Wednesday, July 26, 2006

Toward An Episcopal Culture for Health Care: the Poor

"The poor you will always have with you." (Matthew 26:11a)

“Truly I tell you, just as you did it to one of the least of these who are members of my family, you did it to me.” (Matthew 25:40)

I work in a health system that is explicitly “faith-based” (those words are in the mission statement of the system and of each institution in it) and specifically (if not as self-consciously) Episcopal. That is, the system is a ministry of the Episcopal Church, and is one of the few hospital systems started by Episcopalians that still has some organic connection with an Episcopal diocese.

Once upon a time, before there was a system, there was the original hospital. I started with the system in that hospital, and still refer to it as “the Mother House.” (Yeah, I have heard “mother ship,” but in my old age I’m more monastic than sci fi fan.) And in the halls of the Mother House, along with other pieces of printed information, one could find a brochure describing the hospital’s policy on uncompensated care. The policy included this principle, if not these exact words: no one would be refused care based on the inability to pay.

We no longer have that brochure. We still have a policy, and under the policy we will still care for all who come to us - well, almost. You see, even we have had to set some limits.

Oh, we are still providing uncompensated care - more than all the other non-government hospitals in our area. But we've had to set some limits, asking patients for copays up front, and refusing some patient transfers if there's not a really clear medical reason for moving the patient. We've made some clear distinctions between "charity care," and "bad debt," based on whether patient and family cooperate on seeking resources. We want to care for all regardless of the ability to pay; but we can no longer do so, much less say so.

How does this fit with an Episcopal culture for health care? The Baptismal Covenant calls on us to “seek and serve Christ in all persons, loving your neighbor as yourself,” and to “strive for justice and peace among all people, and respect the dignity of every human being.” As I have noted before, the General Convention is on record as calling for universal access to quality health care. How, then, can we as an Episcopal health system turn anyone away?

The answer is, at least in part, well known: if we set limits, we serve fewer patients. If we set no limits and end up folding financially, we serve no one – not the patients, nor our staff, nor the larger community. This becomes part of any argument from a perspective of distributive justice: in a society in which health care is a limited resource, some choices will have to be made. We have made choices that we think will allow us to serve the greatest number of patients. We have provided options to assist in getting care those who have no resources. We will go to great lengths to help patients and families ho want help, and are willing to cooperate in the process. But we can’t take care of everyone.

Are there other options for us as an institution? One is, of course, to work so that health care is not so limited a resource. We can advocate with government to increase the funds and the services of Medicare and Medicaid. We can negotiate with insurance companies to offer our patients and their customers the best services at the best rate. In fact we do both; but those are difficult processes. Medicare and Medicaid are held hostage to the political will, and the will is not there. Indeed, Medicare reimbursements are figured something like this: “This is what you say a procedure costs. However, looking at your regional market, as we define it, this is what we think it should cost. Based on wanting to hold down that cost, we will pay you 60% or so of what we think it should cost, regardless of what you say it does cost.” We can advocate, working to change not just the naked figures, but more broadly the political will.

We can participate in research. This can help two ways. Some research directly affects costs, either demonstrating that the cheaper procedure is as effective, or developing the new procedure or drug that is so much more effective as to be worth the cost. Research can help indirectly by paying the health care costs of those who consent to participate, freeing up other dollars for patients who need assistance. And in fact we do participate in research. At the same time, questions remain. Just how much benefit, and for whom, should a new procedure or drug provide to be worth new and greater costs? If the older, cheaper drug or procedure is almost as effective, how close is close enough? And how do we determine which patients will only benefit from the newer drug of procedure?

These are some of the considerations as we consider how we will care for the greatest number of people. And, of course, none of them are simple. However, it seems to me that for an Episcopal culture for health care these issues must be grasped and engaged, as determinedly and as fiercely as at Jabbok. And we must not be complacent, either that we are doing enough or that we are doing enough more than someone else. Surely a vision of the Kingdom includes the opportunity for us to serve all, whatever the circumstances. And so it was that I said to our leadership, when the new policy was introduced, “We must make hard decisions, but we must not be satisfied with them. The Episcopalians who stand behind us and pray for us expect no less. We are not choosing today between good and bad, but between lesser sin and greater sin. Even if we're doing what we must, let us acknowledge that with a real sense of sadness.”


Marie said...

What's that line in the confession (at least the one we use)? "We repent of the evil that enslaves us, the evil we have done and the evil done on our behalf." I tell you, the healthcare system in this country is "the evil done on our behalf". I don't know what to do about it, but you are right. We should hold it before our eyes, never forgetting to grapple with it and remember that it is part of our corporate sin that we do NOT take care of "the least among us".

Marshall Scott said...

Well, some of us are working toward the political will. It will come, I fear, when the system is so slow and expensive that we will have convulsive change, and not planned, organized change. we may have missed that opportunity in the early '90's. Still, it is the stated vision of the Church.