Healthcare is a Human Right - For Everyone

I had an opportunity to meet with Sigrid Becker-Wirth of MediNetz-Bonn.  She is a remarkable woman.  Sigrid had worked as a high school teacher in Bonn, but had to leave her job because of complications from Multiple Sclerosis.  She had already been inspired by the life of Archbishop Oscar Romero of El Salvador, who was murdered in part due to his concern for the poor and the outcasts, and she came to view the undocumented in Germany as kindred souls with those who suffered in Central America.  She felt she was being called to act on their behalf.

                                                    Sigrid Becker-Wirth with the author

Her answer was to co-found MediNetz-Bonn, joining a network of MediNetz organizations located throughout Germany that help the serve undocumented.  MediNetz-Bonn is located in a building appropriately called Oscar Romero Haus.  Every Monday people come to her office for assistance. They are of many different ethnicities but all share the status of being illegalized, as Sigrid put it.

MediNetz-Bonn cannot help the patients directly.  Instead, Sigrid built relationships with people who, like her, believe that healthcare is a human right. She then got to work on finding physicians who would treat the undocumented for a very low price whenever MediNetz-Bonn refers a patient to them. Eventually Sigrid got 80 doctors in and around Bonn to participate.

Of course, as is the case with Casa de Salud, many times a single doctor in his/her exam room cannot resolve a patient's situation. So Sigrid went back to work and eventually got five hospitals to accept MediNetz-Bonn patients. The hospitals receive payment from the patient on what amounts to a sliding scale.  Just as important, they agree to ignore the "duty to denounce," which typically would require hospital personnel other than doctors do inform the authorities when they encounter someone who is not in the country legally.

MediNetz-Bonn has been a boon to the approximately 4,000 undocumented people in the Bonn area. Information about medical services is available in multiple languages.  When a person needs a referral, they speak with a MediNetz-Bonn volunteer who fills out a referral form.  The patient uses this as their "ticket" for an appointment with the appropriate doctor.  And should a patient need a service for which a hospital cannot afford to deeply discount (cancer treatment, for example), MediNetz-Bonn draws from its fundraising done exclusively to help defray such costs.

This is wonderful work, and thanks to my experience at Casa I'm in a position to particularly appreciate what Sigrid has achieved.  Still, her efforts - like those at Casa - have the unfortunate side effect of relieving politicians from finding long term solutions to these problems.  As Heide Castañeda (an anthropologist who has done extensive work in Germany) writes, "[These organizations] effectively remove responsibility of the state to address poverty and the needs of marginal communities by de-politicizing the issues, relying on low-cost local labor, and...often fail to address the reasons why those services are needed in the first place."

Sigrid is clearly aware of this, which is why she simultaneously works with politicians in search of "lasting solutions." For example, she is lobbying for a real "right to treatment." Currently any person can get basic treatment by obtaining a healthcare card issued by the Social Services authority.  But that office works closely with the Office for Foreigners, which registers the person, making them subject to deportation.

A lasting solution is still absent, but Sigrid is heartened by the three-year model project recently launched by the regional government of Lower Saxony that in two cities, including the capital city of Hanover, allows undocumented people to receive care without registration.

Nevertheless, Sigrid realizes it will be a long term effort.  Most regional and state governments fear that it would be financially unsustainable to provide full access to immigrants, especially if it resulted in an even greater influx of people when word spreads that a particular region is providing assistance.  But for Sigrid, it is about human rights, and most especially, the absolute right of a human being to get care when he or she is sick.

A German Response to Malpractice Lawsuits

Today I met with the Expert Committee for Medical Malpractice Claims, also known as the Gutachterkommission, which offers an alternative to lawsuits for patients who believe they have been harmed by a physician.

The formation of the Committee was largely a response to escalating and costly malpractice claims in the 1970s.  Insurance companies and the Medical Association of North Rhine, which provides professional representation for the approximately 56,500 doctors in North Rhine (a part of the German federal state North Rhine-Westphalia) decided to create the Committee, which is composed of independent doctors and jurists.

The people I spoke with were the Chairman of the Committee, Dr. H.L. Laum, the Chief Executive, Dr. Friedrich Kienzle, and the Office Manager, Mr. Ulrich Smentkowski.   They all stressed that the goal of the Committee was to, as best they could, arrive at the truth of what happened when malpractice is alleged, without regard to the financial repercussions of their findings.

In short, when a patient believes he/she has been harmed, they can initiate a proceeding with the Committee.  The Committee will review the patient's statement and the doctor's records, as well as interview other doctors who treated the patient (if applicable).   At the end of the process, which averages 12 months, the Committee will deliver a non-binding opinion.

A patient is not obligated to use the Committee and retains the right to initiate a lawsuit after it issues its opinion.  The Committee members I spoke with were very proud that approximately 90% of its opinions resolved the matter (on average, the Committee has found that malpractice occurred in about a third of its proceedings; that number has been fairly consistent over a number of years).  They also stated that, of those cases where a patient did choose to pursue a lawsuit, the court affirmed the Committee's findings 98% of the time.

I asked why there was no patient representation on the Committee.  Dr. Laum said the Committee believes that such representation would not be helpful because the lay person would lack the medical and juridical knowledge to contribute to the process in a meaningful way.  Nevertheless, another Expert Committee formed in a different German state recently added patient representation to its membership.

In all, the conversation was a very interesting look into how another major Western country has tried to deal with the contentious issue of medical malpractice and the lawsuits that can result.  No doubt this arrangement would be open to a wide range of criticisms in the United States. I could easily see some of my attorney friends question the impartiality of a group whose membership is largely drawn from the same profession and who, at least in America, have often demonstrated a reticence to criticize their colleagues. One might also ask to what extent patients felt the Committee was their only real option.  The cost to the patient for a proceeding before the Committee is paid by insurance, with the rest of the cost covered by the dues the physicians pay to the Medical Association.  But if you choose to sue, you must find - and pay out of pocket - for a lawyer.  And there is the potential question of whether this process allows a physician to keep his/her license when circumstances dictate a suspension or loss of license.

Still, it seems to me to be a step in the right direction, one that starts to put more weight on fact finding than fault finding.

Admittedly, I don't have a great deal of knowledge in this area.  Post Fellowship, I plan to examine whether such a system has been considered or in some form initiated in the U.S.  Perhaps it could bridge a compromise between those who believe malpractice lawsuits serve principally to increase insurance costs that then deter doctors from practicing, and those who think punitive damages are a just punishment for medical errors.

My Eisenhower Fellowship Begins

Tomorrow (April 27) officially begins my Eisenhower Fellowship.  I will meet with Sophia Schlette (@SophiaSchlette), an international health policy expert who advises health care decision-makers on how to transfer health systems knowledge, good practice, and innovative approaches across countries. I have read her work extensively over the last few months and have been impressed by her insights. I'm thrilled to have a one-on-one with her.

Next, I will have an opportunity to speak with members of the Medical Malpractice Committee of the Medical Association North Rhine, a professional association for the approximately 56,500 doctors in that part of the German federal state of North Rhine-Westphalia. Given what a contentious issue medical malpractice and tort law is in the U.S. and the degree to which it incentivizes physicians to practice "defensive medicine," I will be eager to learn how the Germans have confronted this challenge.

I will conclude the day with representatives of MediNetz.  This organization seeks to help some of the four hundreds of thousands without a valid residence permit in Germany. According to MediNetz, undocumented immigrants in Germany have only a very limited access to health care.  The organization seeks to work with legislators to find a lasting solution to this challenge.  While engaging in the political process, MediNetz addresses the practical issues of people without access to care by running a limited clinic (every Monday from 18:00 to 20:00 on the premises of the Caritas center Delbrêl in Mainz Neustadt).  Services are provided free of charge exclusively by volunteer doctors. Drug, laboratory costs, and, if necessary, hospitalizations are funded by donations and by patient contributions.   I am looking forward to learning more about MediNetz and to compare their model with the one used by Casa de Salud in St. Louis.

If any readers have particular lines of questioning they would like me to pursue or just general thoughts about these topics, please post a reply.

A Healthy Lifestyle is Afoot in Amsterdam

I am in Amsterdam for a few days before my Eisenhower Fellowship begins in Bonn.  The first thing one is struck by is the incredible number of bicycles.  In fact, if you're not careful, you will literally be struck by a bicycle.

Throughout most of the city, bikes have their own thoroughfares adjacent to the traffic lanes for cars.  These are not like the bike lanes in the States, where usually you just have a white bicycle stenciled on the pavement and, viola, a bike lane. No, these are honest-to-goodness traffic lanes for bicycles and motorcycles.  In the main part of the city, the interior lanes are reserved for public transit, including the GVB trams which have a Disney monorail feel to them and, for  a low price, will get you close to most places. Finally, pedestrians have their own sidewalk, but it runs immediately parallel to the bike lanes, so walker beware.

In the U.S. we have a major obesity problem. It's the result of lots of factors, not the least of which are portion sizes and a penchant for fried, fast, and fried fast foods.  But there is also the contributing factor of living in spaces that devalue physical exercise.  Most of us - certainly those who are urban dwellers - live in areas that privilege the automobile.  If we decide to go to the local Starbucks for a coffee, all most all of us will choose to get in our car and drive there (only 1.0% of all trips taken in the U.S. are by bicycle, and 10.4% are on foot).  Not so in Amsterdam. You'd almost  certainly walk or ride your bike, which helps take the caloric edge off of that double chocolate frappucino.

As we look to combat obesity, which now affects over 35% of all Americans and costs us upwards of $200 billion per year, we need to look to solutions beyond the medicinal. Investing in cityscapes that make it easier - if not outright incentivize - the use of bicycles and our own two feet for transportation will have a huge return.  It can improve health, save on medical and energy costs, reduce pollution, and generally create a more livable environment. 

This is already backed by data.  Levels of diabetes, high blood pressure, and obesity are all lower in cities

with higher shares of commuters bicycling or walking to work. Likewise, where commuters bicycle or walk to work in higher shares, more of the population is meeting the recommended amount of weekly physical activity.   Stats also show a positive impact on job growth, individual transportation costs, retail sales, traffic congestion, air quality, property values and stability, health and worker productivity, and events and tourism.

The Alliance for Biking and Walking has a very robust report on current efforts to make city spaces that help us be healthy.

Immigrants: A Test of National Character

I come to Germany for my Eisenhower Fellowship as the fate of immigrants is on the minds of Germans and the entire European Union following the sinking of a boat in the Med with hundreds of migrants on board. The EU is struggling with the incongruity of its rhetoric on immigration (as exemplified by the Strategic Guidelines for legislative and policy planning adopted by the European Council in June 2014 that demands “full respect for fundamental rights" of immigrants and refugees) and the increasing hostility of EU citizens towards immigrants.

Of course, this is not unique to Europe. One need only look at the U.S. and the furor over the "invasion" from Mexico even during this period of net negative migration, not to mention the spectacle last year of Americans shouting at children arriving from Central America trying to escape extreme violence in their home countries.

But in Europe, Germany is setting the tone. Due to geography and economic prosperity, Germany attracted a substantial share of the 627,000 people who applied for asylum in the EU in 2014. It is the case again this year, and as the New York Times just reported, towns and villages across Germany are pleading for money and assistance to take care of their new arrivals (an estimated 300,000 will apply for asylum this year).  There is resistance, including the burning of migrant housing.  But as one German mayor told the Times, "Wealthy Germany can afford to help."

This is true, in the same way that America can provide for the immigrants that come to its shores and borders. No doubt there are real costs to properly welcoming and integrating immigrants, but there is plenty of data showing that immigrants boost the economy over the long term.

So in many ways, dealing with immigrants is a test of national character. Do we approach challenges with a mentality of scarcity or opportunity?  Does our sense of security come from homogeneity or from shared purpose?  Do we believe in our founding values or do we pay them lip service?

How we treat immigrants answers these questions more vividly than any rhetoric.

The Power of Direct Experience

During my participation in the 2015 Opening Seminar for Eisenhower Fellowships, I had the privilege of attending a leadership seminar by the social scientist Joseph Grenny.  Over the course of three hours, he presented a lot of excellent and thought-provoking concepts, but, for me, none more so than the power of direct experience.

Drawing from his thirty years of observation, Grenny highlighted a couple of examples.  First, he recalled a university call center that was under-performing.  Working at a call center is a difficult job.  It is repetitive, static, numbing, and subject to confrontations with people who don’t want to be solicited at home.  Wages are typically low and turnover high.   

In this particular call center, the university assembled the employees and brought in a young woman of color.  For ten minutes, she talked to the workers about her experience as the first person in her family to get a college education and the difference that had already made in her life. She finished by expressing her thanks to the call center workers because, through their efforts, the university had raised the money for her scholarship, without which she could never have gotten her degree.

Three months later, the university looked at the results from this call center.  Productivity had soared and the amount of money brought in had increased exponentially.

Grenny also noted a seminar for CEOs of some of the world’s largest hospitals. They were there to discuss ways to improve the overall healthcare experience for patients.  The facilitator, Dr. Don Berwick, the former leader of the Centers for Medicare and Medicaid Services, was afraid that all it would amount to was an intellectual exercise that would result in zero change. So he told the CEOs that he wanted to reconvene them in a month’s time, and that during the intervening month they should pick a patient in their respective hospitals and personally investigate their case.

The following month Dr. Berwick was amazed by the result.  The executives were emotionally connected to the cases they related, and they discussed how illusory many of their patient experience protocols actually were.  They subsequently became much more intent on making real changes to positively affect patient care.

These examples reinforced my ideas about change.  Real change does not come about through laws or policies or systems.  These are all necessary things, but not sufficient. Change happens when we are directly affected, when our empathy is engaged because we personally know someone whose life has been impacted.

This can seem daunting.  How many people must be personally engaged before a critical mass is reached and progress is made?  It becomes all too easy to be discouraged and just accept the status quo.

But we should never underestimate the power of just a few people to dramatically affect the world.  As Joseph Grenny demonstrated in a social science context, a few simple actions can have an outsized impact. Similarly, in the everyday world, the personal and passionate engagement of several individuals – or even one person – can make a consequential impact on the lives of many.

 

The key is not to wait for those others to emerge, but to be one of them yourself.

‘‘Illegality’’ as a health risk

In my continuing preparation to travel to Germany next week for my Eisenhower Fellowship, I am reading a great deal of material related to the care of immigrants in that country. A particularly interesting piece is from an anthropologist based in my home town of Tampa, Florida.  As part of an ethnographic study of a clinic in Berlin, Dr. Heide Castañeda explored, among other themes, the effect the state of "illegality" or ‘‘undocumentedness’’ has on health.  

Castañeda references a study by McGuire and Georges that found that the concept of allostatic load, defined as the accumulation of biological risk associated with persistent hyperarousal, is applicable to the lives of migrants without legal status. The investigators argued that the prolonged biological stress associated with their status worsened the health risks of migrants, in combination with variables like accessibility, affordability, and willingness to seek care.

There are already myriad reasons to provide care for immigrants, even those who are not in the U.S. legally, not the least of which is that, as a nation of immigrants, it is the right thing to do. But Castañeda's work reveals yet more evidence that by excluding immigrants from care, we may very well be contributing to the deterioration of their health which we will then have to address through uncompensated care in an emergency department or in-patient hospital setting.  This is morally repugnant and economically nonsensical.

Finished in Philly

Final day in Philadelphia was a great capper to the week.  Thanks to Natalie from the Eisenhower Fellowships staff, I met this morning with Peter Gonzales from Welcome Pennsylvania, which has done great work in connecting work-authorized immigrants with jobs.  This has obviously helped the immigrants, but it has also boosted the PA economy, creating shared prosperity.

The rest of the morning was spent in the "fishbowl," listening and commenting on the Fellows' project plans, and getting feedback from them about my own project. It was honest and informative and enlightening.

At lunch I had a dialogue with another Fellow whose project also centers on healthcare.  He reminded me that our current epiphany about healthcare as being fundamental to the social contract is really a return to the roots of the emergence of civil society, where we first moved away from seeing the person only in terms of what he/she could contribute to the survival of the  group and began to recognize the intrinsic value of a human life. 

From this point of view, perhaps there could be an alignment between the interests of those who describe themselves as pro-life and those who are often at odds with this group but who adhere to humanistic principles.  In this case, both sets of people might make common cause and use their combined clout to pressure politicians and healthcare providers and payors to reconceptualize healthcare as a right. This doesn't mean that we need to abandon market-based mechanisms or turn healthcare  totally over to government.  But the first step to any real changes in the healthcare space is a change of mindset, from thinking that healthcare is for those who can afford it and/or "deserve" it, to believing that basic care is something we guarantee to all by the very fact that they are a human being. 

The Eisenhower Experience

Today was the first time my Fellowship really hit me.  I spent the entire day surrounded by people from throughout the United States and all over the world who are doing incredible things and and who are leveraging their Eisenhower Fellowships to do even more.

There is Tamiko Nakamura from Japan, striving to foster connections between the legal and scientific communities to create cross disciplinary legal education models; Noelle Lim from Malaysia, who besides being the host of the most popular English language radio show in her country, is working to provide access to the best schools in the U.S. and the U.K. for low-income Malaysian students; Ephey Malo from Nigeria, seeking to drive innovation in her country's energy sector to help create stability and opportunity; and Louella Pesquera of the Philippines, a prosecutor of government graft, looking to drive multi-national collaborations to enhance prosecutorial impact in corruption cases.

These are just some of the 32 Fellows gathered now in Philadelphia.  The discussions we had today have been amazing, and not just because they were about interesting things.  They demonstrated the dynamism of the people that Eisenhower Fellowships has put together for its 2015 programs, and I, much to my delight, have found new and gifted collaborators for the work I am trying to do.

In addition, with help from the EF staff (thanks, Natalie Barndt!) I will meet tomorrow with the ED of The Welcoming Center for New Pennsylvanians, an organization focusing on economic development and new immigrants.  Between my work at Casa de Salud and my involvement with the St. Louis Mosaic Project, I trust we will have a lot to discuss.

More from Philadelphia

Great meeting and dinner with the USA Fellows and the Fellows from around the world.  The people ranged from the brother of the king of the Netherlands to the founder of a small non-profit in Malaysia. Everyone had very compelling stories and aspirations. I especially enjoyed hearing my colleague from Australia discuss how his company plans to mine data in an effort to convert the profit motive of healthcare from treating sickness to maintaining wellness.

The other conversation that struck me today was over dinner with my colleague from Nigeria. He talked about how people waited all day in order to vote, and that voter turnout was among the highest in the region most threatened by Boko Haram.  That's incredibly inspiring, and an implicit admonishment to our complacency here in the U.S.  We forget that democracy is not gifted, it is earned.

Eisenhower kickoff

I'm in Philadelphia for a meeting of all the USA and International Fellows. An amazing group of people that I'm looking forward to working and exchanging ideas with.  I'm particularly interested in speaking with Paul Nicolarakis from Australia, who wants to establish a social enterprise supporting healthy life extension, and Stacy Chang from California, who will travel to Kenya and Sweden to identify solutions for global health.

Speaking of which, I just read a fascinating article in the Atlantic that came to my attention via Sophia Schlette, a health policy expert that I will have the honor of speaking with when I'm in Germany later this month.  The article clearly shows how successful health initiatives are those that meet people where they are and then make incremental changes, or as Vesa Korpelainen says in the piece, "relentless, congenial nudging."

Outing the Immigrant

Interesting information from my research: There is a "duty to denounce" to the authorities the irregular (undocumented) situation of an immigrant, but it is not applicable to doctors and paramedics, who are bound by "professional secrecy." Yet, public officers and civil servants, even if working within the healthcare services, are obliged to report the the irregular status of an immigrant that they encounter during the course of their work. That's quite a dynamic, one I would think is not very conducive to the creation of trust I think is necessary within the field of healthcare. And in fact, there is evidence that this undermines the access to care for these immigrants in Germany.

I will try to explore why the Germans operate in this fashion, to what extent it is affecting the care of immigrant populations, and how this compares to federal and individual state policies and practices in the U.S. with regard to providing care to the undocumented.