JamesLHollyMD.com

	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
Governance Board Governance Board Responsibilities Governance Board Leadership Training The SETMA Team and The SETMA Culture SETMA's Mission, Vision and Goals: Patient Safety and Quality Care Harassment, Neglect, Abuse, Exploitation - Role of HCAHPS & CAHPS Healthcare Provider Standards Providers Responsibility Medication Refills, Reconciliation and Maintenance Provider and Leadership Use of Data and Analytics Commitment To All Patients -- Ethnic Disparities Kaizen - Board Creates Culture of Safety and Quality SETMA's Policy and Practice for Advanced Directives SETMA's Policy on Completion of Medical Records Care Guidelines : Improve processes to evaluate and treat Integrated patient safety program (Sentinel Events) Effectively Manages all programs, services or sites Provides Patients with information about Primary-care Medical Home Organization-wide Planning to Maintain Focus on safety and quality Organization-wide Planning to Maintain Focus on safety and quality SETMA's Performance Quality & Safety Judged by CMS SETMA's Performance Quality & Safety Judged by CMS SETMA Awarded by HIMSS for Quality and Safety 2011 John M. Eisenberg Patient Safety and Quality Awards Application Healthcare Quality Award 2012 Principles of Quality and Metrics Principles Contacting SETMA & Secure Texting PC-MH Mission, Vision, Goal, Access, End-of-Life Communications and Public Reporting Change Existing Processes to Improve Performance Team Members Focused on Safety and Quality	Your Life Your Health View Articles by Subject Aging Well Behavioral Health Cardiovascular Disease Risk Care Coordination Care Transitions Children's Health COGNOS Project Diabetes Exercise Healthcare Reform:Public Policy HIPAA & Security Labor Day Less Initiative Medical Home Medical Records Men's Health Mental Health Nutraceuticals Nutrition Smoking Cessation Thanksgiving Weight Management Women's Health All Articles	Public Reporting Public Reports by Year (2009-2017) Public Reports by Type Fall Risk, Pain, Functional, Wellness, Stress Assessment Fall Risk, Pain, Functional, Wellness, Stress Assessment for 2011 AND 2012 Core Measures: SETMA & Baptist Hospital Core Measures for January to December 2011 PQRS Diabetes Measures - Blood Pressure Diabetes Measures - Glyco and LDL Diabetes Measures - Nephropathy Screening, Foot Exam, and Eye Exam Preventive Measures - Screening (BMI, Colorectal Cancer, Mammography, Osteoporosis) Preventive Measures - Influenza, Pneumococcal, Urinary Incontinence Preventive Measures - Tobacco Use NQF Care for Older Adults Comprehensive CHF Care Diabetes Measures Diabetes Measures - Blood Pressure Control Diabetes Measures - Glyco and LDL Diabetes Measures - Smoking Cessation Female Measures General Health Measures Medication Measures Persistent Medications Medication Measures Pediatric Measures HEDIS (NCQA) Effectiveness of Acute Care Effectiveness of Chronic Care - Clinic/Hospital Effectiveness of Chronic Care - Clinic Only Effectiveness of Chronic Care - Diabetes (Smoking Cessation) Effectiveness of Chronic Care - Diabetes (Glyco and LDL) Effectiveness of Chronic Care - Diabetes (Blood Pressure Control) Effectiveness of Preventive Care Effectiveness of Preventive Care - Older Adults Effectiveness of Chronic Care - Diabetes Measures Effectiveness of Chronic Care - Persistent Medications (MPM) NCQA Diabetes Recognition Program Audit LESS Initiative PCPI PCPI Hypertension PCPI Diabetes PCPI Chronic Stable Angina PCPI Care Transitions PCPI CHF PCPI Weight Management PCPI CKD Stages IV V SETMA Lipid Audit Lipids Treatment Audit Tutorial Lipids Tutorial AQA COGNOS Project SETMA Audit for CKD Stages I III Patient Satisfaction Survey	Accreditations/Awards Achievements which have Advanced SETMA: The Time-line, Philosophy and Principles which Underlie that Advancement Awards	Diabetes Center of Excellence Education Diabetes Order Referral Form Seven Stations 2011 Advances in Diabetes Diabetes Tutorial Diabetes Prevention
EPM Tools Association of Medication and Diagnosis Automated Team Function Behavioral Health Adult Weight Management Tutorial Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Behavioral Health in SETMA's Patient-Centered Medical Home Model of Care Depression Tutorial Fall Risk Tutorial Health Insurance Portability and Accountability Act (HIPAA) Privacy Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive LESS Initiative Tutorial Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Pain Management Tutorial Reduction of Antipsychotic Medications Toolkit Smoking Cessation Tutorial Stratifying End-of-Life Risk for Hospice Services Tutorial Chronic Conditions Tutorial Chronic Renal Disease Management Tool Tutorial Calculating the Stages of Renal Disease Proteinuria Disease Management Tools Acute Coronary Syndrome Tutorial Adult Weight Management Tutorial Angina Tutorial Cardiometabolic Risk Syndrome Tutorial Chronic Renal Disease Tutorial Congestive Heart Failure Tutorial Diabetes Tutorial Hypertension Tutorial Lipids Tutorial Lipid Quality Audit Tutorial Primary Pulmonary Hypertension Tutorial Framingham Cardiovascular Risk Cardiometabolic Risk Assessment Framingham Heart Study Risk Calculators Tutorial Frederickson Classification of Dyslipidemia LDL Level Lipid Disease Management Risk Assessment General principles about ICD-9 Codes and HCC/RxHCC Codes Charge Posting Tutorial Coding to Ensure Accurate Health Risk Scoring E & M Codes Tutorial HCC & RxHCC Risk HCC/RxHCC Risk Tutorial ICD-9 Code Training Manual Hepatitis Screening Hospital Based Tools Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial Admission Orders Tutorial Daily Progress Notes Tutorial Care Transition Data Set from PCPI Tutorial Using The Clinic and Hospital Follow-up Call Templates Respiratory Failure Tutorial Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA's Internal HCAHPS Survey Master GP Suite of Templates Master GP Suite of Templates Tutorial Medical Home Support Materials Department of Care Coordination, Director of Care Coordination and Care Coordination Referral Template Electronic Tickler File Electronic Tickler File Tutorial Follow-up Calls Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Services Medical Home Coordination Review Tutorial Medical Home Plan of Care and Treatment Plan Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Patient-Centered Medical Home Annual Questionnaires Patient-Centered Medical Home: SETMA's Medical Home Coordination Review (MHCR) Tutorial Patient Document for Coordination of Care Transitions of Care Management Coding (TCM Code) Tutorial Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial Nursing Home Depression Tutorial Fall Risk Tutorial Hydration Assessment Tutorial Nursing Home Guidelines for Care Tutorial Nursing Home Principal Suite of Templates Nutrition Assessment Tutorial Reduction of Antipsychotic Medications Toolkit Skin Care Tutorial Outpatient Infusion Center for Intravenous Antibiotic Therapy and Other Meds Preventive Health Tools Adult Weight Management Tutorial CHF Exercise Tutorial Diabetic Exercise Tutorial Diabetes Prevention Tutorial Exercise Prescription Tutorial Hypertension Prevention Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Initial Preventive Physical Exam & Annual Wellness Visit Tutorial LESS Initiative Tutorial Progression to Type 2 Diabetes Smoking Cessation Tutorial Progression to Type 2 Diabetes Quality Metrics ACO and Medicare Advantage Stars HEDIS: NCQA, History, Quality, Safety, STARS, ACO ACO Quality Measures Performance Tool ACO Quality Measures Performance Tool Tutorial STARs - A Tutorial for Utilizing SETMA's Deployment of the STARS MA Program Specialized Tools Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Association of Medication & Diagnosis Chronic Conditions Tutorial Chronic Care Management Code (CCM) Tutorial Depression Tutorial Drug Interactions Tutorial Electronic Tickler File Tutorial Evaluation Lower Urinary Tract Symptoms in the Male Fall Risk Tutorial Future Labs Tutorial Hydration Assessment Tutorial HCC Risk Training Tool Hypertension: Fulfilling Quality Metrics for the PCPI Program Laboratory Results - Signing Off: Why and How Medication Module Tutorial Medication Reconciliation Tutorial Nutrition Tutorial Pain Management Tutorial Problem List Reconciliation Tutorial Progression to Type 2 Diabetes Referral Skin Care Tutorial SOAAP Opioid Risk Assessment Stratifying End-of-Life Risk for Hospice Services Tutorial Texas State Reportable Infectious Diseases Tutorial Transitions of Care Management Coding (TCM Code) Tutorial	Transforming Your Practice Library Introduction to SETMA's TCPI Library Transforming Your Practice (TCPI) Summary Document of TCPI CMS Quality 12.2015 TCPI Leadership and Governance Care Coordination HIPPA and Security Data Analytics Care Transitions LESS Initiative Medical Records Clinical Decision Support Hospital Care Tools Disease Management Tools Preventive Health Tools Behavioral Health Transformation Tools New Transformation Tools Patient-Centric Care Nursing Home Medical Home Display and Explanation of SETMA's Patient-Centered Medical Home Tools	Medical Home The Story and the Ideals Introduction to Preventive Health Tools PC-MH Patient Engagement & Alternative Payment Models Preventive Care: The Best Way to Treat Illness is Don’t Get it Coordination of Care Patient-Centric Care Population Health Transition of Care - One form of Care Coordination HCAHPS - Hospital Consumer Assessment Of Healthcare Providers and Systems CAHPS - Consumer Assessment of Health Care Provider and Systems Teaching Tool for PC-MH Course – Patient Care Activation, Engagement, Shared-Decision Making Display & Explanation of PC-MH Tools SETMA's Medical Home Pilgrimage Concierge Medicine not Medical Home Medical Neighborhood Security & HIPPA Referrals Patient Web Portal Health Information Exchange Medication Reconciliation The Automated Team Coordination of Care Medical Home Description & Standards AAAHC Joint Commission NCQA Planetree URAC NCQA Interview February 14, 2014	Facebook	Letters

Your Life Your Health - Rationing Health Care vs. Rational Healthcare

James L. Holly,M.D.

August 06, 2009

Your Life Your Health - The Examiner

In the July 19, 2009 New York Times, an extensive article appeared which promoted the rationing of healthcare as the only way to manage the cost of healthcare in the future. Subsequent letters to the editor have responded positively and negatively to this article. The article's author's name, Peter Singer, of Princeton University, seemed familiar to me. As I read the article, I remembered his letter to the editor in the 1985 Journal of Pediatrics in which he argued that a pig might have greater value that a human child who was born with severe birth defects. In subsequent years, Singer would be bolder in proposing that a child would not be considered a child until at least a month after birth during which month healthcare professions could determine that the child had no value to society and therefore would be euthanized.

In the August 2, 2009 New York Times an opinion piece appeared which reviewed the current state of technological advances in medical science and discussed them in relationship to healthcare policy, asking the question, "How much longevity does a person have the 'right' to?" The suggestion was that a judgment as to the resources which society should expend upon a person could be based on the person's contribution to society, or even upon their ability to make a contribution. This is more subtle than Singer's position but it starts at the same place: a human being has value only based on mental, or physical ability, contribution to society, or the potential for contribution to society.

The Declaration of Independence of the Unites States of America begins with the statement, "We hold these truths to be self-evident, that all men are created equal; that they are endowed by their Creator with inherent and inalienable rights; that among these are life, liberty, and the pursuit of happiness..." "Inalienable" means "incapable of being repudiated or transferred to another; "unforfeitable: not subject to forfeiture." Neither the individual nor the government can surrender, remove or abrogate these rights. No government, no jurisdiction, no law, no policy and no other instrument of social or governmental decision-making process can make a distinction for the purposes of access to healthcare between humans on the bases of any other asset, liability, capacity, incapacity, productivity or lack thereof.

This must then be the context of the discussion of healthcare policy; it is the context of the Constitution and the social doctrine of our community which establishes irrevocably the value of the individual based on that individual's "humanness" and not on the basis of their wealth, education, station in life, productivity, or other performance measure.

If then this is the foundation of the discussion how do we deal with "rationing" of healthcare versus the "rationality" of healthcare decisions? Furthermore, what are the "rights" which each individual can claim to healthcare; what are the "responsibilities" each individual has for his/her healthcare, and what are the "realities" of the circumstances n which those "rights" and responsibilities" must be exercised?

Rationing and Rational

How do these differ, or do they? "Rationing" is defined as the controlled distribution of resources and scare goods or services. Rationing controls the size of the ration, one's allotted portion of the resources being distributed on a particular day or at a particular time. The rationing of health care has occured in various forms in the United States and Western Europe in the post-World War II era. Massachusetts enacted a controversial rationing program during the 1980s that was subsequently repealed.

In his article, Peter Singer states: "In the current U.S. debate over healthcare reform 'rationing' has become a dirty word. Meeting (in June) with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons' attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline 'Obama Will Ration Your Health Care,' Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, 'Americans will not put up with such limits, nor will our elected representatives.' And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNN News in April, 'There is no rationing of health care at all' in the proposed reform."

Rationing in healthcare is not defined by a contractual relationship in which the government agrees to pay for certain procedures but not for others. Rationing occurs when distinctions are made between individuals within a group, in which case it would be declared that a certain procedure would be paid for if a person is below age _____, or if a person is mentally competent, or if a person is able to communicate, or if any other subjective condition is placed upon a person's individual and personal qualifications for care.

If "life" is an inalienable right, laws or policies which differentiate between individuals on any basis other than their human-ness is a violation of those individuals' constitutional rights. This would not preclude society from declaring contractually that it would provide a certain level of care to everyone but another level of care to no one.

"Rational care" on the other hand is that care which is determined by an individual or his/her legal, personal representative, next of kin or guardian. This care would constitute that which is made in consultation with a personal healthcare provider and could include the withdrawal of current care, or the withholding of extraordinary means of life support based on the individual's, or in the case of the individual's loss of competency, the family's, decision. This would include the rational decision not to support life with extraordinary hydration and/or nutrition, ventilation or intervention with invasive or non-invasive procedures. What the government may not do without "rationing" care; the individual or the individual's family can do on the basis of "rational" care.

There is a time to die. While the Constitution implicitly and the Declaration of Independence explicated does not even give the individual the right to abrogate their "right to life," which means that euthanasia or suicide cannot be legalized, it is not necessary to prolong life artificially. It is a rational decision to recognize that at some point no matter what is done, no positive result will occur. It is rational to decide to go home, to be with your family and to allow the natural course of life to transpire with the support of family and healthcare professionals who can make that process comfortable.

Other elements of rational healthcare are:

It is evidence-based - care should not be based on opinion, experience, prejudice or personal bias. It should ONLY be based on sound science. Unfortunately, there is not always sound science available in every condition but where there is, it should be the basis and standard of rational care.
Its foundation is a healthy lifestyle - any claim to a right of healthcare (more on this later) has to be based on the responsibility of a lifestyle which includes exercise, weight control, temperance and no smoking, to name a few.
Its foundation is also based on preventive care - rational care must include the demand for appropriate preventive care including immunizations and evidence-based screening procedure.
Expensive and Excellent are not synonyms - we often associate expense with value; in healthcare, just because something is expensive does not mean that it is excellent. Because a unique healthcare delivery model boasted of extraordinary success, SETMA sent a provider to that clinic. The care cost over $3,000 (out of pocket, no insurance accepted) and consisted of less than a two-minute physical examination, which included assessments available in any routine office visit. Expensive did not correlate with excellence.
More healthcare is not always better healthcare - In the May 14, 2009 Examiner, Your Life Your Health article was entitled "Can More Care Provide Less health?" Please refer to Related Articles below.
Technology cannot add value or quality to life and does not always add quantity -- The things which make our lives valuable are not driven by technology and ultimately, they are not driven by the length of our lives.
The object of healthcare decisions is the welfare of the individual and not of the family - Very often, healthcare decisions and the associated cost of those decisions are not made for the benefit of the patient but for the benefit of the family. Guilt for past neglect of a family member or for unresolved conflicts cannot be remedied by irrational care at the end-of-life or in a healthcare crisis which is hopeless.
End of life decision should be made before the need arises - Every person, age 50 and above, and those younger than that with serious, chronic illnesses, should have a serious conversation with themselves, with their families and with their healthcare provider about their desire for care in a life-threatening situation.

Next week, we will continue this with a discussion of the "rights," "responsibilities" and "realities" of healthcare for patient and provider.

Related Articles

	Can More Care Provide Less Health?

About SETMA	In The News	Syllabus PC-MH Externship	Patient Information	Presentations
Governance Board	Your Life Your Health	Public Reporting	Accreditations/Awards	Diabetes Center of Excellence
EPM Tools	Transforming Your Practice Library	Medical Home	I-CARE Initiative	NextMD