Thursday, February 24, 2011

Medicare Preventive Services - Are We Using Our Money Well?

I have written before about the importance of evaluating medical procedures to evaluate effectiveness. I’ve noted that this will be important under our new health care law, so that the Government and insurance companies pay for what works – and don’t pay for what doesn’t. But, as I’ve also noted, who of us really wants to receive a treatment that hasn’t been shown to work, much less one that has been shown not to work?

That has been the point of the US Preventive Services Task Force (USPSTF). The USPSTF is not in fact part of the new health care law. Instead, it is a program of the Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services (HHS). It’s a panel of primary care physicians and epidemiologists who review published research to assess what works and what doesn’t. The program has functioned for more than twenty five years, but last year rose to public attention when it suggested new recommendations for mammograms.

With all that in mind, I wanted to take note of a recent article. A group of physicians has published, “Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage,” (Lesser et al, Annals of Family Medicine, Vol.9, No.1 [January-February], 2011). The Center for Medicare Services (CMS) has published recommendations for preventive services for Medicare patients (in 2007 and revised in 2009). The researchers compared those with recommendations from USPSTF, and looked at what Medicare would pay for. They looked both at individual preventive services, and also at what they identified as “preventive coordination:” that is, for coordination in addition to the service there needed to be reimbursement for risk assessment, patient motivation, and/or arranging the service. Much of this would be covered by the Welcome to Medicare Visit, an initial preventive physical exam for new Medicare beneficiaries. On the other hand, many were only covered as a part of the Welcome to Medicare Visit, and not if needed later. As a result, they stratified their results in four categories. “Fully covered” meant that both the service and preventive coordination as recommended by USPSTF were covered by Medicare. “Partially covered” meant that the service was covered, and preventive coordination was covered, but only as part of the Welcome to Medicare Visit. “Partial coverage with inconsistent indication” meant that the Medicare did reimburse for some patients and not for others. “No coverage” meant that the preventive services recommended by USPSTF were not covered by Medicare.

The researchers identified 15 preventive interventions recommended by USPSTF. While Medicare provided partial payment for 93% of the procedures (14 of 15), they provided full payment of both the procedure and for preventive coordination for only one (7%). On the other hand, the researchers identified 16 procedures that USPSTF recommends against, either fully or after a certain age. Medicare reimbursed for seven (44%), regardless of age. The researchers also noted that both USPSTF and Medicare recommended preventive services for at-risk populations, but sometimes defined those populations differently (focusing in different risks).

This is an interesting study. Medicare is the largest institution reimbursing providers for health care. CMS is continually searching (under no small pressure from the Executive and Legislative branches) for ways to support and provide appropriate care, and get the best bang for the buck. Effectiveness has gotten attention in the recent passage of our new health care law, but it has actually been an issue for some time. One would think it important that two agencies, both within the HHS, to talk with each other about recommendations. And perhaps they do; but these differences between what USPSTF recommends, based on review of the literature, and what Medicare recommends functionally (by being willing to pay for it) raise a question about that.

These days we’re inundated with news about how little money Government has (at all levels), and the necessity of controlling costs. (Remarkably, there are no discussions about raising revenue; but that’s a topic for another day.) Comparative effectiveness of medical interventions and efforts at preventive care are both important for controlling health care costs for the long term. Perhaps coordination will get better with time. Unfortunately, this study suggests that we aren’t coordinating well enough with the tools we already have.

Monday, February 21, 2011

One Further Reflection on the Lessons for Epiphany 7 - And on a "Christian Nation"

Yesterday in the lesson from Leviticus we heard these verses:

9When you reap the harvest of your land, you shall not reap to the very edges of your field, or gather the gleanings of your harvest. 10You shall not strip your vineyard bare, or gather the fallen grapes of your vineyard; you shall leave them for the poor and the alien: I am the Lord your God. (Leviticus 19:9-10)
They were in context with this summary verse:

18You shall not take vengeance or bear a grudge against any of your people, but you shall love your neighbor as yourself: I am the Lord. (Leviticus 19:18)
Now, for the Israelite, there was no distinction of "church and state."  These were laid down, effectively, as both religious and civil laws.

So, isn't this a Biblical mandate for social welfare? At least, isn't that where we would expect a Biblical conservative to some down, connecting this with, say, Matthew 25?  Just wondering....

Saturday, February 19, 2011

All You Need is Love: a Sermon for Epiphany 7, Year A

As I read through the lessons for today, and especially the Old Testament and the Gospel lessons, I found myself thinking of a song.  That will not surprise most of you.  I found myself focusing on what it means to love your neighbor, and thinking of a song.  But, it wasn’t enough to think of the song.  I had to place the song in context.

Now, you know the song.  It was “All You Need Is Love,” by the Beatles.  We all know it:

All you need is love.
All you need is love.
All you need is love, love.
Love is all you need.

But, I didn’t just think of the song.  I thought of it in a specific context: specifically, I thought of it in the movie, “Yellow Submarine.”  If you haven’t seen it, “Yellow Submarine” might have been something of a soundtrack in search of a plot, but it was in its day quite a production.  It was animated; and if it didn’t have the modern effects of 3D, it had the bright, exaggerated images of Peter Max.  It was psychodelica in all its glory. 

You can find it on YouTube, by the way.  It’s broken up into seventeen parts, but it’s all there.  Still, there was nothing like going to see it in a theater, up there on the big screen.  Those colors and images could be just overwhelming!  It was especially great at a midnight show.  You sat there in the theater, with your date beside you; and almost as much fun as the movie itself were all the folks sitting in the front three rows in – let’s say in an altered state.  They sat there, their heads thrown back and their eyes wide open, saying, “OH, GOD! OH, WOW! OH, GOD!”

I suppose we might not all remember that.  Some would be too young, of course; and a few might be too old.  And then there are those who don’t’ remember because they were sitting down there in the first three rows….

If you don’t know the movie, the story is that Pepperland, a paradise under the sea, is attacked by the Blue Meanies, with their fierce armies, their Apple Bonkers, their Snapping Turks, and especially their fiercest weapon, the terrible Flying Glove.  Only Fred escapes, and makes his way to London where he finds the Beatles – who look astonishingly like Sergeant Pepper’s Lonely Hearts Club Band!  Fred enlists them to go back with him, and together they are able to free Pepperland and drive out the Blue Meanies.

That’s where the song comes in.  When the terrible Flying Glove attacks them, they sing, “All You Need is Love.”  And as they sing, the words take form.  They take on shape and substance; and it is the words. “All you need is love,” that defeat the Flying Glove and put the Meanies to flight.

And that’s what came to me as I reflected on the lessons.  The words took on shape and substance, and love overcame evil.

That’s just like the lessons today.  Think about the lesson from Leviticus.  It begins with God’s blanket proclamation, “You shall be holy, because I the Lord your God am holy.”  But, then, listen to what holiness looks like: you don’t harvest your field fencerow to fencerow.  You don’t gather up every grape that falls to the ground.  Instead, you leave it for the poor and the stranger. Holiness is about caring for others, even if it’s messy and inefficient, even if it costs you something.

You don’t steal, you don’t lie, you don’t make victims of the innocent.  You aren’t unfair, you don’t slander, and you don’t take revenge. You love your neighbor as yourself, even when – especially when - you have an advantage.  That’s what it means to be holy: love takes shape and form until what you do for another looks like what you would do for yourself.

That’s what Jesus was referring back to – but it sounds like things had deteriorated over time.  “You have heard,” he said, “an eye for and eye, and a tooth for a tooth.”  That is, you make the punishment fit the crime: you don’t overlook it, but neither do you overreact.  But Jesus says that isn’t enough.  And he doesn’t focus on what it means when you do the punishing, but when you’re the one getting punished.  “Don’t resist the evil one,” he said,  “Turn the other cheek.  And, find ways to give more than is demanded.  So, if you get sued for your coat, give it up - and not just your coat, but your tunic.  And if you’re forced into labor, do twice as much as required.  Find ways to give, even when it’s not deserved, even when it’s not fair.”

“And about that old attitude – ‘love your neighbor and hate your enemy’ – I’m telling you to love your enemy.  After all, God makes the sun shine and the rain fall so that crops grow– and he does it whether the owner is just or unjust, righteous or unrighteous. Anyone can love a person who loves him back, or welcome a person who’ll welcome in return.  You’re called to do more. You’re called to a love that can take some pain. You’ve got to give your love shape and substance, because that’s what it means to be perfect as the Lord your God is perfect.”

That’s what it was, you know, that brought to mind that scene from “Yellow Submarine.”  As I said, again and again the words, “All you need is love,” took form and substance, and defeated the Flying Glove.  But, they didn’t do it by breaking the Glove, or attacking it, or driving it off. Instead, the words were broken by the Glove, and yet they kept forming.  They were smashed again and again, and yet they kept coming.  The words didn’t resist, but simply faced the attack until the Glove was overwhelmed, not by force, but in the rubble of its own making.

We’re called to do more.  We’re called to a love that serves others, even when it’s messy and inefficient and costly.  We’re called to a love that will bear pain, and seek to give even in the face of injustice.  We’re called to love our neighbor, and not just the neighbor who will love us back.  We’re called to love our neighbor – even to suffer for our neighbor – just as we might love, and suffer for, ourselves.

Now, this is a hard teaching, and it raises an important question.  Is Jesus asking us here to be so self-sacrificing as to be destructive to another or to ourselves?  After all, life isn’t simple, and sometimes what seems kind at first can have harmful consequences.  No matter how much the addict might plead, it isn’t really a kindness to provide the drug. We know as parents that, no matter how the child cries, what the child wants isn’t necessarily what the child needs.

Nor do I think Jesus is calling for us to be self-destructive.  None of Jesus’ examples, nor those from Leviticus, were life threatening, or even all that unusual. Even the forced labor was permitted under Roman law. On the other hand, I think we need to think about this with real humility.  After all, he also said there is no greater love than to lay down one’s life for another – and then proceeded to do so for us.

But, perhaps those questions are distractions. If we aren’t called to be self-destructive, neither does that let us off the hook.  We are called to love neighbor as self, and not just the neighbor who loves us but the neighbor who hates us. We are called to love in ways that are messy, that cost us, that can cause us pain.  We are called to be holy as God is holy, to be perfect as God is perfect.  And if our love has shape and form and substance, love will truly be all we need.

Thursday, February 10, 2011

Notes for Episcopal Chaplains (and Others)

I have a couple of things I want to bring to your attention. First, a new edition of the AHN Newsletter is up on the Anglican Health Network web site. It's always a good reminder of healthcare activities across the Communion, many of which are supported in our institutions and our dioceses in the Episcopal Church. This edition has something closer to home: an article by AEHC member Matt Cobb about chaplaincy, AEHC, and international connections. The article begins on page 6. Go take a look.

And while you're looking, there's other articles of interest. On page 5 there's an article on chaplaincy in the National Health Service in the UK. It's an opportunity to consider a different model. The next article is from a psychologist at Rush University. Episcopal chaplaincy is well represented at Rush/Pres/St. Luke's from Bishop Anderson House. Spend some time with these and other articles in the AHN Newsletter.

The second thing I want to let you know about is plans for our AEHC events when the Association of Professional Chaplains (APC) meets next month in Dallas (you can get more details about the APC events here). All of our events will take place Friday, March 25, at the convention hotel, the Hyatt Regency DFW. Our speaker at the Banquet will be Lee Hogan, Program Director for the Anglican Health Network. Here is the schedule of events:

7:15- Holy Eucharist
9:15-Annual meeting
6:00p- Pre-Banquet reception in the Hospitality Suite Rm. # 1372
7:00- Banquet- Lee Hogan Program Director for the Anglican Health Network.

The cost of these events will be $100 total. Please send your registration and money to the address below:

Babs France
4223 Swift Ave
San Diego, CA 92104-6605

Folks on the AEHC e-list have received notice and a registration form, and there will also be a mailing to AEHC members; but there's no need for you to wait.  Send your contact information and a check by March 11, and we'll be happy to have you join us.
So, check out the AHN Newsletter. Then, make plans to hear a representative of AHN when we gather for our annual meeting. I hope to see all of you there.

Wednesday, February 09, 2011

On Stories and Medicine and Faith

It's been a big week for my work in other settings.  Today my newest piece is up at Episcopal Cafe.  It centers on the importance of stories: how they can be important for learning about health, and important for learning about the Christian faith.  As always, I'd be happy to hear your comments on the post, whether at the Cafe or here.

In health care, stories are part of the field of "Narrative Medicine."  If you're not familiar with it, let me suggest a place to start.  Susan Palwick is a valued blog colleague.  You can see a link to her blog, Rickety Contrivances of Doing Good, in my list because she's an Episcopal chaplain, volunteering in a local hospital emergency room and writing about it.  She's also a published author (I can personally recommend The Necessary Beggar) and university professor; and in those capacities she lectures on Narrative Medicine at the medical school in Reno, Nevada.  She has blogged about that, and you can look at some of that here.  It's an interesting field, and should catch the notice of chaplains.  I encourage you to take some time with what Susan has written.

Tuesday, February 08, 2011

Up Again at Ground Rounds.

My post from last month on the Mississippi sisters has been accepted for this week's Grand Rounds.  I always think it's an honor to be accepted, and to be included in good company.  Take a look at what others have submitted.  There are some great articles that could pique a chaplain's interest.

I have written before about Grand Rounds, the ongoing blog carnival on health care.  As a "blog carnival," it collects blog posts from across the web and across health care, offering great stuff for clinical, ethical, and, yes, spiritual reflection.  It's new every week, and on a different site.  So, if you're interested in following it, check out the Grand Rounds Archive and Schedule.  That way, you can look in frequently, and always be in the know.

Thursday, February 03, 2011

Remembering the Dorchester Chaplains

Perhaps it’s the cold weather by itself. Perhaps it’s because I haven’t been home in a while because of the weather (my decision and my wife’s, and not my hospital’s). For one reason or another, there is something particularly resonant about the observation today of the lesser feast of the Dorchester Chaplains.

The Dorchester Chaplains were military chaplains. Their story is told in the book, No Greater Glory by Dan Kurzman. They were chaplains in the United States Army shipping with troops on the USAT Dorchester when on February 3, 1943, it was attacked and sunk by a submarine of the Navy of Nazi Germany. In the midst literally of fire, flood, and terror, they cared for those in their charge. They offered support, they assisted into the lifeboats, and gave up their life jackets. They stayed with the ship, witnessed to be praying together by one of the last witnesses; and together they disappeared into dark, cold waters. “Greater love has no one than this: to lay down one’s life for one’s friends.”

And in that light, I am reflective on this morning’s temperatures – 10 degrees below 0F when I woke this morning – and conscious how I would fare exposed as they were. A verse from today’s Daily Office lesson – “For you shall go out in joy, and be led back in peace” (Isaiah 55:12) – sounds different, feels different for these who died in the midst of war.

I have written before of my esteem for my colleagues in military chaplaincy. They provide care in difficult circumstances, and protect freedom to practice religion for those whose time and place are not under their control. I can appreciate their work, when mine has much in common with theirs; but rarely in my career (for good or ill, I can’t say “never”) has my ministry required anything like their sacrifice and risk. This is a day to remember the peaceful, compassionate ministries and sacrifice of the Dorchester Chaplains; and to appreciate the peaceful, compassionate ministries and sacrifices of their colleagues who continue to serve.