1. Reforming healthcare: an ethical perspective

2. Health care schizophrenia I don’t care how much it costs, I want the best care available. It costs what? That’s outrageous! Everyone in America should have appropriate access to health care. I am not willing to pay any more taxes, and I don’t want socialized medicine. Government should fix it. Let the market fix it.

3. Here is the real bottom line: The current state of health care is unethical. It is neither just nor fair. There is no morally defensible reason why some Americans get excellent medical care at costs they can afford and other Americans lose their homes or go into bankruptcy attempting to secure treatment for a seriously ill loved one. The current proposals being debated in Congress all go a long way towards making health care in America more just. At the same time, there is nothing in the current proposals that threatens a patient’s right to choose, a critical feature of an ethically acceptable health care system. - Ruth Faden

4. ethics of health reform "This historic legislation, for the first time, enshrines a national commitment to guarantee that all of us in this country have meaningful access to appropriate medical care. As a consequence, our society is now more just. Our people have a greater prospect of securing for themselves and their families not only more health, but also more of everything that is essential to human well-being, including personal security, respect and self determination.“ - Ruth Faden

5. ethics of health reform “examination of the issues in healthcare reform would require consideration of much different arguments than already presented. ethical issues would center on the moral right discussion and would begin with not “what is best for me” but rather “how should we as a society be acting so that our actions are morally correct” - Beverly O’Malley

6. ethics of health reform What neither side will admit is that medical rationing is part of the future. We can't afford a system where everybody gets whatever care they want regardless of cost and effectiveness. The only question is whether we'll ration intelligently and fairly, or not. - Beverly O’Malley

7. ethics of health reform However, all ethical decision making is structured around values. In order for universal health care to be embraced by all citizens in the United States, they will first have to agree to the collective value of equity and fairness and embrace the goal of meeting their collective responsibility to each other while maintaining individual rights and freedoms. That may prove to be the most difficult obstacle of all. - Beverly O’Malley

8. ethics of health reform When a third party— government, insurer or employer—controls most of the health care funds, that entity eventually becomes the decision maker, not the patient. An ethical health care system doesn’t just promise people they will get the care they need, it empowers people so they can get that care. - Merrill Matthews. PhD Institute for Policy Innovation

9. ethics of health reform What action will bring the most good to the most people? What action in and of itself is a good act and helps us to fulfill our duties, obligations, and responsibilities to each other? What action in and of itself shows caring and concern for all citizens?

10. reform in america

11. employer-sponsored health care 1940s1940s

12. government-sponsored health care To provide coverage for the elderly as well as poor women and children, Congress enacted Medicare & Medicaid in the mid- 1960s. 1960s1960s

13. The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 requires hospitals to screen and stabilize (treat) every patient who comes to the hospital ED seeking care, regardless of the patient’s ability to pay and regardless of what it costs the hospital to provide the care. 1980s1980s health care for all…through an unfunded mandate

15. the affordable care act 20102010

16. 3 key myths about health reform  health reform means giving up control of my own healthcare decisions  health reform will control healthcare costs by depriving patients of important but costly medical treatments  health reform will deny older Americans medical treatment at end of life

17. strategic directions coverage delivery system reforms payment reforms transparency health IT

18. Improve the safety and reliability of America’s health care system Engage patients and families in managing health and making decisions about care Ensure patients receive well-coordinated care across all providers, settings, and levels of care Guarantee appropriate and compassionate care for patients with life-limiting illnesses Improve the health of the population Eliminate waste while ensuring the delivery of appropriate care National Priorities Partnership: Overarching Objectives

19. implications for hospitals achieve solid hospital-physician (clinical) alignment measure, report and deliver superior outcomes reduce costs form strategic alliances

20. implications for physicians apply evidence-based practices to achieve best clinical results deliver the right care…at the least cost coordinate your patients’ care with other providers learn to manage risk in partnership with hospital and physician colleagues

21. Percent Seeing 10 or More Different Physicians during the Last Six Months of Life

22. Percent of Deaths Occurring In Hospital

23. Percent of Cancer Patients Dying in Hospital

24. Percent of Decedents Enrolled In Hospice during the Last Six Months of Life

25. Guiding Ethical Principles  Beneficence- obligation to benefit patient and to further their welfare and interests  Respect for autonomy- protect and defend the informed choices of capable patients  Nonmaleficence- obligation to prevent or minimize risk of harm  Justice- fairness of access to health care

26. Ethical Obligations of Clinicians  Respect patient’s rights/autonomy and maintain confidentiality  Communicate honestly about patient’s diagnosis, treatment and prognosis  Determine patient’s decision making capacity  Actively participate in informed consent process

27. 27 Patient-Centered Care Continuum

28. 28 Conceptual Shift from “Curative Model” Medicare Hospice Benefit Life Prolonging Care Old Palliative Care Bereavement Hospice Care Life Prolonging Care New DiagnosisDeath

29. Palliative Care Teams Address 3 Domains  Physical, emotional, and spiritual distress  Patient-family-professional communication and decision-making  Coordinated, communicated, continuity of care and support for practical needs of both patients and families across settings

30. 30 ‘Mainstreaming’ Palliative Care  Providing palliative care simultaneously with all other appropriate medical treatment  Actively integrating palliative care into care transition programs  Expanding palliative care services and resources across entire care continuum  Demonstrating positive impact of palliative care from a “triple aim” perspective

31. How Advance Directives and POLST Work Together Adapted with permission from California POLST Education Program © January 2010 Coalition for Compassionate Care of California

32. POLST: An outcomes continuum Better informed consent + Patient’s documented wishes + Family consensus Patients’ wishes known & honored = + Portable MD orders = Satisfaction & communication Risk & Costs = = Hospice LOS = Hospital LOS = Pain management = Hospice & Palliative Care Utilization

33. 33 SC Triple Aim Platform

34. Keys to a Healthy South Carolina 1.Health care must become highly reliable. 2.Patients must be more engaged. 3.We must deliver compassionate and patient-centered care at the end of life. 4.We must improve health status and reduce health disparities. 5.We must improve efficiency and reduce waste. 6.We must improve coordination of care. 7.Payment models must be reformed and aligned.

35. SC Coalition for the Care of the Seriously Ill ( SC CSI) Founding Members: SCMA, SCHA, TCC, SC Healthcare Ethics Network, LifePoint, AARP, SC Nurses Association Mission: All persons in SC with serious, chronic, or terminal illnesses will have an active voice in the care decision process