kate Hilton, JD, MTS, is leading a team focused on supporting the capacity of leaders to organize and create sustainable conditions for transforming health and care.
For the record: Ganz focused on faith-based organizing, and his proteges at Organizing for Health specialize in leveraging faith-based organizations as well. The two trainers for the CFMC series – Kate Hilton and Ella Auchincloss – picked up community organizing experience while working for the Episcopal Church. Kate Hilton, the daughter of a hospice doctor, brings conflicts over end-of-life decisions into the debate. She has done community organizing through Donald Berwick’s Institute for Healthcare Improvement, the Mott Foundation, National Council of La Raza, and The Middle East Initiative at Harvard University.
Ella Aunchinloss, director of the Hauser Center for Nonprofit Organizing at Harvard’s Kennedy School of Government, stressed throughout CFMC’s four-month training series that there are many “change theories,” but community organizing involves using resources to build power, with emphasis on collective action.
“If the change you want to see involves mobilizing people and involves mobilizing all of the resources available by virtue of that collective, then you’re using the right theory of change for the challenge that you face. To give you an example, if you wanted to find a cure for cancer, organizing as a theory of change may not be the right theory. . . .If there was a scientific breakthrough that did involve the use of a scarce resource of, say, some sort of or drug protocol, you might consider using community organizing in order to shift the power dynamics that make that drug protocol either scarce or scarce to your community.”
In one session, participants were taught how to “map actors.” They were taught how to identify constituents (Auchincloss reminds the organizers that “patients are not constituents”), and and how to target supporters and competitors who have resources to which the movement wants access. Mapping also includes identifying who is the “opposition.” Auchincloss turned to one of the QIO members to provide a real-life example of mapping actors. It turns out the “opposition” was a team of physicians who said they were there to treat sick people. Doctors do usually treat sick people; that’s a good thing. Nevertheless, the physicians were identified as resisters because supposedly they just wanted to make money.
Hilton and Auchincloss, in the footsteps of their mentor Ganz, taught the organizers to begin their public relations campaigns with a “story of self”, a personal anecdote that will tug at their audience’s heartstrings, or conjure a fear. Organizers were told to cull their community for stories of “intolerable situations” to “create a compelling story or narrative of why people need to take action.” The series ended on May 24 with a call to action: “Contact a patient or family representative in your community by June 15th to learn what you can about their experiences.”
Sharpen your discernment skills; the propaganda blitz is on its way.