Click here for a full text transcript of the conversation.

Host Ira Flatow said in his introduction:

“Lost in the fray [of acronyms and actuarial tables] is the whole reason to have the health care debate in the first place…we’re going to try to reel it back in to talk about our values. What role do they play in shaping health care policy?”

Flatow noted that in its recent collection of essays, Connecting American Values with Health Reform, “The Hastings Center has tried to bring values back into the discussion.”

Len Nichols, health policy director at the New America Foundation, also participated in the show. Nichols, a health economist who wrote an essay on stewardship for the Hastings Center collection, said that passage of the final health care reform legislation is contingent on leadership that promotes shared values. “It is sometimes true is that those values seem to differ among political antagonists….but when you probe deeply and get in a dialogue you find out the values are actually shared,” Nichols said. “I believe most people share them and therefore we will end up with a bill that moves our country forward.”

But let’s look at the numbers.  According to recent data from the American Medical Association, there are 921,904 physicians in the United States.  According to recent data from the Bureau of Labor Statistics, there are 2,505,000 registered nurses.

These millions of nurses have opinions on health reform. As a profession, they’re for it. Strongly for it.  The American Nurses Association takes the position that health care is a human right, and that the failure of a society to provide basic care to its citizens also fails nurses in their professional role. The ANA argues that a public option is the option that is most likely to support the professional integrity of nurses, as shifting the system’s focus toward access to prevention, chronic disease management, and primary care will do a better job of deploying one of the system’s limited resources: nurses themselves.

There is evidence that the current health care system’s well-documented incentives, rewarding quantity rather than quality, are particularly hard on nurses, who are responsible for hands-on care and so spend significant time with patients and families. Research on the problem of moral distress in health care – those situations in which a health care professional perceives that structural conditions are preventing the professional from acting in patients’ best interests or are forcing the professional to act against patients’ interests – suggests a connection between nurses’ professional integrity and how nurses are deployed.  According to one recent study comparing physicians’ and nurses’ perspectives on the care of dying patients in the ICU, 45% of nurses surveyed told investigators that they had quit, or considered quitting, a job due to moral distress.

There is a chronic shortage of nurses in the US.  If the current health care system’s incentives and the outcomes it produces are putting such pressure on nurses’ professional integrity that nurses consider leaving jobs – or the profession itself – a system oriented toward those interventions that require the highest nurse-to-patient ratios will not be sustainable on the basis of workforce as well as cost.

Nancy Berlinger is Deputy Director and a Research Scholar at The Hastings Center and teaches health care ethics in the Nursing Management, Policy, and Leadership graduate program at Yale School of Nursing.

It is a business truism that if you can’t measure it, you can’t manage it.  Our healthcare system is incredibly adept at measuring revenue, procedures performed, and patients moved out the door.  In our current system, physicians and facilities get tangible rewards for managing these measures efficiently.  However, research such as the Dartmouth Atlas illustrates that more of these things—payments, procedures, and patient throughput—aren’t yielding better health outcomes.

We need to focus on measuring quality and holding providers accountable for it.  We need to redefine efficiency as using our resources to get the best health outcomes.

As the largest payer in healthcare, the Centers for Medicare and Medicaid Services (CMS) has made substantial progress toward building accountability into the system.  Nearly all hospitals that provide services to Medicare patients report on quality measures such as steps to avoid infection, mortality rates for certain surgeries, and quality of patient experience.   However, there is still a long way to go towards accountability throughout healthcare. When CMS gave physicians an opportunity to report their use of good practices in caring for Medicare patients and offered a financial incentive for that reporting, the initial response rate was below twenty percent.  That level of accountability is not enough.

Health care reform must support the efforts underway at CMS and among private payers to measure the use of good practices, the rates of positive health outcomes such as diabetes or blood pressure under control, and the level of patient satisfaction with communication and controlling pain.  We must achieve a high level of measurement so that physicians and providers can manage their quality and be held accountable for it.  Only then can we get to the point where doing health care well is as rewarding as simply doing a lot of it.

These are some of the American Values highlighted in the Hastings Center’s report on “Connecting American Values with Health Reform.”

Watching health reform unfold here in Washington, however, that “Connection” is painfully elusive.  The debate is not a careful calibration of competing rights, values and obligations. It’s a political moshpit. Instead of values, we have vitriol.

Outside of Washington, even extremely astute people ask me why we can’t fix a health care system that is inefficient, inequitable and  downright inexplicable.

I patiently explain that this fight is not purely about policy (or values). Health policy becomes a gritty proxy for politics.

Values,  or at least ideology – particularly about the size and reach of government – play a role in politics. But an awful lot of what passes for policy debate is trench warfare before the next election.  Look at the list of amendments proposed for any of the major bills – and ask yourself how many are meant to improve the health and well-being of the American people and the American economy, and how many are meant to score points, woo donors, placate interest groups and create a C-Span moment.(Both parties do this, particularly while in the minority; theatrics is the next best thing to votes.)

Still, for those who believe (as President Obama tells us)  in a moral imperative to cover the uninsured and create an economically sustainable health system, it is  tempting to indulge in a little values-imbued wishful thinking.

What would the health reform debate look like if, as Thomas Murray wrote in the introduction to the Hastings essays, values were the “beating heart of health reform?”  What if the health care debate truly was aimed at realizing our national vision of “liberty and justice for all”? What would it look like if we dropped that vitriol, and returned to values? If, as Dr. Murray wrote, we centered on this simple core idea:

Everyone should be responsible for participating in whatever way is appropriate. When anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them.

To have such a conversation, the first requirement would be honesty. I’m not sure if it’s Jeffersonian, Hamiltonian or Jacksonian but I certainly like to think of honesty as an American value.

If we were honest, we’d still have genuine and perhaps unbridgeable differences about the public plan, or the level of subsidies or the practicality of certain models of care.

But we wouldn’t be screaming about death panels, abortion mandates, illegal immigrants, taxpayer funded sex change operations and a government takeover of health care.

If we were honest, we would reach beyond bipartisan platitudes about a broken system and acknowledge that there is no such thing as the status quo in health care. Our system gets a bit more broken each day, and all sectors of society bear the cost in incalculable (and inequitable)  ways..

If we were honest, we would stop talking about “consumer” and “providers”  buying and selling goods and services in a rational market. We’d talk about patients and families and doctors and nurses, and understand that health care is not a “commodity” in the usual sense of the word.

Above all, we’d stop talking about how health reform is going to bring a scary heartless bureaucratically-induced rationing – and recognize that we are already rationing. Only we ration irrationally, in unkind, unfair and unscientific  ways. Our surest path to deeper and coarser rationing – the Medicare equivalent of slash and burn – is to do nothing.

That brings me to two of the final “Connecting Values” essays – Quality and Efficiency.  Both are concrete and pragmatic, less abstract than liberty or justice. But in health reform, they may be our salvation. We don’t, after all, have a Congressional Justice and Fairness Office “scoring” health legislation. We have a Congressional Budget Office – and budgets  may reflect our national values and priorites more than our shouted political discourse.

So rather than having two stark choices (taxing more or cutting benefits – aka rationing) we have a third path, that budgetary nirvana of delivery system reform, realigned payment incentives and comparative effectiveness research. New ways of delivering care, including a renewed emphasis on treating the frail and the chronically ill in the community instead of in the ER and ICU. New models of shared-decision making, and more and better palliative care, both of which may change how patients and families weigh when to reach for  the brass rings of modern medical technology, when to give chicken soup and Tylenol a try, when the time has come to seek a gentle end.

Maybe in 10 or 15 years from now, we’ll be back to shouting. Maybe these new models – accountable care organizations and multi-specialty physician group practices and advanced medical homes and  concurrent care – will  turn out to be one more set of next best things that weren’t so good after all. Maybe we are fooling ourselves when we listen to the quality and efficiency gurus who say we can have higher quality for lower cost. But I don’t think so. I’ve spend enough time talking to patients and clinicians at the forefront of change – from Annapolis to Akron to Anchorage — to believe that there is a better way. A way that will bring us quality and efficiency as well as justice and responsibility and compassion. If we can stop shouting long enough to get there.

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

Some major fault lines in the current health reform debate arise out of conflicting notions about the definition and goals of efficiency. There is, however, a simple and intuitively appealing concept of efficiency that I believe should be a central virtue of any health reform effort: To be efficient means to use our resources in the best possible way to achieve our ends. This makes “efficiency” an instrumental ideal—a goal whose meaning depends on whatever substantive ends we embrace.

Economics offers some distinctions that can help us think about our choices. Consider the distinction economists draw between “static”and “dynamic” efficiency. Static efficiency is a short-run, “at any given moment in time” formulation; it requires that a society operates within a given production process as defined by the available technology and organizational systems. Achieving static efficiency requires production or technical efficiency (ensuring that goods or services are produced at minimum cost) and allocative efficiency (ensuring that the right set of goods are produced and distributed to the right individuals). Dynamic efficiency looks at the long term, but it is not quite so well-defined. It refers to the rate at which our capacity to produce outputs improves over time. Dynamic efficiency requires being efficient in our use of research and development resources in producing new products and processes.

Defining either static or dynamic efficiency requires us to further specify our aims. We do need minimum cost production regardless of our goals. However, as discussed below, we can only decide what to produce (how to be allocatively efficient) once we specify our goals. Dynamic efficiency requires a trade-off, too, since the more we spend on research today, the less we have to consume today—even if we are better off tomorrow. Moreover, our goals should determine what new products and processes we should try to develop, as well as how to trade current consumption against future gains. When it comes to health policy, two of the most widely used formulations of “efficiency” incorporate very strong assumptions about those goals.

Two Perspectives on Health System Efficiency

Public health practitioners often define the goal of efficiency in terms of maximizing the overall or average health of a target population. As attested to by Web sites full of statistics about overall life expectancy, infant mortality, and so on, much discussion and analysis takes this form. More complicated versions of this approach require us to develop some complex index—like “Quality Adjusted Life Years”—that combines the morbidity and mortality consequences of various diseases. There are enormous ethical and practical problems in such a task, since many important value judgments are subsumed in the process of index construction. For example, how do we value pain relief versus saving lives, or mental health versus physical health? How do we value saving the young versus the old, or the productive versus the disabled?
This view of efficiency is oriented toward need—toward what experts believe will produce the “biggest bang for the buck” in order to make everyone healthy. Historically, the roots of this view—now often called cost-effectiveness analysis—are in engineering and in the use of quantitative techniques to improve military operations during and after World War II (what came to be called “operations research” and “systems analysis”). In those cases, the goal to be achieved was specified in concrete terms like “enemy planes shot down.”

The “health/needs” camp includes advocates of “effectiveness research,” who push for increased use of clinical protocols and drug formularies and who want to eliminate what they see as inappropriate (and wasteful) variations in patterns of care across the country. They believe we could get more with less if only care was delivered rationally.

By contrast, health care economists typically define “efficiency” in terms of satisfying individuals’ desires to the maximum extent possible. (This implicitly assumes that the existing distribution of income is either acceptable or will be “fixed” by someone else). They seek Pareto optimality – a state in which no one person can be made better off without someone else being made worse off. Thus being “better off ” is defined in terms of each person’s own subjective level of well-being.

This approach focuses on demand: giving people what they want in order to make them happy. It is embodied in cost-benefit analysis, which was developed after World War II when Congress ordered the Army Corps of Engineers to limit itself to projects for which the “benefits exceed the costs.” From the beginning, the task was to value a diverse set of gains and costs in comparable ways. Not surprisingly, these came to be expressed in monetary terms, based on the value that beneficiaries placed on various outcomes.

Those who advocate for consumer-driven health care, higher copayments and deductibles, and the substitution of savings accounts for insurance are in the “happiness/demands” camp. They believe that we can control costs only if consumers compare the benefit of more costly and elaborate care with their potential gains in happiness from, say, more costly and elaborate cars, and choose accordingly.

In terms of static efficiency, both the health/needs and the happiness/demands groups favor improved technical or production efficiency. Both also want to be “allocatively” efficient, but they have different views on what this implies because of their different goals. This is demonstrated in their conflicting attitudes toward fostering generic drugs: the “health” camp most wants cost-reducing changes in practice, while the “happiness” camp is content with innovation that increases cost as well as performance, provided the gains are something people will pay for.

Policy Implications

In my view, efficiency in terms of health outcomes has to be a major concern in U.S. health reform. We have the highest health care costs in the world among industrial countries (between 50 percent and 100 percent higher than most) and similar—or worse—health outcomes. With roughly 40 percent of all our costs going into nonclinical activities (administration, sales, paper processing, and profits) we clearly could use a major improvement in technical efficiency. And since there is also much evidence that we overuse scarce resources resources in nonproductive ways, we have major problems with allocative efficiency as well.

Ironically, both the health care economics and public health approaches to efficiency tend to ignore the distribution of gains. Equity, as they consider it, is a value that conflicts with efficiency. But this is an illegitimate and rhetorical sleight-of-hand that seeks to capture the social legitimacy of “efficiency” for those not concerned with distribution. A society could surely decide that helping those who get less care, suffer more, and die younger is especially important, and then ask, “Are we efficiently meeting our goals of making the worst off better off?” Indeed, advocates of greater justice within the American health care system would be wise to focus on what I propose to call distributive efficiency, since funding for improving equity will always be limited. We must make sure, for example, that “safety net” hospitals that disproportionately serve the poor are every bit as technically efficient as other hospitals—which, alas, has not always been the case.

Finally, the biggest health policy challenge facing most industrial countries at this moment is enhancing dynamic efficiency—finding new ways to treat patients that reduce the costs of care. Aging societies, with increasing chronic disease, will face significant cost pressures for many years to come. And the citizens of increasingly wealthy and secular societies are also likely to want more costly health care over time.

The only way the impending avalanche of health care costs can be reduced is if we focus our health care research on innovations that decrease costs rather than on innovations that drive them up. To do that, we need to create a market for cost-reducing innovations. And to do that, we need to move from fee-for-service payment (which often encourages the overuse of expensive new drugs and procedures) to bundled payments for episodes of illness or capitated payments that cover all of a given person’s costs for the year. Only then will hospitals and doctors find that efficiency—which research shows, ironically, also often produces better clinical outcomes—is in their interest. And only then will our entrepreneurs and scientists have an incentive to develop those cost-reducing innovations, thereby really increasing our efficiency where it counts.

Marc J. Roberts, PhD, is professor of political economy and health policy at the Harvard School of Public Health, where he has taught a course on the ethics of public health policy for more than fifteen years.

This is the introductory essay in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

The atmosphere was tense. Representatives of the insurance industry were huddled in one corner.  The other members of the Task Force on Genetic Information and Insurance, mostly academics and consumer representatives, were bunched across the room. As chair of the task force, I was in the middle, trying to make sense of the disagreement, which was growing more intense by the minute.

Our mandate was to provide recommendations about what health insurers should and should not do with genetic information. This was the early 1990s; there wasn’t much information available about an individual’s genes, but the avalanche of genetic information was gathering strength. The first few pebbles had arrived recently, and ever larger ones, such as the tests for genes linked to breast and ovarian cancer, would appear soon. We had time—not a lot, but some—to plan for how private health insurers would deal with information about our genetic risks for diseases, from the rare and inexorable progression of Huntington’s disease to far more common ones such as Parkinson’s, diabetes, and heart disease. Health insurers were accustomed to shaping policies according to the risks people presented. If someone with cancer was like a house afire, someone with a genetic risk of cancer was a house with a smoldering pile of rags in the corner.

The standoff in that room, though, was puzzling. We asked the insurers if they believed that everyone should have access to insurance whatever their risks: Yes, they agreed, everyone should have access to insurance. So, they were in favor of universal access, right? No, they adamantly insisted, universal access would be the death of the  industry. Finally, we understood what frightened them: to insurers, universal access meant that people could sail along without any insurance coverage until the day they became ill, when they could march into the insurer’s offices and demand to be covered.

That’s not what we had in mind, we explained. Everyone should have to pay their fair share and, when they needed care, their health insurance would be there to cover the cost. We described it as universal participation.  Fine, said the insurers, we can agree with that.

Among the lessons I learned from chairing the task force (including: Don’t fly from England to San Francisco and expect to control a contentious meeting), one stands out for this collection of provocative essays: understanding what’s at stake in a public policy debate is as vital as it can be elusive.

Connecting American Values with Health Reform is our effort to identify what is at stake amidst the swirling confusion of proposals for delivery systems, financing, cost control, and other details necessary for any practical reform. These details, though, are instruments carrying with them the impedimenta of history, habit, and interests.  To see things afresh, it helps to return to foundational questions: What do we want health reform to accomplish? What values should our institutions and practices be built upon, embody, and achieve?

The language of values has another virtue: Unlike health policy mavens, most Americans are baffled by the alphabet soup of program acronyms, economic models, and the difference between cost-benefit and cost-effectiveness analyses. Heck, most of us can’t explain the difference between Medicare and Medicaid. But we all understand what values are, and we can defend our preferences among them. Which leads to another reason The Hastings Center undertook this project.

Values can be wielded like cudgels to batter your opponents. That, unfortunately, has been all too common in recent political discourse. But values worth taking seriously — including all the values addressed in this collection of essays – are far more subtle, multifaceted, and interesting ideas that can cross political boundaries. Liberty, Bruce Jennings reminds us in an echo of Isaiah Berlin’s classic formulation, includes both freedom from and freedom to — and each of those meanings of liberty deserves attention in health reform. Liberty can mean the freedom from the imposition of a particular health plan and physicians; but it also demands a health care system that does not deny a would-be entrepreneur the freedom to pursue her vision, a freedom not available to the parent of a child with diabetes, for whom health insurance would be unaffordable outside the protective umbrella of a large group policy.

We chose the authors of these essays to represent a broad spectrum of beliefs. We assigned each of them a particular value to address, but we did not tell them what to say about it, other than to display the complexity residing within each value and spell out the policy implications of taking that value seriously for American health reform.

In reading these essays, I found moments of great illumination and insight along with occasional areas of disagreement; familiar ideas displayed in new and revealing aspects; new arguments, distinctions, and concepts. I was provoked, enlightened, and occasionally surprised. I hope that other readers will have a similar experience.

Most of all, I came away convinced that values are the beating heart of health reform, that these authors have begun a marvelous conversation about those values, and that the implications for American health reform are concrete and vitally important. A handful of ideas stand out.

First, simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice.  Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform.

Second, when we acknowledge, as we must, that our goal is health, we are obliged to think much more broadly than our patchwork system of health care. Healthy children, healthy adults, and healthy communities are the outcome of many factors—from decent housing and safe areas for play and exercise to good jobs and schools.  Health care, crucial for episodes of acute illness and for the care of chronic diseases, is a significant but not dominant determinant of a community’s health. As responsible stewards of community resources, we should invest our finite public funds according to where they will do the most good. At times the best investment for health may be in education, job creation, or environmental protections, not in health care.

Third, the practice of individual underwriting in health insurance—making it harder to get the sicker you are — should be given a prompt funeral and buried with a stake through its heart. A concept such as actuarial fairness — which makes good moral sense in commercial insurance where risks are voluntary and the losses measured in money — has no place in deciding who gets access to the health care they need.

Fourth, efficiency and communal responsibility are essential if we are to have an affordable, effective, and sustainable health care system. This will require, at a minimum, systematically studying and improving the quality
and effectiveness of what we do in the name of health care. It will also require restructuring incentives so that providers are rewarded for results rather than for the numbers of procedures or tests they perform. There is good evidence that such changes would also lead to a higher quality of care.

Finally, the concept the task force developed more than fifteen years ago—universal participation—may be one whose time has finally come. The core idea is simple enough: everyone should be responsible for participating in whatever way is appropriate; when anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them. I was delighted to find the concept, if not the term, endorsed so often in these essays.

Whatever combination of private and public programs we choose, it’s a good time to connect American values with American health reform.

Thomas H. Murray is the President of the Hastings Center.