Contraceptive Coverage Expanded: No More ‘Moral’ Exemptions for Employers

Ari Blaff

Yahoo News

Originally posted 30 JAN 23

Here is an excerpt:

The proposed new rule released today by the Departments of Health and Human Services (HHS), Labor, and Treasury would remove the ability of employers to opt out for “moral” reasons, but it would retain the existing protections on “religious” grounds.

For employees covered by insurers with religious exemptions, the new policy will create an “independent pathway” that permits them to access contraceptives through a third-party provider free of charge.

“We had to really think through how to do this in the right way to satisfy both sides, but we think we found that way,” a senior HHS official told CNN.

Planned Parenthood applauded the announcement. “Employers and universities should not be able to dictate personal health-care decisions and impose their views on their employees or students,” the organization’s chief, Alexis McGill Johnson, told CNN. “The ACA mandates that health insurance plans cover all forms of birth control without out-of-pocket costs. Now, more than ever, we must protect this fundamental freedom.”

In 2018, the Trump administration sought to carve out an exception, based on “sincerely held religious beliefs,” to the ACA’s contraceptive mandate. The move triggered a Pennsylvania district court judge to issue a nationwide injunction in 2019, blocking the implementation of the change. However, in 2020, in Little Sisters of the Poor v. Pennsylvania, the Supreme Court, in a 7–2 ruling, defended the legality of the original Trump policy.

The Supreme Court’s overturning of Roe v. Wade in June 2022, in its Dobbs ruling, played a role in HHS’s decision to release the new proposal. Guaranteeing access to contraceptions at no cost to the individual “is a national public health imperative,” HHS said in the proposal. And the Dobbs ruling “has placed a heightened importance on access to contraceptive services nationwide.”

The info is here.

Do You Really Want to Read What Your Doctor Writes About You?

Zoya Qureshi

The Atlantic

Originally posted 15 NOV 22

You may not be aware of this, but you can read everything that your doctor writes about you. Go to your patient portal online, click around until you land on notes from your past visits, and read away. This is a recent development, and a big one. Previously, you always had the right to request your medical record from your care providers—an often expensive and sometimes fruitless process—but in April 2021, a new federal rule went into effect, mandating that patients have the legal right to freely and electronically access most kinds of notes written about them by their doctors.

If you’ve never heard of “open notes,” as this new law is informally called, you’re not the only one. Doctors say that the majority of their patients have no clue. (This certainly has been the case for all of the friends and family I’ve asked.) If you do know about the law, you likely know a lot about it. That’s typically because you’re a doctor—one who now has to navigate a new era of transparency in medicine—or you’re someone who knows a doctor, or you’re a patient who has become intricately familiar with this country’s health system for one reason or another.

When open notes went into effect, the change was lauded by advocates as part of a greater push toward patient autonomy and away from medical gatekeeping. Previously, hospitals could charge up to hundreds of dollars to release records, if they released them at all. Many doctors, meanwhile, have been far from thrilled about open notes. They’ve argued that this rule will introduce more challenges than benefits for both patients and themselves. At worst, some have fretted, the law will damage people’s trust of doctors and make everyone’s lives worse.

A year and a half in, however, open notes don’t seem to have done too much of anything. So far, they have neither revolutionized patient care nor sunk America’s medical establishment. Instead, doctors say, open notes have barely shifted the clinical experience at all. Few individual practitioners have been advertising the change, and few patients are seeking it out on their own. We’ve been left with a partially implemented system and a big unresolved question: How much, really, should you want to read what your doctor is writing about you?

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Open notes are only part of this conversation. The new law also requires that test results be made immediately available to patients, meaning that patients might see their health information before their physician does. Although this is fine for the majority of tests, problems arise when results are harbingers of more complex, or just bad, news. Doctors I spoke with shared that some of their patients have suffered trauma from learning about their melanoma or pancreatic cancer or their child’s leukemia from an electronic message in the middle of the night, with no doctor to call and talk through the seriousness of that result with. This was the case for Tara Daniels, a digital-marketing consultant who lives near Boston. She’s had leukemia three times, and learned about the third via a late-night notification from her patient portal. Daniels appreciates the convenience of open notes, which help her keep track of her interactions with various doctors. But, she told me, when it comes to instant results, “I still hold a lot of resentment over the fact that I found out from test results, that I had to figure it out myself, before my doctor was able to tell me.”

The info is here.

Beyond individualism: Is there a place for relational autonomy in clinical practice and research?

Dove, E. S., Kelly, S. E., et al. (2017).

Clinical Ethics, 12(3), 150–165.

https://doi.org/10.1177/1477750917704156

Abstract

The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of ‘relational autonomy’ in particular have argued that people’s identities, needs, interests – and indeed autonomy – are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique directed at an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangible and positive impact on clinical practice and research. These solutions leave the ultimate decision to the person most affected, but encourage and facilitate the consideration of this person’s care and responsibility for connected others.

From the Discussion section

Together, these cases show that in our quest to enhance the practical value of the concept of relational autonomy in healthcare and research, we must be careful not to remove the patient or participant from the centre of decision-making. At the same time, we should acknowledge that the patient’s decision to consent (or refuse) to treatment or research can be augmented by facilitating and encouraging that her relations to, and responsibility for, others are considered in decision-making processes. Our case studies do not suggest that we should expand consent requirements to others per se, such as family members or community elders – that is, to add the requirement of seeking consent from further individuals who may also be seen as having a stake in the decision. Such a position would undermine the idea that the person who is centrally affected by a decision should typically have the final say in what happens with and to her, or her body, or even her data. As long as this general principle respects all legal exceptions (see below), we believe that it is a critical underpinning of fundamental respect for persons that should not done away with. Moreover, expanding consent or requiring consent to include others (however so defined) undermines the main objective of relational autonomy, which is to foreground the relational aspect of human identities and interests, and not merely to expand the range of individuals who need to give consent to a procedure. An approach that merely extends consent requirements to other people does not foreground relations but rather presumptions about who the relevant others of a person are.

The article is here.

Confronting Health Worker Burnout and Well-Being

V. Murthy

NEJM, July 13, 2022

DOI: 10.1056/NEJMp2207252

Here is an excerpt:

Burnout manifests in individuals, but it’s fundamentally rooted in systems. And health worker burnout was a crisis long before Covid-19 arrived. Causes include inadequate support, escalating workloads and administrative burdens, chronic underinvestment in public health infrastructure, and moral injury from being unable to provide the care patients need. Burnout is not only about long hours. It’s about the fundamental disconnect between health workers and the mission to serve that motivates them.

These systemic shortfalls have pushed millions of health workers to the brink. Some 52% of nurses (according to the American Nurses Foundation) and 20% of doctors (Mayo Clinic Proceedings) say they are planning to leave their clinical practice. Shortages of more than 1 million nurses are projected by the end of the year (U.S. Bureau of Labor Statistics); a gap of 3 million low-wage health workers is anticipated over the next 3 years (Mercer). And we face a significant shortage of public health workers precisely when we need to strengthen our defenses against future public health threats. Health worker burnout is a serious threat to the nation’s health and economic security.

The time for incremental change has passed. We need bold, fundamental change that gets at the roots of the burnout crisis. We need to take care of our health workers and the rising generation of trainees.

On May 23, 2022, I issued a Surgeon General’s Advisory on health worker burnout and well-being, declaring this crisis a national priority and calling the nation to action with specific directives for health systems, insurers, government, training institutions, and other stakeholders. The advisory is also intended to broaden awareness of the threat that health worker burnout poses to the nation’s health. Public awareness and support will be essential to ensuring sustained action.

Addressing health worker well-being requires first valuing and protecting health workers. That means ensuring that they receive a living wage, access to health insurance, and adequate sick leave. It also means health workers should never again go without adequate personal protective equipment (PPE) as they have during the pandemic. Current Biden administration efforts to enhance domestic manufacturing of PPE and maintain adequate supplies in the Strategic National Stockpile will continue to be essential. Furthermore, we need strict workplace policies to protect staff from violence: according to National Nurses United, 8 in 10 health workers report having been subjected to physical or verbal abuse during the pandemic.

Second, we must reduce administrative burdens that stand between health workers and their patients and communities. One study found that in addition to spending 1 to 2 hours each night doing administrative work, outpatient physicians spend nearly 2 hours on the electronic health record and desk work during the day for every 1 hour spent with patients — a trend widely lamented by clinicians and patients alike. The goal set by the 25×5 initiative of reducing clinicians’ documentation burden by 75% by 2025 is a key target. To help reach this goal, health insurers should reduce requirements for prior authorizations, streamline paperwork requirements, and develop simplified, common billing forms. Our electronic health record systems need human-centered design approaches that optimize usability, workflow, and communication across systems. Health systems should regularly review internal processes to reduce duplicative, inefficient work. One such effort, Hawaii Pacific Health’s “Getting Rid of Stupid Stuff” program, has saved 1700 nursing hours per month across the health system.

The info is here.

Thousands of Medical Professionals Urge Supreme Court To Uphold Roe: ‘Provide Patients With the Treatment They Need’

Phoebe Kolbert

Ms. Magazine

Originally posted 21 JUN 22

Any day now, the Supreme Court will issue its decision in Dobbs v. Jackson Women’s Health Organization, which many predict will overturn or severely gut Roe v. Wade. Since the start of the Dobbs v. Jackson hearings in December, medical professionals have warned of the drastic health impacts brought on by abortion bans. Now, over 2,500 healthcare professionals from all 50 states have signed a letter urging the Supreme Court to scrap their leaked Dobbs draft opinion and uphold Roe.  

Within 30 days of a decision to overturn Roe, at least 26 states will ban abortion. Clinics in remaining pro-abortion states are preparing for increased violence from anti-abortion extremists and an influx of out-of-state patients. The number of legal abortions performed nationwide is projected to fall by about 13 percent. Many abortion clinics in states with bans will be forced to close their doors, if they haven’t already. The loss of these clinics also comes with the loss of the other essential reproductive healthcare they provide, including STI screenings and treatment, birth control and cervical cancer screenings.

The letter, titled “Medical Professionals Urge Supreme Court to Uphold Roe v. Wade, Protect Abortion Access,” argues that decisions around pregnancy and abortion should be made by patients and their doctors, not the courts.

The info from Ms. Magazine is here.

Here is how the letter begins:

Medical Professionals Urge Supreme Court to Uphold Roe v. Wade, Protect Abortion Access

As physicians and health care professionals, we are gravely concerned that the U.S. Supreme Court appears prepared to end the constitutional right to an abortion. We urge the Supreme Court to to scrap their draft opinion, uphold the constitutional right to an abortion, and ensure that abortions remain legal nationwide, as allowed for in Roe v. Wade. In this moment of crisis, we want to make crystal clear the consequences to our patients’ health if they can no longer access abortions.

Abortions are safe, common and a critical part of health care and reproductive medicine. Medical professionals and medical associations agree, including the American Medical Association, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American College of Nurse Midwives and many others.

Prohibiting access to safe and legal abortion has devastating implications for health care. Striking down Roe v. Wade would affect not just abortion access, but also maternal care as well as fertility treatments. Pregnancy changes a person’s physiology. These changes can potentially worsen existing diseases and medical conditions.

As physicians and medical professionals, we see the real-life consequences when an individual does not get the care that they know they need, including abortions. The woman who has suffered the violation and trauma of rape would be forced to carry a pregnancy.

Denying access to abortion from people who want one can adversely affect their health, safety and economic well-being, including delayed separation from a violent partner and increased likelihood of falling into poverty by four times. These outcomes can also have drastic impacts on their health.

The entire letter is here.

South Carolina bill permits health care providers refuse non-emergency care based on beliefs

Brooke Migdon

The Hill

Originally posted 1 APR 22

Story at a glance

• Legislators in South Carolina on Friday passed a bill which would allow healthcare providers to deny care based on their personal beliefs. It would also apply to insurance companies, which may be entitled to refuse to pay for care.

• The bill would also protect those who decline to provide medical services from civil, criminal or administrative liability.

• Some say the bill, known as the “Medical Ethics and Diversity Act,” would disproportionately affect the LGBTQ+ community, as well as women and people of color.

South Carolina lawmakers on Friday passed a bill allowing medical professionals and insurance companies to deny care based on personal belief. Some say the legislation, which now heads to the state Senate for consideration, would disproportionately impact LGBTQ+ people, women, and people of color.

Under the bill, titled the “Medical Ethics and Diversity Act,” South Carolina law would be altered to excuse medical practitioners, health care institutions and health care payers from providing care that violates their “conscience.” It would also shield those who decline to provide medical services to patients from civil, criminal or administrative liability.

Dozens of state residents in February testified against the bill, calling it vague and overbroad. They also shared concerns that the legislation would disproportionately impact marginalized communities.

In a statement on Friday, Human Rights Campaign Legal Director Sarah Warbelow said she finds it “disturbing” that politicians in South Carolina are prioritizing individual providers’ beliefs over the wellbeing of patients.

“This legislation is dangerously silent in regards to the needs of patients and fails to consider the impact that expanding refusals can have on their health,” she said. “Religious freedom is a fundamental American value that is entirely compatible with providing quality, non-discriminatory healthcare. It is not a license to deprive others of their rights simply because of personal beliefs.”

Warbelow said the bill sends a message to patients with non-medical views inconsistent with that of their doctors that they are “not equal members of society entitled to dignity and respect.”

The info is here.

Editor's Note: Those politicians who pass laws based on culture wars are clearly violating the principle-based ethics on which all medical ethics rely.  If they pass harmful laws that conflict with health care ethics, then they are not fit to serve.

Anti-Black Racism as a Chronic Condition

Nneka Sederstrom and Tamika Lasege, 

In A Critical Moment in Bioethics: Reckoning 

with Anti-Black Racism through Intergenerational 

Dialogue,  ed.  Faith  E.  Fletcher  et  al., 

Special  Report, Hastings Center Report 52, no. 2 

(2022):  S24-S29.

Abstract

Because America has a foundation of anti-Black racism, being born Black in this nation yields an identity that breeds the consequences of a chronic condition. This article highlights several ways in which medicine and clinical ethics, despite the former's emphasis on doing no harm and the latter's emphasis on nonmaleficence, fail to address or acknowledge some of the key ways in which physicians can—and do—harm patients of color. To understand harm in a way that can provide real substance for ethical standards in the practice of medicine, physicians need to think about how treatment decisions are constrained by a patient's race. The color of one's skin can and does negatively affect the quality of a person's diagnosis, promoted care plan, and prognosis. Yet racism in medicine and bioethics persist—because a racist system serves the interests of the dominant caste, White people. As correctives to this system, the authors propose several antiracist commitments physicians or ethicists can make.

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Here are some commitments to add to a newly revised Hippocratic oath: We shall stop denying that racism exists in medicine. We shall face the reality that we fail to train and equip our clinicians with the ability to effectively make informed clinical decisions using the reality of how race impacts health outcomes. We shall address the lack of the declaration of racism as a bioethics priority and work to train ethicists on how to engage in antiracism work. We shall own the effects of racism at every level in health care and the academy. Attempting to talk about everything except racism is another form of denial, privilege, and power that sustains racism. We will not have conversations about disproportionally high rates of “minority” housing insecurity, food scarcity, noncompliance with treatment plans, “drug-seeking behavior,” complex social needs, or “disruptive behavior” or rely on any other terms that are disguised proxies for racism without explicitly naming racism. As ethicists, we will not engage in conversations around goal setting, value judgments, benefits and risks of interventions, autonomy and capacity, or any other elements around the care of patients without naming racism.

So where do we go from here? How do we address the need to decolonize medicine and bioethics? When do we stop being inactive and start being proactive? It starts upstream with improving the medical education and bioethics curricula to accurately and thoroughly inform students on the social and biological sciences of human beings who are not White in America. Then, and only then, will we breed a generation of race-conscious clinicians and ethicists who can understand and interpret the historic inequities in our system and ultimately be capable of providing medical care and ethical analysis that reflect the diversity of our country. Clinical ethics program development must include antiracism training to develop clinical ethicists who have the skills to recognize and address racism at the bedside in clinical ethics consultation. It requires changing the faces in the field and addressing the extreme lack of racial diversity in bioethics. Increasing the number of clinicians of color in all professions within medicine, but especially the numbers of physicians, advance practice providers, and clinical ethicists, is imperative to the goal of improving patient outcomes for Black and brown populations.

The info is here.

Recognizing and Dismantling Raciolinguistic Hierarchies in Latinx Health

Ortega, P., et al.

AMA J Ethics. 2022;24(4):E296-304.

doi: 10.1001/amajethics.2022.296.

Abstract

Latinx individuals represent a linguistically and racially diverse, growing US patient population. Raciolinguistics considers intersections of language and race, prioritizes lived experiences of non-English speakers, and can help clinicians more deftly conceptualize heterogeneity and complexity in Latinx health experiences. This article discusses how raciolinguistic hierarchies (ie, practices of attaching social value to some languages but not others) can undermine the quality of Latinx patients’ health experiences. This article also offers language-appropriate clinical and educational strategies for promoting health equity.

Raciolinguistics

Hispanic/Latinx (hereafter, Latinx) individuals in the United States represent a culturally, racially, and linguistically diverse and rapidly growing population. Attempting to categorize all Latinx individuals in a single homogeneous group may result in inappropriate stereotyping,1 inaccurate counting,2, 3 ineffective health interventions that insufficiently target at-risk subgroups,4 and suboptimal health communication.5 A more helpful approach is to use raciolinguistics to conceptualize the heterogeneous, complex Latinx experience as it relates to health. Raciolinguistics is the study of the historical and contemporary co-naturalization of race and language and their intertwining in the identities of individuals and communities. As an emerging field that grapples with the intersectionality of language and race, raciolinguistics provides a unique perspective on the lived experiences of people who speak non-English languages and people of color.6 As such, understanding raciolinguistics is relevant to providing language-concordant care7 to patients with limited English proficiency (LEP), who have been historically marginalized by structural barriers, racism, and other forms of discrimination in health care.

In this manuscript, we explore how raciolinguistics can help clinicians to appropriately conceptualize the heterogeneous, complex Latinx experience as it relates to health care. We then use the raciolinguistic perspective to inform strategies to dismantle structural barriers to health equity for Latinx patients pertaining to (1) Latinx patients’ health care experiences and (2) medical education.

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Conclusions

A raciolinguistic perspective can inform how health care practices and medical education should be critically examined to support Latinx populations comprising heterogeneous communities and complex individuals with varying and intersecting cultural, social, linguistic, racial, ancestral, spiritual, and other characteristics. Future studies should explore the outcomes of raciolinguistic reforms of health services and educational interventions across the health professions to ensure effectiveness in improving health care for Latinx patients.

The info is here.

Why nurses are raging and quitting after the RaDonda Vaught verdict

B. Kelman & H. Norman

www.npr.org

Originally published 5 APR 22

Emma Moore felt cornered. At a community health clinic in Portland, Ore., the 29-year-old nurse practitioner said she felt overwhelmed and undertrained. Coronavirus patients flooded the clinic for two years, and Moore struggled to keep up.

Then the stakes became clear. On March 25, about 2,400 miles away in a Tennessee courtroom, former nurse RaDonda Vaught was convicted of two felonies and now faces eight years in prison for a fatal medication mistake.

Like many nurses, Moore wondered if that could be her. She'd made medication errors before, although none so grievous. But what about the next one? In the pressure cooker of pandemic-era health care, another mistake felt inevitable.

Four days after Vaught's verdict, Moore quit. She said the verdict contributed to her decision.

"It's not worth the possibility or the likelihood that this will happen," Moore said, "if I'm in a situation where I'm set up to fail." In the wake of Vaught's trial ― an extremely rare case of a health care worker being criminally prosecuted for a medical error ― nurses and nursing organizations have condemned the verdict through tens of thousands of social media posts, shares, comments and videos. They warn that the fallout will ripple through their profession, demoralizing and depleting the ranks of nurses already stretched thin by the pandemic. Ultimately, they say, it will worsen health care for all.

Statements from the American Nurses Association, the American Association of Critical-Care Nurses, and the National Medical Association each said Vaught's conviction set a "dangerous precedent." Linda Aiken, a nursing and sociology professor at the University of Pennsylvania, said that although Vaught's case is an "outlier," it will make nurses less forthcoming about mistakes.

"One thing that everybody agrees on is it's going to have a dampening effect on the reporting of errors or near misses, which then has a detrimental effect on safety," Aiken said. "The only way you can really learn about errors in these complicated systems is to have people say, 'Oh, I almost gave the wrong drug because ...'"

"Well, nobody is going to say that now."

The info is here.

Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice

Abbasi J.

JAMA. Published online March 30, 2022.

doi:10.1001/jama.2022.5074

Here is an excerpt:

Worsening staffing issues are now the biggest stressor for clinicians. Health care worker shortages, especially in rural and otherwise underserved areas of the country, have reached critical and unsustainable levels, according to the National Institute for Occupational Safety and Health (NIOSH).

“The evidence shows that health workers have been leaving the workforce at an alarming rate over the past 2 years,” Thomas R. Cunningham, PhD, a senior behavioral scientist at NIOSH, wrote in a statement emailed to JAMA.

In the absence of national data, Etz says the Green Center data point to a meaningful reduction in the primary care workforce during the pandemic. In the February 2022 survey, 62% of 847 clinicians had personal knowledge of other primary care clinicians who retired early or quit during the pandemic and 29% knew of practices that had closed up shop. That’s on top of a preexisting shortage of general and family medicine physicians. “I think we have a platform that is collapsed, and we haven’t recognized it yet,” Etz said.

In fact, surveys indicate that a “great clinician resignation” lies ahead. A quarter of clinicians said they planned to leave primary care within 3 years in Etz’s February survey. The Coping With COVID study predicts a more widespread clinician exodus: in the pandemic’s first year, 23.8% of the more than 9000 physicians from various disciplines in the study and 40% of 2301 nurses planned to exit their practice in the next 2 years. (The Coping With COVID study was funded by the American Medical Association, the publisher of JAMA.)

A lesson that’s been underscored during the pandemic is that physician wellness has a lot to do with other health workers’ satisfaction. “The ‘great resignation’ is affecting a lot of our staff, who don’t feel necessarily cared for by their organizations,” Linzer said. “The staff are leaving, which leaves the physicians to do more nonphysician work. So really, in order to solve this, we need to pay attention to all of our health care workers.”

Nurses who said they intended to leave their positions within 6 months cited 3 main drivers in an American Nurses Foundation survey: work negatively affecting their health and well-being, insufficient staffing, and a lack of employer support during the pandemic.

“Health care is a team sport,” L. Casey Chosewood, MD, MPH, director of the NIOSH Office for Total Worker Health, wrote in the agency’s emailed statement. “When nurses and other support personnel are under tremendous strain or not able to perform at optimal levels, or when staffing is inadequate, the impact flows both upstream to physicians who then face a heavier workload and loss of efficiency, and downstream impacting patient care and treatment outcomes.”

The info is here.

Implementing The 988 Hotline: A Critical Window To Decriminalize Mental Health

P. Krass, E. Dalton, M. Candon, S. Doupnik

Health Affairs

Originally posted 25 FEB 22

Here is an excerpt:

Decriminalization Of Mental Health

The 988 hotline holds incredible promise toward decriminalizing the response to mental health emergencies. Currently, if an individual is experiencing a mental health crisis, they, their caregivers, and bystanders have few options beyond calling 911. As a result, roughly one in 10 individuals with mental health disorders have interacted with law enforcement prior to receiving psychiatric care, and 10 percent of police calls are for mental health emergencies. When police arrive, if they determine an acute safety risk, they transport the individual in crisis for further psychiatric assessment, most commonly at a medical emergency department. This almost always takes place in a police vehicle, many times in handcuffs, a scenario that contradicts central tenets of trauma-informed mental health care. In the worst-case scenario, confrontation with police results in injury or death. Adverse outcomes during response to mental health emergencies are more than 10-fold more likely for individuals with mental health conditions than for individuals without, and are disproportionately experienced by people of color. This consequence was tragically highlighted by the death of Walter Wallace, Jr., who was killed by police while experiencing a mental health emergency in October 2021.

Ideally, the new 988 number would activate an entirely different cascade of events. An individual in crisis, their family member, or even a bystander will be able to immediately reach a trained crisis counselor who can provide phone-based triage, support, and local resources. If needed, the counselor can activate a mobile mental health crisis team that will arrive on site to de-escalate; provide brief therapeutic interventions; either refer for close outpatient follow up or transport the individual for further psychiatric evaluation; and even offer food, drink, and hygiene supplies.

 

Rather than forcing families to call 911 for any type of help—regardless of criminal activity—the 988 line will allow individuals to access mental health crisis support without involving law enforcement. This approach can empower families to self-advocate for the right level of mental health care—including avoiding unnecessary medical emergency department visits, which are not typically designed to handle mental health crises and can further traumatize individuals and their families—and to initiate psychiatric assessment and treatment sooner. 911 dispatchers will also be able to re-route calls to 988 when appropriate, allowing law enforcement personnel to spend more time on their primary role of ensuring public safety. Finally, the 988 number will help offer a middle option for individuals who need rapid linkage to care, including rapid psychiatric evaluation and initiation of treatment, but do not yet meet criteria for crisis. This is a crucial service given current difficulties in accessing timely, in-network outpatient mental health care.

The info is here.

New billing disclosure requirements take effect in 2022

American Psychological Association

Originally published 10 December 21

All mental health providers will need to provide estimated costs of services before starting treatment.

Beginning January 1, 2022, psychologists and other health care providers will be required by law to give uninsured and self-pay patients a good faith estimate of costs for services that they offer, when scheduling care or when the patient requests an estimate.

This new requirement was finalized in regulations issued October 7, 2021. The regulations implement part of the “No Surprises Act,” enacted in December 2020 as part of a broad package of COVID- and spending-related legislation. The act aims to reduce the likelihood that patients may receive a “surprise” medical bill by requiring that providers inform patients of an expected charge for a service before the service is provided. The government will also soon issue regulations requiring psychologists to give good faith estimates to commercial or government insurers, when the patient has insurance and plans to use it.

Psychologists working in group practices or larger organizational settings and facilities will likely receive direction from their compliance department or lawyers on how to satisfy this new requirement.

Read on for answers to FAQs that apply to practicing psychologists who treat uninsured or self-pay patients.

What providers and what services are subject to this rule?

“Provider” is defined broadly to include any health care provider who is acting within the scope of the provider’s license or certification under applicable state law. Psychologists meet that definition. 

The definition of “items and services” for which the good faith estimate must be provided is also broadly defined to encompass “all encounters, procedures, medical tests, … provided or assessed in connection with the provision of health care.” Services related to mental health substance use disorders are specifically included.

What steps do I need to take and when?

Psychologists are ethically obligated to discuss fees with patients upfront. This new requirement builds on that by adding more structure and specific timeframes for action.

The rest of the vital information is here.

Note: Compliance is not optional.  This is a new, consumer protection, health-care law in the United States.

COVID Medical Coverage is Over: Insurers are restoring deductibles and co-pays, leaving patients with big bills

Christopher Rowland

The Washington Post

Originally posted 18 Sept 21

Here is an excerpt:

But this year, most insurers have reinstated co-pays and deductibles for covid patients, in many cases even before vaccines became widely available. The companies imposed the costs as industry profits remained strong or grew in 2020, with insurers paying out less to cover elective procedures that hospitals suspended during the crisis.

Now the financial burden of covid is falling unevenly on patients across the country, varying widely by health-care plan and geography, according to a survey of the two largest health plans in every state by the nonprofit and nonpartisan Kaiser Family Foundation.

If you’re fortunate enough to live in Vermont or New Mexico, for instance, state mandates require insurance companies to cover 100 percent of treatment. But most Americans with covid are now exposed to the uncertainty, confusion and expense of business-as-usual medical billing and insurance practices — joining those with cancer, diabetes and other serious, costly illnesses.

(Insurers continue to waive costs associated with vaccinations and testing, a pandemic benefit the federal government requires.)

A widow with no children, Azar, 57, is part of the unlucky majority. Her experience is a sign of what to expect if covid, as most scientists fear, becomes endemic: a permanent, regular health threat.

The info is here.

How Does Cost-Effectiveness Analysis Inform Health Care Decisions?

David D. Kim & Anirban Basu

AMA J Ethics. 2021;23(8):E639-647. 

doi: 10.1001/amajethics.2021.639.

Abstract

Cost-effectiveness analysis (CEA) provides a formal assessment of trade-offs involving benefits, harms, and costs inherent in alternative options. CEA has been increasingly used to inform public and private organizations’ reimbursement decisions, benefit designs, and price negotiations worldwide. Despite the lack of centralized efforts to promote CEA in the United States, the demand for CEA is growing. This article briefly reviews the history of CEA in the United States, highlights advances in practice guidelines, and discusses CEA’s ethical challenges. It also offers a way forward to inform health care decisions.

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Ethical Considerations

There have been a few criticisms on ethical grounds of CEA’s use for decision making. These include (1) controversies associated with the use of QALYs, (2) distributive justice, and (3) incomplete valuation. We discuss each of them in detail here. However, it is worth pointing out that cost-effectiveness evidence is only one of many factors considered in resource allocation decisions. We have found that none of the international HTA bodies bases its decisions solely on cost-effectiveness evidence. Therefore, much of CEA’s criticisms, fair or not, can be addressed through deliberative processes.

QALYs. The lower health utility, or health-related quality of life, assigned to patients with worse health (because of more severe disease, disability, age, and so on) raises distributional issues in using QALYs for resource allocation decisions. For example, because patients with disabilities have a lower overall health utility weight, any extension of their lives by reducing the health burden from one disease “would not generate as many QALYs as a similar extension of life for otherwise healthy people.” This distributional limitation arises because of the multiplicative nature of QALYs, which are a product of life-years and health utility weight. Consequently, the National Council on Disability has strongly denounced the use of QALYs.

Alternatives to QALYs have been proposed. The Institute for Clinical and Economic Review has started using the equal value of life-years gained metric, a modified version of the equal value of life (EVL) metric, to supplement QALYs. In EVL calculations, any life-year gained is valued at a weight of 1 QALY, irrespective of individuals’ health status during the extra year. EVL, however, “has had limited traction among academics and decision-making bodies” because it undervalues interventions that extend life-years by the same amount as other interventions but that substantially improve quality of life. More recently, a health-years-in-total metric was proposed to overcome the limitations of both QALYs and EVL, but more work is needed to fully understand its theoretical foundations.

The info is here.

Health Care in the U.S. Compared to Other High-Income Countries: Worst Outcomes

The Commonwealth Fund

Mirror, Mirror 2021: Reflecting Poorly

Originally posted 4 Aug 21

Introduction

No two nations are alike when it comes to health care. Over time, each country has settled on a unique mix of policies, service delivery systems, and financing models that work within its resource constraints. Even among high-income nations that have the option to spend more on health care, approaches often vary substantially. These choices affect health system performance in terms of access to care, patients’ experiences with health care, and people’s health outcomes. In this report, we compare the health systems of 11 high-income countries as a means to generate insights about the policies and practices that are associated with superior performance.

With the COVID-19 pandemic imposing an unprecedented stress test on the health care and public health systems of all nations, such a comparison is especially germane. Success in controlling and preventing infection and disease has varied greatly. The same is true of countries’ ability to address the challenges that the pandemic has presented to the workforce, operations, and financial stability of the organizations delivering care. And while the comparisons we draw are based on data collected prior to the pandemic or during the earliest months of the crisis, the prepandemic strengths and weaknesses of each country’s preexisting arrangements for health care and public health have undoubtedly been shaping its experience throughout the crisis.

For our assessment of health care system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States, we used indicators available across five domains:

• Access to care
• Care process
• Administrative efficiency
• Equity
• Health care outcomes

For more information on these performance domains and their component measures, see How We Measured Performance. Most of the data were drawn from surveys examining how members of the public and primary care physicians experience health care in their respective countries. These Commonwealth Fund surveys were conducted by SSRS in collaboration with partner organizations in the 10 other countries. Additional data were drawn from the Organisation for Economic Co-operation and Development (OECD) and the World Health Organization (WHO).

The info is here.

Diagnostic Mistakes a Big Contributor to Malpractice Suits, Study Finds

Joyce Friedan

MedPageToday.com

Originally posted 26 May 21

Here are two excerpts

One problem is that "healthcare is inherently risky," she continued. For example, "there's ever-changing industry knowledge, growing bodies of clinical options, new diseases, and new technology. There are variable work demands -- boy, didn't we experience that this past year! -- and production pressure has long been a struggle and a challenge for our providers and their teams." Not to mention variable individual competency, an aging population, complex health issues, and evolving workforces.

(cut)

Cognitive biases can also trigger diagnostic errors, Siegal said. "Anchor bias" occurs when "a provider anchors on a diagnosis, early on, and then through the course of the journey looks for things to confirm that diagnosis. Once they've confirmed it enough that 'search satisfaction' is met, that leads to premature closure" of the patient's case. But that causes a problem because "it means that there's a failure to continue exploring other options. What else could it be? It's a failure to establish, perhaps, every differential diagnosis."

To avoid this problem, providers "always want to think about, 'Am I anchoring too soon? Am I looking to confirm, rather than challenge, my diagnosis?'" she said. According to the study, 25% of cases didn't have evidence of a differential diagnosis, and 36% fell into the category of "confirmation bias" -- "I was looking for things to confirm what I knew, but there were relevant signs and symptoms or positive tests that were still present that didn't quite fit the picture, but it was close. So they were somehow discounted, and the premature closure took over and a diagnosis was made," she said.

She suggested that clinicians take a "diagnostic timeout" -- similar to a surgical timeout -- when they're arriving at a diagnosis. "What else could this be? Have I truly explored all the other possibilities that seem relevant in this scenario and, more importantly, what doesn't fit? Be sure to dis-confirm as well."

The info is here.

Record-High 47% in U.S. Think Abortion Is Morally Acceptable

Megan Brenan

Gallup.com

Originally posted 9 June 21

Americans are sharply divided in their abortion views, including on its morality, with an equal split between those who believe it is morally acceptable and those who say it is morally wrong. The 47% who say it is acceptable is, by two percentage points, the highest Gallup has recorded in two decades of measurement. Just one point separates them from the 46% who think abortion is wrong from a moral perspective.

Since 2001, the gap between these readings has varied from zero to 20 points. The latest gap, based on a May 3-18 Gallup poll, is slightly smaller than last year's, when 47% thought abortion was morally wrong and 44% said it was morally acceptable. Americans have been typically more inclined to say abortion is morally wrong than morally acceptable, though the gap has narrowed in recent years. The average gap has been five points since 2013 (43% morally acceptable and 48% morally wrong), compared with 11 points between 2001 and 2012 (39% and 50%, respectively).

Democrats and political independents have become more likely to say abortion is morally acceptable. Sixty-four percent of Democrats, 51% of independents and 26% of Republicans currently hold this view.

The info is here.

Memorial Sloan Kettering Gave Top Doctor $1.5 Million After He Was Forced to Resign Over Conflicts of Interest

Katie Thomas & Charles Ornstein

ProPublica

Originally published 22 Dec 20

Here is an excerpt:

After months of review, Memorial Sloan Kettering overhauled its conflict-of-interest policy, barring its top executives from serving on corporate boards of drug and health care companies and placing limits on how executives and top researchers could profit from work developed at the institution.

Like other major hospitals, Memorial Sloan Kettering’s finances have taken a hit during the coronavirus pandemic. For the first three quarters of 2020, the hospital reported an operating loss of $453 million compared with an operating profit of nearly $77 million in the first nine months of 2019. The hospital saw a decline in surgical procedures and clinic visits, as well as clinical trials and other research. The hospital did receive $100 million in relief funds as part of the Coronavirus Aid, Relief and Economic Security (CARES) Act.

Baselga wasn’t the only former official to receive severance from Memorial Sloan Kettering in 2019. It also paid more than $250,000 in severance to Avice Meehan, the hospital’s former chief communications officer, according to its IRS filing. Meehan declined to comment.

Laurie Styron, the executive director of CharityWatch, an independent watchdog group, said that hospitals often compensate their staff generously because they must attract highly trained and educated doctors who would be well-paid elsewhere. Still, she said, the multimillion-dollar sums can surprise donors, who typically give money to support research or patient care.

The info is here.

How Might Artificial Intelligence Applications Impact Risk Management?

John Banja

AMA J Ethics. 2020;22(11):E945-951. 

doi: 10.1001/amajethics.2020.945.

Abstract

Artificial intelligence (AI) applications have attracted considerable ethical attention for good reasons. Although AI models might advance human welfare in unprecedented ways, progress will not occur without substantial risks. This article considers 3 such risks: system malfunctions, privacy protections, and consent to data repurposing. To meet these challenges, traditional risk managers will likely need to collaborate intensively with computer scientists, bioinformaticists, information technologists, and data privacy and security experts. This essay will speculate on the degree to which these AI risks might be embraced or dismissed by risk management. In any event, it seems that integration of AI models into health care operations will almost certainly introduce, if not new forms of risk, then a dramatically heightened magnitude of risk that will have to be managed.

AI Risks in Health Care

Artificial intelligence (AI) applications in health care have attracted enormous attention as well as immense public and private sector investment in the last few years.1 The anticipation is that AI technologies will dramatically alter—perhaps overhaul—health care practices and delivery. At the very least, hospitals and clinics will likely begin importing numerous AI models, especially “deep learning” varieties that draw on aggregate data, over the next decade.

A great deal of the ethics literature on AI has recently focused on the accuracy and fairness of algorithms, worries over privacy and confidentiality, “black box” decisional unexplainability, concerns over “big data” on which deep learning AI models depend, AI literacy, and the like. Although some of these risks, such as security breaches of medical records, have been around for some time, their materialization in AI applications will likely present large-scale privacy and confidentiality risks. AI models have already posed enormous challenges to hospitals and facilities by way of cyberattacks on protected health information, and they will introduce new ethical obligations for providers who might wish to share patient data or sell it to others. Because AI models are themselves dependent on hardware, software, algorithmic development and accuracy, implementation, data sharing and storage, continuous upgrading, and the like, risk management will find itself confronted with a new panoply of liability risks. On the one hand, risk management can choose to address these new risks by developing mitigation strategies. On the other hand, because these AI risks present a novel landscape of risk that might be quite unfamiliar, risk management might choose to leave certain of those challenges to others. This essay will discuss this “approach-avoidance” possibility in connection with 3 categories of risk—system malfunctions, privacy breaches, and consent to data repurposing—and conclude with some speculations on how those decisions might play out.

Beyond burnout: For health care workers, this surge of Covid-19 is bringing burnover

Wendy Dean & Simon G. Talbot

statnews.com

Originally posted 25 Nov 20

Covid-19 is roaring back for a third wave. The first two substantially increased feelings of moral injury and burnout among health care workers. This one is bringing burnover.

Health care systems are scrambling anew. The crises of ICU beds at capacity, shortages of personal protective equipment, emergency rooms turning away ambulances, and staff shortages are happening this time not in isolated hot spots but in almost every state. Clinicians again face work that is risky, heart-rending, physically exhausting, and demoralizing, all the elements of burnout. They have seen this before and are intensely frustrated it is happening again.

Too many of them are leaving health care long before retirement. The disconnect between what health care workers know and how the public is behaving, driven by relentless disinformation, is unbearable. Paraphrasing a colleague, “How can they call us essential and then treat us like we are disposable?”

It is time for leaders of hospitals and health care systems to add another, deeper layer of support for their staff by speaking out publicly and collectively in defense of science, safety, and public health, even if it risks estranging patients and politicians.

Long before the pandemic emerged, the relationships between health care organizations and their staffs were already strained by years of cost-cutting that trimmed staffing levels, supplies, and space to the bone. Driven by changes in health care reimbursement structures, systems were “optimized” to the point that they were continually running at what felt like full capacity, with precious little slack to accommodate minor surges, much less one the magnitude of a global pandemic.

The info is here.