Thursday, July 18, 2019

Who Is an Episcopal Chaplain?

I have posted this both here and on Chaplair, the blog of the Assembly of Episcopal Healthcare Chaplains. I would hope that comments would be posted there, or both there and here, to encourage conversation among members of AEHC and friends of Episcopal Chaplains.

Twelve years ago I posted on my own blog , “To Become an Episcopal Chaplain.” All these years later, it is the most viewed of any of my more than 800 posts. I will be revising that post, as I have done in the past. However, as I prepare to bring that up to date, I wonder if it’s not worth asking a slightly different question: who is an Episcopal chaplain?

I want to think about this for several reasons. One is that the healthcare industry has changed a great deal over my career.  When I was President of AEHC I received several calls with the same question (including one from an office in the Episcopal Church Center): how many Episcopal hospitals are there? But, the question at the time was based on the assumption that most care, or at least most chaplains, was associated with hospitals. One thing I can confidently assert, though: there are fewer hospitals than at the beginning of my career. At the same time, there are more places chaplains are working. For some time, the fastest growing arena of healthcare has been hospice, the one corner of the healthcare industry that requires some form of chaplaincy. While I don’t have specific statistics, I also have a sense that there are more retirement communities and long term care facilities; and any associated with the Episcopal Church will have some provision for spiritual care.

That leads me then, too, to think about the future of AEHC. AEHC in one sense also started with that assumption. Indeed, our original title was the Assembly of Episcopal Hospitals and Chaplains. (We did recognize that the number of hospitals was shrinking. That’s why we changed the name.) If we are to serve the Episcopal Church, and to serve chaplains in the Episcopal Church, we need to consider how we will reach out colleagues in many different venues. 

That also means thinking about how we communicate and reach beyond our certifying bodies. I first became part of the College of Chaplains, one predecessor of APC, more than 30 years ago, and I believe strongly in the value of certification. The annual meetings of our certifying bodies have also made it easy for Episcopalians to gather. That challenges us with two opportunities. The first is to reach out to those who are not certified, and whose positions aren’t going to press them for certification. The second is to demonstrate the value of certification and to support and mentor those Episcopalians who pursue it. 

So, who is an Episcopal healthcare chaplain? The answer is certainly not a matter of order of ministry. Happily, the Episcopal Church can endorse a person in any order of ministry – any of the four – who demonstrates a call to ministry in healthcare.  Nor, really, is it a matter of venue. If the venue is focused on healthcare, a chaplain there is a healthcare chaplain.

That does, though, press us to think about how much healthcare focus we would want to require. There is no question that the care of souls in a parish or a school or a university setting does involve caring for folks with health issues. However, chaplaincy is a matter of focus. Pastoral care of the sick engages the sick person and immediate community. The Chaplain does so, and also engages the institution and in some meaningful sense integrates with the staff and administration.  So, I would insist that the chaplain is serving all patients or clients, and not only Episcopalians. That may not mean that the chaplaincy is paid, or is central to the income of the chaplain. I’m aware of more than one Episcopal long term care facility served by a parish Associate. That Associate participates in leadership, provides an on call response, and serves all residents. The associate is paid through the parish, but functions as a professional chaplain in care of that long term care facility. Another venue to consider is pastoral counseling, Any parish cleric will provide some pastoral counseling; but the professional pastoral counselor is focused on the wider community, and not an individual congregation. These are examples to help us distinguish the healthcare chaplain from the school chaplain, the correctional chaplain, or the military chaplain. (I would note, for example, that the Association of Professional Chaplains will consider unpaid work toward required hours for certification, but the functions must be those of a chaplain.)

Is an Episcopal chaplain endorsed for healthcare ministry? I am a strong advocate of endorsement, and will be writing more about the current status of endorsement. However, there is a lack of information about endorsement, especially among the bishops. That’s a problem, because we’re an Episcopal church, and endorsements are provided by bishops. We have an Endorsing Officer, and an Office of Record to communicate endorsement to the certifying bodies; but the endorsement itself (or the critical confirmation of it) comes from the diocesan bishop. Bishops can also endorse persons for healthcare ministry who are not interested in being certified. While I would very much want to see all chaplains endorsed, I don’t think our recognition of them should wait.

Should we have educational expectations of an Episcopal chaplain? This is an interesting question, with some interesting ramifications. Our current endorsement process only requires that the individual meet the diocesan bishop, and that the bishop feel the person has a vocation for healthcare ministry. I have often observed that in at least this we are virtually pentecostal. Other communions are more rigorous, to the point that one must have completed all paperwork toward certification before requesting endorsement. To some extent, we are better preparing professionals for healthcare work. All our seminaries integrate clinical pastoral education (CPR) into their programs; and many dioceses require or encourage CPE for ordinands who are alternatively educated. On the other hand, these may not be requirements for jobs. While Medicare will not reimburse for hospice care without a chaplain on the team, Medicare takes no position about the qualifications of the chaplain. Also, not only do we endorse lay persons without specifying an educational track, but many dioceses have most if not all ordinands in alternative programs for education that will not integrate CPE. This, like endorsement, can only be addressed with our bishops; and I don’t want to require AEHC to wait to engage such chaplains.

And, for all my enthusiasm to engage those working in healthcare chaplaincy, regardless of how they got there, I want to see us strongly encourage education and endorsement. In one sense, if one is to call oneself an Episcopal chaplain, one must also recognize that those outside the Church will expect a reflection of the Church. Sooner or later, the question is will arise, “What does the Episcopal Church say about…?” An Episcopal chaplain must at least be competent in not only the words but also the faith of the Book of Common Prayer. An Episcopal chaplain must have some sense of what the General Convention has said regarding engagement in the larger community. This is what education can form, and endorsement can confirm. I don’t think that requires a seminary education; but perhaps the same canonical expectations should apply. I don’t know that it requires CPE, but I don’t know of many comparable programs to help a minister understand himself or herself in the practice of spiritual care.

So, these are my first thoughts on the question, “Who is an Episcopal Chaplain.” I would hope we can have an interesting and a helpful conversation on this. I think it would be something to offer to the Church, and something to help shape the continuing mission of AEHC.

Tuesday, June 18, 2019

The Executive Council of the Episcopal Church Speaks to Vaccination

Most of the world may not have noticed, but the Executive Council of the Episcopal Church met last week. For those who don't know, the Executive Council is charged with carrying forward the decisions and programs of the General Convention between meetings every three years.

And even among those who are aware of the Executive Council, not all are aware that they also pass resolutions. Resolutions of General Convention are the highest-level statements of the positions and programs of the Episcopal Church. However, actions of Executive Council are also important. They address specific actions to carry out General Convention resolutions, and address issues that have come up since General Convention. If you're interested in a summary of all the actions of the most recent Executive Council, you can find them here. And if you're a real Episcopal geek, you can look for actions of Executive Council for the last 40 years or so in the Digital Archives of the Episcopal Church, here. (And thanks to the Episcopal Cafe, where these news stories have been shared.)

One resolve of Council had particular resonance for me, and I reproduce it in full:

Express grave concern and sorrow for the recent rise in easily preventable diseases due to anti-vaccination movements which have harmed thousands of children and adults; condemn the continued and intentional spreading of fraudulent research that suggested vaccines might cause harm; recognize no claim of theological or religious exemption from vaccination for our members and reiterates the spirit of General Convention policies that Episcopalians should seek the counsel of experienced medical professionals, scientific research and epidemiological evidence; call on the Office of Government Relations to advocate to the United States government for stronger vaccination mandates informed by epidemiological evidence and scientific research; urge all religious leaders to support evidence-based measures that ensure the strongest protections for our communities; ask congregations and dioceses to partner with medical professionals to counter false information, and to become educated about programs in their communities that can provide vaccinations and immunizations at reduced or no cost to those in need (MB011).

Some of my readers may know that one of my responsibilities in my last position (happily, one I could share with colleagues), was to review requests for exemption on religious grounds from mandatory flu vaccination. It was an interesting process, and perhaps I'll write more another time.

However, one matter I brought to that process was a request I'd received years earlier. I had a call from a priest, a rector in Virginia. She needed some help. She had a parishioner, a mother, who was terrified because of the misinformation, then already rampant, about vaccinations for children and autism. The parish priest wanted to ask the hospital chaplain whether I knew of any support for exemption in the Episcopal Church. I took some time to look into the Digital Archives myself (I am a geek), and found confirmation of what I already thought. General Convention had not spoken specifically about vaccines, but had a long history of supporting receiving modern medical care. Indeed, I suggested to the priest that, if anything, most would lean on that verse in Ecclesiasticus,"The Lord created medicines out of the earth, and the sensible will not despise them." (38:4) I suggested that the priest accompany the mother and children to the pediatrician to help the mother hear clearly what the doctor had to say, and to support her in her anxiety.

There are a few - a very few - religious traditions that reject vaccinations, even if they don't reject all health care. There are more folks who take a moral position (sometimes expressed in religious language, but often not; and in either case often poorly) against vaccinations as a violation of one's person. In those latter cases, it is always in individualistic choice, rejecting the concept of accepting a vaccine to love neighbor as self, by accepting vaccination to protect those who medically cannot. In taking this position, the Executive Council is certainly standing on sound science. What is more important, though, is that they are standing on sound faith: the expectation that Episcopalians can accept vaccination, not only to protect themselves, but also to protect their neighbors.

Thursday, June 13, 2019

Distributing the Costs of Care, Part 3: It’s Already All of Us

So, I’ve asserted (and I hope folks have agreed) that a thing costs what it costs, whether a strawberry or a medical procedure. I’ve also discussed that what makes those things seem affordable to us (at least, to the extent we do find them affordable; but we’ll come back to that) is that costs aren’t really just costs to us: the costs are distributed across a lot of people in the network of the economy. The clear conclusion (and hardly a new one) is that we’re all in this together.

This always gives me pause when leaders in government and business talk about reducing healthcare costs. If I pay attention, it becomes clear that they’re not talking about reducing what a thing costs. They’re talking about reducing what it costs  in one category or another. And, they’re not always talking about the same category. When the political leader speaks about reducing costs, sometimes he or she talks about reducing what I as an individual pay out of pocket; or sometimes about what I pay in premiums; or sometimes about what I pay (and, sometimes, what we all pay) in taxes. And, sometimes when I listen the leader is talking about what a business pays in the process of being accountable (that’s what regulations do, after all); or what the total is paid through taxes, as opposed to how that affects my pocket.

But, note that, as the current system is running (employer based insurance for most, Government-based insurance for the elder and the poorer), those changes are mutually exclusive. To reduce what I pay out of pocket, I end up paying more in premiums; or, conceivably, I could end up paying more in taxes. A thing costs what it costs, and the difference is in how those costs are distributed.

Also concerning to me are those polĂ­tical leaders (and, I will say I don’t hear this from healthcare providers or from supply industries) who seem to want to reduce how much I pay for the benefit of someone else (and, really, usually someone elder or poorer or both). Now, as an Episcopal priest I will assert that such an argument is immoral - broadly un-Biblical, and definitely un-Christlike. However, I also want to look back at our discussion so far and suggest that it’s simply unworkable.

A thing costs what it costs. If costs are redistributed, they appear to change, but that’s deceptive. They will still come back to me, but in a different form - and sometimes one that is destructive.

For example, there are ongoing efforts to reduce Government expenditures for Medicaid, both federal and state. The visible consequence as of those are pretty hard. Look at the number of rural and regional hospitals that have closed over the past few years. People lose care. Communities lose jobs. But also, people end up getting care that costs more, traveling farther, needing more intense and expensive care, and dying. Since hospitals cannot by law refuse emergency care (and that is the law), they make up elsewhere what they lose on those patients. Their basic costs structures go up; their negotiations with insurers go up; and my bills go up. The analogy of squeezing the balloon is apt: it may appear to reduce my taxes, and look good for the political leader, but it will still hit me somewhere else.

What can most effectively reduce my personal expenses? To most widely distribute the costs across the most people. Which leads us to Medicare for All.

It wouldn’t surprise anyone who knows me that I think we would all benefit most from a system offering universal access and requiring universal participation. That is, everyone can get care, because this most widely distributes the amortization of costs of equipment and paying for professionals. And, everyone pays something, in some way that is progressive related to economic capacity (considering both income and wealth), because this most widely distributes, and most justly distributes, financial resources in the system.

Now, at this point no one knows what a Medicare for All plan would do, except perhaps these two points; mostly because there is more than one plan proposed under that heading, and they don’t all agree. However, I do want to note that in some ways we already have something for all in Medicare.  

We normally just think of the insurance for folks over 65 and folks with significant disabilities paid for by Medicare. However, that also means Medicare is perhaps the biggest insurer, and so has a great deal of influence in how widely costs are distributed. I’m not on Medicare, but my insurer knows what Medicare is willing to pay, and wants to negotiate my rates accordingly.

Another aspect in which Medicare serves all is that most if not all medical education is paid for in full by Medicare. This certainly applies to the vast majority of medical residency positions. For most medical residents, hospitals are reimbursed in full for the cost of salaries and perhaps for benefits. In addition, Medicare pays in part for many other kinds of clinical education. This includes nurses, therapists of various kinds, and even chaplains. If you get care from a physician who is in or has completed a residency, your physician was provided to you in part by Medicare. For teaching hospitals, this means that a good deal of the budget that allows them to take care of the poor and allows them to keep their equipment current is relieved by Medicare.

Finally, we can’t undervalue how Medicare has kept many, many seniors out of poverty. Some of us may remember commercials on television before Medicare was in acted, identifying the elderly in urban settings as particularly and acutely poor. Now that I am retired and up on the Plateau, I see that level of financial concern in the rural poor almost every day. Medicare by itself has raised many folks out of poverty and bankruptcy for the two generations we’ve had it.

These are ways in which Medicare currently serves all of us. These are also examples of the value of seeing our healthcare as a social good, and not just as an individual good.

A thing costs what it costs, whether a strawberry or a medical procedure. We are concerned about paying for the healthcare of others, but in fact we are already doing that. We can decide whether that continues to be something that happens outside our view, or if we want to be deliberate and public and all involved in those decisions. To do that, we need to distribute those funds and those costs as widely as possible; and in these United States as widely as possible means all citizens and all residents.

The thing costs what it costs, and we are all always  already sharing those costs, whether we are aware of it or not. Maybe it’s time to recognize that social connection and to see healthcare as a social good, and not just a retail product.

Thursday, May 09, 2019

Distributing the Costs of Care, Part Two: More Than Just Me

A thing costs what it costs. That’s as true for a medical procedure as it is for a strawberry.

I started with a new primary care provider recently. That start involved meeting with a new professional provider, and a set of lab studies and tests - nothing exciting, but part of the process.

Now, I will have certain expenses out of pocket for that, but how those charges are determined is, again, a reflection of a slew of costs. There is the cost of the professional’s time; and, trust me: these days any health care business has some idea what to charge by the hour, even if that’s not how the charge is reported on the bill. And then, going into that cost is the cost of educating that professional, which may or may not include education loan debt. There is the cost of the computer system used to keep the records, the software it runs on, and the hardware that holds it. There’s the cost of the malpractice insurance that any professional will have; for after all, a suit can be filed before anybody actually determines whether the facts support it. And of course there are the costs of the facility - rent, utilities, insurance. There are also costs of getting paid: paying someone to issue the bills, to report to the insurance company, to know relevant law and regulation. And, there are the costs of not getting paid. Medical debt has been an important cause of bankruptcy for individuals, even if that’s been reduced under the Affordable Care Act. Sometimes people can’t, or won’t pay.

And that’s a simple new patient visit. Had I needed a procedure, then there would have been more costs: the required equipment, and amortization of that; the costs of nurses and other technicians, including their professional education and expenses; and, again, losses to charity care or refusal to pay. That’s kind of like the dropped box of strawberries: costs are raised and/or shifted to that the institution can cover here what is lost there. The big difference in healthcare of course, is that it’s not a $4.00 box of strawberries, but a $50,000 hospital stay.

All of this affects, but isn’t shown in the bill I will receive. What the bill will show, though, is something about the ways that my out of pocket costs are reduced by the distribution of charges. There are, of course, all the other patients in my new professional’s practice. More important, though, is insurance. Insurance, really, is the ultimate distribution of charges. I’m one of a large group that pays into the insurance company, and so far I’ve hardly ever had to use as much in one year as I paid - or, since so far my insurance is been provided by employer, as much as was paid in on my behalf. The insurance company distributes the costs of any current claim across the premiums paid by all the covered members. Then, again, my employer distributes the costs. The employer negotiates with the insurance company based on a pool of covered employees, figuring that the expenses for any individual employee will be lower. (I’ve written before that the currency of that negotiation is not dollars but “covered lives” - you and me and our family members.)

A medical procedure costs what it costs. For good and ill, though, I won’t see that cost. What I will see is what I pay out of pocket, and also what the insurance company paid on my behalf. Oh, and I may also see the results of the negotiation between hospital and insurance company as a discount or reduction. Of course, that’s what I see. Another patient with another insurer or another employer (or a person not having either) will see different numbers. That’s because there’s a different negotiation with each different company. Oh, and because for any given procedure with any given patient the insurer may renegotiate and pay less - which almost inevitably ends up with you or me paying more out of pocket.

We hear about that a lot now in efforts for “price transparency” for medical procedures. Everybody agrees it would be a nice idea. However, it’s hard in practice. There are differences in negotiations between each institution and each insurer. There are differences in negotiations between each medical practice (and most medical practices are still small businesses). Newer equipment costs more, and takes more procedures to amortize out that older. And, of course, large research and educational health care centers in urban settings take both higher risk patients, who need more resources; and more patients who can’t pay. A procedure costs what it costs; but the various inputs into those costs can vary a lot from setting to setting, as can the various ways to distribute costs as widely as possible. A procedure costs what it costs; and it may well cost more in one place than another.

Of course, we may also be willing to pay those costs. If I need a procedure, I may be willing to pay more for the professionals and the institution that have more experience - literally, that have offered that procedure more times to more patients. Professionals and institutions with more experience get better results. Or, I may be high risk myself for one reason or another. So, I may well be willing to pay for an institution with more resources. I don’t know I’ll need them; but if I do need them I don’t want to have to go somewhere else.

Then, of course, there is emergency care. If it’s really an emergency, I’m not about to start haggling over prices. I want to be where the right people and the right equipment are available for a good outcome, not a lower bill. And, I want those resources available 24 hours a day, whether I’m using them right now or not. “Just in time” may work well enough in having the right parts at the car plant for assembly, but I don’t want to trust “just in time” staffing for my emergency room. “Just in time” staffing may not be just in time to save me.

But, still, the biggest issue with price transparency, and one of the biggest things shaping what I pay out of pocket, is the sheer number of different insurance companies negotiating with the number of different health systems and institutions, and professional practices; and that includes the two biggest insurers, Medicare and Medicaid.

Once again, that sheer number is also part of the distribution of costs. My out of pocket expense feels small because the insurer distributes all my expenses across the premiums of all of us who are members; and because my providers, professional and institution alike, distribute my expenses across all the patients cared for using that expertise and equipment. A thing costs what it costs, whether a strawberry or a medical procedure. It can just feel less expensive to me because of how a lot of other people participate in paying those actual costs; and that will be the starting place for part Three.

This Week’s Challenge on Informed Consent

In this week’s news, this article from the New York Times caught my eye:
Louisiana Tests Unapproved Anti-Addiction Implant on Inmates. Now, there have been a number of references to the fact that these devices haven’t had FDA review. However, that lack of review only highlights the more basic problem: the problem of informed consent.

I actually learned in detail about research ethics in healthcare before I learned about clinical ethics - the difference between ethics in research and ethics in actual treatment. Our concept of Informed Consent is actually rooted in professional and political reaction to abusive research, and only then applied to abusive care. Reflecting such research horrors as the Tuskegee Syphilis Experiment and the atrocities that came to light in the Nuremberg trials, we developed the standard that human subjects participating in research have the right to informed consent: to decide freely whether to participate, based on thorough information about risks, benefits, and procedures.

In that light, then, we developed the concept of “protected classes,” subjects to have special protection because they could not participate in informed consent. While the categories defining protection could be complicated, they largely fell into two broad categories: those who needed protection because they couldn’t or wouldn’t be informed (think children, or adults of limited capacity); or those who needed protection because their capacity to consent wasn’t free.

Among those “protected classes” are prisoners.They are not free in their daily life, and their freedom to consent it assumed to be limited until proven otherwise. That isn’t about the capacity to understand. It’s because being in prison limits freedom of action, and makes one potentially subject to coercion or to inducement that wouldn’t have the same power outside the walls.

The story as reported in The Advocate provides a more thorough discussion of the situation. For example, it lays out how this happened - apparent largesse from the decide manufacturer (who will, perhaps, benefit greatly) - and how the prisoners involved might benefit. The device provides a steady dose of a medication proven effective for some in curbing opioid addiction. However, it also highlights the issues of prisoners and informed consent. In that light, it only highlights the concerns that the device hasn’t had FDA review: part of informed consent has to do with knowing the risks, and FDA review is usually how most of us learn about risks.

It doesn’t explain, though, other aspects of research. For example, in most situations there is a review committee, commonly referred to as an Institutional Review Board or IRB, that reviews risks and benefits on behalf of the institution or company overseeing the research. While the company in this may have one, there’s no reference to it. The company, too, is funding this internally, so we don’t know about conflicts of interest, etc.

All in all, this is a questionable and concerning event. I’m not opposed to these few prisoners benefitting. However, if this becomes a more common practice for bypassing the FDA, it becomes a practice that should concern us all.