Wednesday, August 17, 2011

Sermon Prep, and Identity Crisis (Updated)

I’m looking at the lessons for Proper 16, for this coming Sunday, using the Genesis lesson for the Old Testament. One thing stands out for me immediately: there’s something important about personal identity in this.

Look, for example, at Moses. Was there anyone more set up for an identity crisis? Born of a Hebrew mother, nursed and raised by her, but as an Egyptian prince – is it any surprise that he will find himself very conflicted when he grows up? If you think about it, his confusion comes into focus with his murder of an Egyptian overseer brutalizing a Hebrew slave (something that is, unfortunately, skipped in the lectionary course). Is he the prince, with power of life and death? Or is he the Hebrew, defending his enslaved brother? Even the slave he saves will ask him, “Just who are you?” Is it any surprise that he will have to run away, in a sense to leave both identities, before he can encounter God and so find himself?

And then there’s Jesus’ question to the Twelve: “Who do you say that I am?” We know Peter’s response, because we know the story; and because we know the story, we think we understand what Peter’s response means. But, did Peter and the others? After all, Jesus tells them to keep it a secret – something that must have been a real trial for them. And he gives Peter, whether personally or as representative of the Twelve and so of the community, the Church, a specific role as the foundation of what will come after, with authority to speak for God: “Whatever you bind is bound, and whatever you free is freed.” Just who were they to have this authority, authority that they couldn’t tell anyone about?

And identity is central to Paul’s metaphor for the Church as Christ’s body. “I say to everyone among you not to think of yourself more highly than you ought to think, but to think with sober judgment, each according to the measure of faith that God has assigned.” That’s a real challenge to a community that has been given authority from God to bind and to free. “How do you know who you are, except in the concept of the Body and your specific vocation in it?”

So, while it may not be all about identity in these lessons, that issue is there. Who are we, if we are in this world but not of it? Who are we, if we are citizens of the Kingdom? Who do we say Christ is, and what does that say about who we are as Christ’s body? Sunday is yet a long way off, at least in how I prepare a sermon; but this is where I am today.

Update: I dashed this off today after reading the lessons, and then discovered this post at Miriam's Tambourine from Memphis Theological Seminary (and a hat tip to The Text This Week). I had not read this, but, seeing as it's been available a while, it was clearly written first, and we share a theme. Having lived in Memphis at one time, I have great respect for the folks at MTS. So, you might it to your reflections.

Tuesday, August 16, 2011

On the Importance of Being Earnest - Or At Least Honest

I have written a number of times of the importance for chaplains of being “research informed.” I’ve also written of the difficulties with this, and especially of knowing what we’re reading when we’re reading the research of other professions.

Well, this past week various news sources (for example, here and here)have noted a paper whose authors noted a troublesome trend. The paper itself was presented this spring at the Annual Conference of the Association of College and Research Libraries. Titled, “Retracted Publications in Biomedicine: Cause for Concern,” it was written by John M. Budd, Zach C. Coble and Katherine M. Anderson, all of the University of Missouri.

The paper is not that long, and is a straightforward read. I encourage you to read it. However, some of the problematic results are easily presented. The authors identified more than 1100 studies retracted in the twelve years from 1997 to 2099 by various journals (retractions noted in PubMed, the on line citation source of the National Institutes of Health). Of those retracted, fully 55% were for misconduct. Some of these showed up in the news, but most did not. They note that it is a small percentage of all published research, but it's more than enough. More troubling is they're comparison to an earlier study. In that study, using the same methods, Budd et al discovered that in the years from 1966 to 1996 235 articles were retracted, 40% for misconduct. So, in almost a third the time, almost five times as many articles were retracted, and the proportion retracted for misconduct increased by 15%!

The authors go on to point to several related causes for concern. One is just how long it takes for a retraction to be issued. In the study reported this spring, the mean time to retraction was 17 months. On the other hand, for the median (half took less time and half took longer) was 29 months and the range went to 304 months – more than 25 years! (Yes, that’s only one exceptional article; but still….) In all that time people could be and were put at risk, either in larger studies designed on faulty premises, or in treatment programs that proved unsound.

Even more troubling for the authors were the number of times retracted articles were cited after they had been retracted. Citations before retraction might be unfortunate, but they’re not in themselves evidence of poor practice. Citations after retraction, on the other hand, are – or may be. If a researcher is searching an online database, or looking at the online edition of the journal, it may be easy to see that an article has been retracted (if not always why). However, if the researcher is going from one print source to another – say, looking at the hard copy of a journal based on a citation in a book or other printed source – the fact that the article has been retracted won’t be immediately available. Budd et all note that “Finding a retraction statement does require some diligence on the part of authors and editors.” Much depends on how online sources make retractions apparent, and most make some effort. However, the individual researcher needs to check carefully.

We have a lot at stake these days in the quality of research that gets done, and especially, as Budd et al note, in biomedical research. Across the spectrum of healthcare, from providers to payers to patients, quality of care and demonstrated outcomes are critical. But demonstrated outcomes require good research that is careful about methods, resources, and ethics. Mistakes in research are unfortunate, but not entirely avoidable. On the other hand, misconduct in research unethical and sometimes dangerous. Compounding misconduct by poor review processes or slow retractions is also unethical, as is citation of retracted research. We all have a lot at stake in this. We as the recipients of research need to be able to trust that we’re receiving good information; and we who are researchers (and yes, chaplains are researchers, too!) need to be worthy of that trust.

Thursday, August 11, 2011

Healthcare: It's Where the Jobs Are

The website Health Leaders Media posted on Monday a brief story analyzing statistics from the Bureau of Labor Statistics.  The headline says a lot: Healthcare Sector Drives U.S. Job Growth.

The article notes, “Healthcare created 31,300 new jobs for the month and 170,900 new jobs in the first seven months of 2011. The healthcare sector has accounted for 18.4% of the 930,000 non-farm payroll additions in the overall economy so far this year, BLS preliminary data show.” The July increase is more than a quarter of all new jobs created in the economy. The latter point is despite the fact that hospitals lost 2,000 jobs in June, and that there were losses in July in long term and other care facilities. It represents more than four times the jobs created in health care in 2010 in the same time period. New jobs were evenly distributed largely between hospital and ambulatory care, with slightly more in ambulatory care.

That’s tremendous job growth, both for one month and for the year to date. Which raises a question for me. In a time when jobs are short, and people everywhere in the economy are looking for signs of growth, healthcare is showing great promise. Moreover, jobs in healthcare are good jobs.  They pay well, and have some staying power.  They can’t be outsourced overseas (and won’t, I think, be affected all that much by medical tourism), and the market is only growing, both as the population grows and as it ages.

So, why, then, is there so much interest in cutting reimbursement for healthcare?  I know that it’s expensive (after all, I’m not just a provider; I’m also a consumer), but I also know that, like other forms of maintenance, preventive care is an investment that will save a lot of money down the line – and preventive care also requires people employed to do the work. I know, too, that healthcare is driven, not by low costs or ego satisfaction, but by individual and immediate need; and so simply insisting on paying less isn’t really going to be an effective means of controlling demand. Indeed, because there are so much to be gained later from preventive care now, I think we need to question whether we want to simply reduce demand by reducing payment, or redirect demand by restructuring payment and actually increasing payment for some things.

One way or another, the numbers (albeit preliminary) indicate that healthcare is a sector of the market that is creating jobs, good jobs, in an economy that needs to put people to work. For all the criticism of the Affordable Care Act, this hardly seems the time to cut the payments, including Medicare and Medicaid, that will undermine that sector and all the jobs it includes now, and can add in the future.

Tuesday, August 02, 2011

What We Can Do With Collaboration - And Not Competition

Some time past I wrote about health care and the market.  I noted especially that when choices are negotiated, it isn’t patients who really do the negotiating.  Instead, hospitals, physicians, and insurers negotiate with one another to determine appropriate exchanges of services, reimbursement, and lives – which is to say, us as patients.

So, what would happen if the three parties got together and became partners?  Yesterday the Los Angeles Times reported on just such an event.  Three major players – an insurer, a hospital system, and a large medical practice – collaborated, and in the first year attained some remarkable results: “The collaboration among Blue Shield of California, Catholic Healthcare West and Hill Physicians Medical Group shaved more than $20 million in costs last year and prevented an insurance rate hike for public sector workers in Northern California.”  Now, these are two remarkable results.  The cost savings are remarkable in and of themselves, and would allow the various organizations to save money for patients, marginally reducing fees and premiums.  But just as important were the savings for both government employees and taxpayers in preventing the rate hike.

While the financial savings were significant, I was more interested in some of the clinical results.  For the clinical results reported, cost savings were an important measure.  However, I also they think they indicate quality care for patients.

For example, surgeries for weight loss were reduced last year by 13%.  They did it by offering guidance for better choices.  In essence, patients were taught preventive measures that so that fewer surgeries were required.  The thing is, the same measures are likely to result in fewer cardiac issues and lower incidence of diabetes.  So, the results are lower costs not only in surgeries now, but in improved health later.

Or consider that readmissions after hospital stays were reduced by 15%. The collaborators note that fewer readmissions indicate patient who were healthier at discharge. Readmissions have another consequence for hospitals.  Medicare has structured their reimbursement around Diagnostic Related Groups, or DRGs.  For a great many diagnoses, Medicare sets a specific reimbursement amount.  If the patient costs less, the hospital makes a little more money.  If the patient costs more, the hospital eats the excess expenses.  So, if a patient is healthier faster, not only has the patient benefited, but the hospital gets some financial incentive.  If a patient has a longer stay, the hospital loses money.  The thing is, if a patient is readmitted too soon after a discharge, Medicare considers it part of the same diagnosis, and so doesn’t pay the additional expenses. And it’s not just Medicare: insurance companies also use DRGs to guide their payments, especially in managed care contracts.  So, readmissions lose hospitals lots of money, and a15% reduction means the losses are a lot less. For a not-for-profit like Catholic Healthcare West, that means more money to plow back into equipment and personnel for patient care.

We might argue that there was a fourth partner involved in this.  More than three quarters of the $20,000,000 saved came from the California Public Employees Retirement System (CalPERS) because Blue Shield didn’t raise insurance rates for those covered through CalPERS.  However, this is no small thing: the costs of pension benefits are significant problems in many of our states.  Saving money in this way saves money, or saves services, for many of us.

So, this is an example of collaboration that worked. Of course, it worked precisely because the partners stopped competing, at least in this instance, and instead worked together.  They had some trust to build and some history to overcome before they could collaborate: "Our staffs had a history of combating with each other through negotiations," said John Wray, a senior vice president with Catholic Healthcare West. "We had to trust one another to make it happen. This was a very significant culture change between the organizations."  They even shared some proprietary information. This was simply not your typical “market-based solution.”  Note that it isn’t a government directed solution, either.  At the same time, it’s not competition but collaboration, not proprietary interest but partnership, that brought these results.

Maybe, just maybe, that’s a model that others can follow, so that more of us can benefit.

Monday, August 01, 2011

My Thoughts on Fair Taxation

So, I’ve recently seen once again this statement: “The top ten per cent (income) of Americans pay 55% of all taxes. Let them pay 65% instead.” The point that the author wanted to make was that increasing that to 65% would still not meaningfully address the deficit. It’s at least a different point than is usually made with such a statement.  Usually, the suggestion is that the top 10% are paying more income tax than they should, that in a fair tax structure, collected taxes would somehow be more evenly distributed across all income classes.

I have found myself wondering about those statements, and similar statements I’ve seen (all with varying numbers, but with much the same point).  So, I did a bit of searching, and found this paper, titled “Wealth, Income, and Power.”  The author is William Domhoff of the University of California at Santa Cruz.

The article is illustrated with some very helpful tables and charts.  For example, a chart on wealth distribution indicates that in 2007 households above the 90th percentile (90% of households had lower net worth) controlled 83% of financial wealth.  So, one could argue that instead of paying 55% if all taxes collected, they should be responsible for 83% of taxes. 

But, we don’t tax wealth.  We tax income.  So, let’s look at income distribution.  In 2006 more than 41% of all income received in the United States was received by only 20% of those who received income.  A different table from Citizens for Tax Justice indicates that this group above the 80th percentile of those receiving income received 59% of all income, and paid 64% of all taxes.  Now, that seems pretty even, doesn’t it?  But while it may look “equal” in some sense, it’s impact is not equally felt.  Those above the 80% pay roughly 30% of their income in taxes.  Those between the 60th and 80th percentiles pay about 29%, and those between the 40th and 60th percentiles pay about 25%.  Those below the 40th percentile pay 20% or less.  It looks progressive for a moment.  But, think about how this impacts standard of living.  Those above the 80th percentile receive in income $100,000 and up.  Those below the 40th percentile receive in income $25,000 and less.  30% of even $100,000 ($100,000 minus $30,000 leaves $70,000) has much less impact on purchasing power and standard of living than 20% of $25,000 ($25,000 minus $5,000 leaves $20,000).  $30,000 sounds like a lot of taxes; but $70,000 is still a pretty good discretionary income.  $5,000 sounds like a lot less; but it represents a lot of groceries for folks who are already living pretty close to the margin.

It seem pretty clear that the reasons to tax those who have more in a greater measure than those who have less are first and foremost that they have the wealth in the first place; and second, that they have benefited much more from this economy that we share than most of us.  And after all, they can afford it.  The one person in America whose name is more associated with paying taxes than Grover Norquist is Henry Bloch, the “H” of H & R Block.  He wrote an editorial that appeared in the Kansas City Star  His closing comments were, this past Saturday.

Those of us earning more than $250,000 a year are very fortunate. We have an obligation to help our nation overcome this challenge. While I don’t look forward to paying more taxes, it must be done. And it’s a small price to pay for living in this wonderful country. Responsible change that promotes good public policy and tax fairness is to be welcomed.

So, here are a couple of ways to think about what might make for “fair” taxation.  We could tax wealth, and set it up so that those who own 83% of the wealth are required to provide 83% of taxes paid (instead of 55 or 60%).  Or, we could figure out how to tax so that those at the top have their purchasing power reduced as significantly as those at the bottom.  See, it’s not whether those at the top pay more taxes than those at the bottom.  It’s whether those at the top pay enough more taxes that their lives are proportionally affected as much as those at the bottom.  That might be a truly progressive tax plan.